Cognitive-Behavioral Therapy (CBT) is a structured, supportive approach to psychotherapy that focuses on problem-solving and skill-building, in order to help people live richer, more fulfilling lives. A basic assumption of CBT is that thoughts and beliefs play a major role in the way people feel (emotionally) and act (behaviorally). And then in a reciprocal fashion, emotions and behaviors tend to impact thoughts and beliefs. This explains why psychological processes tend to occur in cycles (both healthy and unhealthy).
Cognitive behavioral therapists are likely to have different styles and approaches in their own practice of CBT. For example, some focus first on thoughts and beliefs, while others focus first on behaviors or even emotions.
We find it extremely helpful to view CBT as consisting of five major components: (1) structure, (2) collaboration, (3) case conceptualization, (4) psychoeducation, and (5) structured techniques. In fact, we have observed that all cognitive-behavioral therapies place emphasis on these components, though to varying degrees. These components are briefly described in the following paragraphs.
Structure is best thought of as the process necessary for staying focused throughout a therapy session. Most therapists (and indeed many patients) have had the experience of being in the midst of a session wondering, “How is this relevant to the patient’s main problem?” We might even ponder, “Do I really need to know all of these details to help this patient?” CBT is, by design, a structured approach to helping people with addictions.
Structure also involves organizing sessions so that problems are defined and addressed. Our approach to CBT can be conducted as either an individual or group modality. When provided individually, we start each session by setting an agenda. This process can be either formal or relaxed, depending on the patient and other circumstances. For example, a patient who is generally well organized and in minimal distress might prefer sessions that are highly structured, while a patient who is less organized and/or in substantial distress might benefit from a more relaxed structure. Agenda setting is followed by a mood check, bridge from last session, prioritizing agenda items, and then problem-solving. In the group setting, group members share their names, addictions, status of their addictions, goals, and context in which the addiction takes place.
Collaboration is typically thought of as the therapeutic bond, alliance, or relationship. We understand that the ability to form alliances across a wide range of patients is essential to therapist effectiveness, and certain interpersonal skills enable such alliances to be established. We strongly advocate for therapists’ attention to their own interpersonal skills and apply them to the fullest extent possible when practicing CBT. While this may seem simple and straightforward, many therapists find it difficult to be warm and empathetic with patients that struggle with lapses and relapses.
We also view the processes of mutual goal-setting and goal achievement to be central to the collaborative relationship. Often times the process of agreeing on goals is more complex than one might expect. Many patients feel uncomfortable committing to goals they have failed to achieve in the past. Given the self-reinforcing nature of addictions, many patients also find it difficult to maintain motivation to change. From minute to minute, day to day, week to week, patients’ enthusiasm for achieving particular goals may wax and wane, corresponding with their moods, circumstances, and so forth. In order to maintain collaborative alliances with patients, it is vital for therapists to avoid being emotionally reactive to both patients’ goal-related failures and successes.
Case conceptualization involves the collection, integration, and corroboration of a patient’s thoughts, beliefs, schemas, triggers, predominant emotions and behaviors – with close attention paid to how these were developed. Essential contextual components of the case conceptualization include friends, family, and the community in which the individual lives. Other components include underlying medical, psychological, or psychiatric problems that might contribute to or exacerbate addictive behaviors. For example, whether the patient might be using drugs, alcohol, or addictive behaviors to self-medicate anxiety, depression, bipolar disorder, schizophrenia – or using opioids to treat physical pain. In order to develop accurate case conceptualizations, therapists must possess highly effective listening skills and the ability to accurately empathize with patients who often behave in self-defeating ways.
Psychoeducation involves the process of transmitting knowledge or skills: either directly, through modeling, or by the process of active listening. Sometimes it is appropriate for the therapist to explain CBT concepts or processes, while at other times doing so might be perceived by patients to be untimely or irrelevant. The determination of when it is most appropriate to teach CBT concepts is an essential part of the case conceptualization and collaborate therapeutic relationship.
Structured techniques are standardized activities designed to guide cognitive, behavioral, or affective changes. Just a few examples of CBT techniques are: the advantages-disadvantages analysis, daily thought record, and functional analysis. These and other structured techniques will be described in detail in a later chapter. As mentioned earlier, one of the most pervasive misconceptions of CBT is that structured activities (i.e., cookbook techniques) are at the heart of therapy. In fact, it is nearly impossible to choose the right structured techniques for patients without careful attention paid to the case conceptualization and the collaborative therapeutic relationship.