Can Cognitive Behavioral Therapy Treat Addiction?

Cognitive Behavioral Therapy (CBT) has been used by therapists to encourage change in thought patterns as a way for patients to work through any problems they are experiencing. The two articles reviewed discuss depression, substance abuse, and CBT-related therapies. Substance abuse and depression can go hand in hand. Another condition that is common with substance abuse is post-traumatic stress disorder (PTSD). The two approaches are behavioral activation and integrated cognitive-behavioral therapy.

The traditional CBT approach focuses on the development of disorder-specific, manual-based treatment protocols to achieve cognitive and behavioral change.

These interventions derive from assumptions based on the cognitive mediational model, i.e., cognitive appraisal of events can affect response to those events, and by modifying the content of these appraisals, desired behavior change may be affected. In the case of depression, negative or dysfunctional thinking in reaction to specific situations increases the likelihood of depressive symptoms; correspondingly, in the case of addiction, thoughts about substance use may give rise to use (Vujanovic et.

al, 2017).

Depression and Behavioral Avoidance Research suggests that there may be a common set of core vulnerabilities contributing to the development of anxiety, depressive, and related “emotional” disorders (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014). Individuals with depression tend to isolate themselves from social situations as a way of coping with negative emotions. Isolation seems like a quick fix but exacerbates negative feelings. According to this model, avoidance reduces opportunities for environmental reinforcement. Treatment, therefore, involves increasing patients’ awareness of avoidance patterns and replacing them with approach behaviors, which then creates opportunities for positive reinforcement (Dimidjian et al.

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, 2006).

The case study involved a female university student named “Gina” seeking treatment for depression at her university’s counseling center. The student described previous bouts of depression that were more severe than her current symptoms. Gina explained that her current symptoms were intrusive and affecting her daily life. She had begun to avoid many activities in her life. It was determined during an interview and testing that Gina fit the benchmarks for having a major depressive disorder.

According to Farchione, Boswell, and Wilner (2017), as often occurs with depression and other emotional disorders, Gina was becoming increasingly avoidant in her life. She was wiofthdrawing from healthy, value-based behaviors, such as socializing with her friends and attending class. Further, she exhibited an increase in depressive behaviors, including talking excessively about her depression with others, frequently listening to sad music, excessively eating unhealthy “comfort” foods (which contributed to the patient’s recent weight gain), and procrastinating on her academic work.depression

Emotional avoidance is a type of behavior that helps to lessen negative emotions. Avoiding what seems hard feels better temporarily. Repeating these behaviors leads to increased stress and a greater likelihood of experiencing a deeper depression. The goal for treatment for Gina was to change her pattern of avoidant behavior. She began psychotherapy with her therapist utilizing a method for treating emotional problems; The United Protocol for Transdiagnostic Treatment of Emotional Disorders (UP).

Her course of treatment involved 14, 50-min weekly sessions of individual psychotherapy. The UP targets such maladaptive emotion regulation strategies (i.e., attempts to avoid or dampen the intensity of uncomfortable emotions) and was designed specifically to help patients reverse this pattern through confrontation and experience of uncomfortable emotions to learn how to respond to their emotions in more adaptive ways (Farchione, et. al 2017).

There are eight treatment modules ranging from increasing motivation to preventing relapses. Behavioral action is not a definite part of the UP model, it works well because the goal of, BA is to decrease avoidance behaviors and use positive approaches when confronted with destructive depression behaviors. Gina’s sessions began with goal setting through questionnaires, education, and identifying her emotional behaviors. Once her emotional behaviors were identified, Gina and her therapist worked on identifying when she was engaging in avoidant behavior. Encouraging more positive responses to situations helped Gina reduce negative reactions to her emotions.

This quantitative study found that including BA along with using a single method of therapy like cognitive behavioral therapy across many disorders helps to change behavior. The authors were unable to differentiate the influence of BA from the other methods used in the study. Gina’s improvements were a result of increased positive support of healthy behaviors and lessening escapism actions.

