The International Journal of Indian Psychology

ISSN 2348-5396 (Online) | ISSN: 2349-3429 (Print)

Volume 8, Issue 4, Oct- Dec, 2020
DIP: 18.01.112/20200804, DOI: 10.25215/0804.112
http://www.ijip.in
Review Paper

The effectiveness of cognitive behavioral therapy for substance

use disorders and the challenges in treating this client group:
a review

Stuti Viren Kapadia1*

ABSTRACT
Objective – The review article presents a critical evaluation of the effectiveness of Cognitive
Behavioral Therapy (CBT) for Substance Use Disorders (SUDs) and the challenges faced in
treating this client group. The review discusses the results of various systematic reviews and
randomized control trials which will further help to formulate an intervention model, leading
to improved health care services for people with substance use disorders. Method – The study
aims to review the policy and guideline documents as well as the academic literature on
effectiveness of CBT and the challenges faced. Literature searches of key health science
databases such as PubMed, PsycINFO, Journal of Substance Abuse Treatment, Journal of
Substance and Alcoholism were conducted using various search terms in combinations.
Results – The policy and guideline documents as well as the academic literature highlight the
effectiveness of CBT for substance use disorders along with other treatment models such as
Mindfulness Based Therapy (MBT), Acceptance and Commitment Therapy (ACT),
Dialectical Behavioral Therapy (DBT), Relapse Prevention (RP). Conclusions – The CBT
based intervention involves various intervention components such as functional analysis of
substance use, identification of triggers for relapse, coping-skills training, behavioral skills
training for drug-refusal, and increased activities not related to substance use. Although CBT
proves to be effective and presents long-lasting effects, further developments on the
mechanism of the application of the effects as well as treating the challenges faced are
important to provide the best possible care.

Keywords: Cognitive Behavioral Therapy, Substance Use Disorders, Contingency

Management, Motivational Interviewing, Relapse Prevention, Mindfulness-Based Therapy
ubstance Use Disorders (SUDs) can be defined as “a cluster of cognitive, behavioral

S 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 behaviors 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

1
MSc in Mental Health Studies, King’s College London
*Responding Author
Received: November 21, 2020; Revision Received: December 03, 2020; Accepted: December 31, 2020
© 2020, Kapadia S.V.; licensee IJIP. This is an Open Access Research distributed under the terms of the
Creative Commons Attribution License (www.creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and reproduction in any Medium, provided the original work is properly cited.
The effectiveness of cognitive behavioral therapy for substance use disorders and the challenges in
treating this client group: a review

drugs. In comparison to other countries, Canada, United Kingdom and United States are
undergoing a swift upsurge in the growth of suds (WHO, 2014). In 2014/15, there were
8,149 hospital admissions with a principal diagnosis of drug use and behavioral disorders
(Statistics on Drug Abuse: England, 2016). 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. The publication of Marlatt and Gordon (1985)
on “Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavior”
proves to be an essential blueprint for CBT approaches to addictive behaviors 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 behavioral and cognitive coping strategies (Carroll & Onken 2005; Sofuoglu et al.
2013). All models seem to include five CBT strategies: (1) functional analysis of substance
use, (2) identification of triggers for relapse, (3) coping-skills training, (4) behavioral skills
training for drug-refusal, and (5) increased activities not related to substance use.

Effectiveness of CBT for SUDs

Currently, cognitive behavioral approaches have maximum empirical support from high
intensity clinical trials and are largely recognized as evidence-based approaches to suds
(U.S. Department of Health and Human Services, 2016) and incorporated in a wide scope of
practice guidelines (American Society of Addiction Medicine, 2015; Centre for Substance
Abuse Treatment, 2004; National Institute on Drug Abuse, 2007; Veterans Administration,
2015). 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 small but substantial treatment effect (g=0.15) for CBT (Magill and Ray 2009).
However, in a seminal review by Morgenstern (2000), CBT showed a very little scope in the
improvement in coping skills for CBT for substance use disorder.

The evidence assisting 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;
Schmitz at al,2001), Motivational Interviewing (Baker etal.,2005) and Contingency
Management (CM) (McKee et al.,2007). Unfortunately, high drop-out rate of 40-45% has
been documented amidst different behavioral 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). But 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 robust (Finney et al.,2006). Although there are mixed findings with
respect to 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 abusers of illicit drugs, to one of the three treatment conditions:

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The effectiveness of cognitive behavioral therapy for substance use disorders and the challenges in
treating this client group: a review

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. The computerized CBT was found to be effective in enhancing the quality of
coping skills of the individual for drug avoidance (Kiluk, Nich, Babuscio, & Carroll,
2010b). Also, when traditional CBT is compared with ‘contextual CBT’s’, 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, robust relationship has been indicated between
extra-session practice assignments (homework) in CBT and treatment outcomes (Dattilio et
al.,2010) as well as reduced drug use (Carroll et al.,2008). Although, more research is
needed in this area, homework in CBT clearly plays an important role in treatment
outcomes.

In difference to numerous evidences 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 behavioral 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 there are few systematic reviews and high intensity clinical trials evaluating
CBT for SUDs, those that have been done, suggest that CBT has modest, but long-lasting
effects.

Challenges Faced
Relapse is a fundamental barrier to the treatment of SUDs (Brandon et al.,2007). 12 months
relapse rates for alcohol and tobacco cessation ranges 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 pre-
requisite for long-term changes in addictive behaviors. Another important barrier faced by
CBT is withdrawal. Although withdrawal is a physiological process, recent theory highlights
the importance of behavioral withdrawal process and that the unavailability of drug, may
leave the individual incapable of dealing with the stress thus prolonging the symptoms
(Baker et al.,2006). In the light of this, Negative affect is a relapse trigger and plays an
important role in maintenance of addictive behaviors (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, and 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 therapist 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

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The effectiveness of cognitive behavioral therapy for substance use disorders and the challenges in
treating this client group: a review

focus on sustainability and others (Harvey et al., 2015; Roman et al., 2012; Barlow, 2010;
Institute of Medicine,1998). Moreover, the lack of authority for the substance use treatment
system to track the progress of treatment outcomes (Humphreys & McLellan, 2011) and the
weak, inconsistent efforts to improve those outcomes (Carroll,2014). In recent years, the
various methods used to train clinicians on how to use the 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 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).

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 in the most cost-effective way. CBT addresses specific targets of
patients that are poorly targeted by medications, engaging and occupational activities,
impact on self-esteem, coping skills and adaptive functioning. Considering the importance
of social relationships, occupational functioning, and emotional wellbeing 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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Acknowledgement
To my mentors, family and friends, I would like to thank them for their extended support
throughout.

Conflict of Interest
The author declared no potential conflicts of interest with respect to the research, authorship
and/or publication of this article.

How to cite this article: Kapadia S.V. (2020). The effectiveness of cognitive behavioral
therapy for substance use disorders and the challenges in treating this client group: a review.
International Journal of Indian Psychology, 8(4), 948-955. DIP:18.01.112/20200804,
DOI:10.25215/0804.112

ABBREVIATIONS

CBT - Cognitive Behavioral Therapy

SUD - Substance Use Disorders
APA - American Psychological Association
WHO - World Health Organization
MATCH - Matching Alcoholism Treatment to Client Heterogeneity
COMBINE- Combined Pharmacotherapies and Behavioral Interventions for Alcohol
Dependence
NIDA - National Institute of Drug Abuse
CM – Contingency Management
MBT – Mindfulness Based Therapy
DBT – Dialectical Behavior Therapy

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