Cognitive behavioural therapy (CBT) for addiction

Cognitive behavioural therapy is a structured talking therapy. It’s based on the idea that your thoughts, feelings and behaviour are linked, and that changing one can change the others. According to the Royal College of Psychiatrists, CBT focuses on your current challenges rather than your past, and it teaches you to spot the links between what you think, what you do and how you feel.

Think about a social event where someone might not say hello to you. The thought ‘they don’t like me’ might lead to feeling rejected, which might lead to leaving early. The thought ‘they simply mustn’t have seen me’ leads somewhere perhaps more positive. CBT helps you notice that gap between event and reaction, and choose where to act.

In addiction treatment, the goal is the same. You and your therapist look at the thoughts and feelings that show up before you drink, use, gamble or act on a compulsion, and you build different responses to them.

Addiction is held in place by patterns. A craving leads to a thought, the thought leads to a feeling, and the feeling leads to a choice. CBT works on each part of that chain. A 2010 review of CBT for substance use disorders describes how CBT for addiction uses learning-based approaches to target behavioural patterns, motivational barriers, and skills people have not had the chance to develop.

For those living with substance dependencies, cravings feel automatic. But, the response to them doesn’t have to be. Once you can see the chain, you can change links in it.

CBT is structured, and it asks for effort. You and your therapist agree what to work on, you practise between sessions, and you come back to look at how it went. That practice between sessions is where most of the change happens. How much you put in shapes how much it can do for you.

CBT is not for everyone. People with complex mental health conditions or unresolved trauma sometimes find that CBT alone does not reach far enough. We talk about that openly at assessment, and if a different approach is the better fit, we say so.

There’s no single CBT exercise. Your therapist will draw on a set of techniques and use the ones that fit your situation. Below are some of the most common in addiction work.

• Thought records.
  You write down a thought, the situation that prompted it, the feeling it caused and the action that followed. Over time, patterns become visible that are hard to see in the moment.
• Identifying negative automatic thoughts.
  These are the thoughts that arrive without you choosing them, often quick and harsh. Examples are ‘I can’t cope’ or ‘nobody likes me’. Naming them takes some of their power away.
• Cognitive restructuring.
  You and your therapist look at the evidence for and against a thought, and find a more balanced way of seeing the same situation. The aim is accurate thinking, not necessarily ‘positive thinking’.
• Relapse rehearsal and role-play.
  You walk through situations that have led to using or drinking before, and practise different responses. Doing this out loud, with a therapist, makes it easier to do in real life.
• Graded task assignments.
  Larger goals are broken into smaller, achievable steps. This is useful early in recovery, when motivation and energy can be low.

Urge surfing.
A craving-management technique drawn from mindfulness-based relapse prevention. Rather than fighting a craving or giving in to it, you notice it, watch how it rises and falls, and let it pass. Cravings are temporary, and learning that in your body is part of what CBT teaches.

A relapse rarely starts at the moment of using. It starts further back, in a trigger that was not noticed, a thought that was not challenged, or a craving that was met alone. CBT is a widely used form of relapse prevention therapy because it works on all three points in that chain.

In a CBT-based relapse prevention plan, you and your therapist map your own triggers, name the early-warning thoughts that tend to show up before a craving, and build a set of responses you can use. Research published in BMJ open describes CBT as a promising treatment for building resilience and reducing relapse among people with substance use disorder.

Relapse is part of many recovery journeys, and CBT does not promise it won’t happen. but it does give you a way to recognise the moments before it, and a way to respond to one if it does. Studies on CBT and emotional regulation in opioid use show CBT can improve how people manage the feelings that drive both relapse and recovery.

CBT is part of the core therapeutic offer across Castle Health. How you take part in it depends on where you are in your recovery, where you live, and what kind of support you need around you while the work is going on.

• Residential: at Castle Craig in Scotland and Smarmore Castle in Ireland, CBT runs alongside medical detox, group therapy and the wider treatment programme. This is the right setting when the home environment is part of the trigger pattern, when detox is needed first, or when stepping out of daily life makes the work possible.
• Outpatient: our outpatient treatment suits people whose lives can carry the work alongside it. Sessions are scheduled around work, family or study. This is often the right next step after a residential stay.
• Online: online CBT has good evidence for mild-to-moderate addictions and for people who would otherwise not be able to access treatment. It’s less suitable when medical detox is needed first, or when the home environment is part of what triggers use.

The best setting is the one that gives the work the best chance to be successful. We talk through all three at assessment and tell you honestly which we think fits.

CBT on its own isn’t often the whole answer. Across the Castle Health brands, we use it alongside medically supervised detox, group therapy, family therapy and structured aftercare. 12 Step programmes have a different weight at different services; at Castle Craig for example, it’s integrated into the programme. Each part does something different, and CBT often becomes more effective when the other parts are in place.

For people whose challenges centre on intense emotions, self-harm urges or emotion regulation, we sometimes recommend dialectical behavioural therapy alongside or instead of CBT.

Castle Health does not stop at discharge. Continuing Care, provided by our partner services after a residential stay, supports the work you have done. Recovery looks different at six months than at six years, and we plan for that.

The first step is a free, confidential call with one of our admissions case managers. They will ask about your situation, request a recent medical summary from your GP, and discuss what kind of support fits. The pre-admission process usually takes a few days. If a residential stay looks like the right fit, we move to a clinical assessment, and from there we build a treatment plan with you.

If addiction treatment with one of our residential addiction treatment programmes looks like the right fit, we move to an assessment with a clinician. From there, we build a treatment plan with you, and CBT will usually be part of it.

• Ask what they are working on, and listen. You do not need to know the technique to take an interest.
• Make space for the homework. CBT involves practice between sessions, and a quiet half hour is sometimes more useful than a long conversation.
• Look after yourself. Family therapy and support for loved ones are part of what we offer at Castle Health, and using that support is not a sign of failure.

• Coaching from the sidelines. Pointing out the thoughts you think they should challenge often backfires. The work has to belong to them.
• Treating CBT as a fix. CBT is part of a longer process and setbacks are part of recovery.

Your first session is usually an assessment. After that, sessions follow a structure: reviewing the homework from the week before, working on a focused issue together, and agreeing what to practise before the next session. A typical session is around 50 minutes. CBT for addiction is collaborative work, and your therapist will check in often to make sure the focus still feels right.

CBT focuses on changing the thought patterns that drive behaviour. DBT, or dialectical behavioural therapy, was originally developed for borderline personality disorder and adds emotion regulation, distress tolerance and mindfulness skills. DBT is often the better fit when intense emotions, self-harm urges or relationship difficulties complicate the picture. Many people in addiction treatment use elements of both.

A short course of CBT is six to 20 sessions, though CBT for addiction often runs alongside a longer treatment programme. People often notice changes in the first few weeks, starting with their ability to spot thought patterns. Deeper behavioural change takes longer, and the practice you keep up after treatment ends is part of what makes it last.

Yes. Online CBT can be effective for some people, particularly with mild-to-moderate problems and those unable to attend in person. It’s sometimes the only realistic way for people to access treatment. It’s less suitable when medical detox is needed first, when the home environment is part of what triggers use, or when face-to-face contact would make a clinical difference. We will tell you honestly at assessment whether online is the right place to start.