An example from the case states that; Gina reported that she was avoiding going out with friends because she felt she would not enjoy the experience and that it would ultimately make her feel more depressed. Over time, Gina began to recognize inconsistencies between what she anticipated happening in these situations and what she experienced. As a result, Gina came to think about these situations in a more flexible, helpful, and often positive way (Farchione, et. al 2017).

Another study looks at Integrated cognitive-behavioral therapy (ICBT) for post-traumatic stress disorder (PTSD) and substance use. This study was both quantitative and qualitative due to urine screens and other measures of alcohol use that were collected and by the measure of PTSD being self-reported by the individual This study was a three-group, repeated-measure, parallel-group, randomized controlled trial design. 221 individuals participated in the study with diagnoses of PTSD and substance use disorder. Individuals were invited to join the study from December 2010 to January 2013. “Members were put into three groups (a) ICBT plus standard care (SC: intensive out-patient programming and other services as usual); (b) an individual addiction counseling (IAC)plus SC; or (c) SC only. To enhance the external validity of findings, study therapists were employees of the agencies that participated in the study. The study was conducted with seven addiction treatment agencies in Vermont and New Hampshire, United States, all serving a large proportion of uninsured or publicly funded patients” (McGovern, et. al 2015).

The measures used for PTSD were a self-identifying worksheet given to participants and a clinical interview for PTSD given by a therapist. Already having a PTSD diagnosis was a requirement for the study. (In regards to PTSD and other factors, childhood sexual assault and adult physical assault were common (McGovern, et. al 2015). Participants were predominantly Caucasian, and female, and in were between 30-35 years old. For the substance use, participants’ drug screen data was gathered and participants were given measures to determine the severity of their drug use. Clinicians planned to evaluate the gravity of the client’s usage at three and six months.

The findings show that ICBT was more successful than IAC in reducing drug use. ICBT demonstrated no clear advantage over the other treatments at 6 months on PTSD symptom severity. However, ICBT demonstrated superior outcomes on drug use, as measured by positive urine drug screens and frequency of reported drug use. Consistent with prior studies of ICBT, patient acceptance (therapy continuation) and ease of therapist delivery were favorable. Study limitations, particularly the absence of a longer-term follow-up, attenuate interpretation (McGovern, et.al 2015).

The findings from both studies show that integrated CBT is effective in treating depression and substance use in individuals with post-traumatic stress disorder. Integrated CBT would help Nic in dealing with his addiction. Due to Nic also having a hard time dealing with his parent’s divorce and subsequent remarriages, a diagnosis of PTSD would not be uncommon. Having Nic in treatment for PSTD and substance abuse would benefit him greatly. It would have allowed him to work on both issues simultaneously. Having Nic exposed to behavioral activation strategies possibly when he was in high school could have lessened the severity of his depression. By having Nic explore and identify his avoidance behaviors, he could have learned positive ways to cope with his feelings.

If Nic had the appropriate tools to deal with his depression, he may not have had to turn to drugs and alcohol to self-medicate. Behavioral Activation could also have helped Nic to process and figure out the underlying cause of his needing to have a perfect external image. Using behavioral activation with other cognitive-behavioral treatment approaches would give Nic more tools at his disposal to deal with negative emotions and not resort to short-term solutions like drugs and alcohol. Short-term solutions led to trauma for all involved. Interventions like ICBT and BA allow individuals to get to the root of their problems and provide solutions and a more positive outlook.

References

1. Farchione, T. J., Wilner, J.G., & Boswell, J.F. (2017). Behavioral Activation Strategies for Major Depression in Transdiagnostic Cognitive-Behavioral Therapy: An Evidence-Based Case Study. Psychotherapy, 54, 225-230. http://dx.doi.org/10.1037/pst0000121
2. McGovern, M.P., Lambert-Harris, C., Xie, H., Meiser, A., McLeman, B., & Saunders, E. (2015).
3. A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder. Addiction,110,1194-1204. Doi:10.1111/add.12943
4. Vujanovic, A.A., Meyer, T.D., Heads, A.M., Stotts. A.L., Villareal, Y.R., & Schmitz, J.M. (2017). Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches. The American Journal of Drug and Alcohol Abuse, 43, 402-415. http://dx.doi.org/10.1080/00952990.2016.1199697