Cognitive Behavioral Therapy and Addiction Counseling

Cognitive behavioral therapy (CBT) is a form of therapy that combines behaviorism concepts such as operant and classical conditioning with cognitive therapy (Magill et al., 2019). CBT is useful when treating addictions, as it provides the client with cognitive tools they can use to regulate their own behavior better while also enhancing the client’s self-awareness regarding the emotional and cognitive triggers that encourage drug use (Bador & Kerekes, 2020). The following provides an overview of CBT as an addiction intervention, including a discussion of behaviorist techniques such as operant conditioning, classical conditioning, positive and negative reinforcement, as well as cognitive concepts such as defense mechanisms and cognitive distortions.
Our thoughts are influenced by our behaviors, creating a repetitive cycle of behaviors, emotions, and thoughts. Over time, this establishes a pattern of normative behaviors that are often repeated (Magill et al., 2019). For instance, someone experiencing sadness or depression might choose to eat a bucket of ice cream, which is an example of an emotion (sadness) directly contributing to a specific behavior (eating ice cream). However, after consuming the ice cream, one may have the cognitive awareness that this is an unhealthy behavior, which in turn contributes to their depression. The negative thoughts that stem from the behavior bring out negative emotions, perpetuating a cycle of dysfunctional behavior.
Breaking the cycle of behaviors, thoughts, and emotions that we have normalized over time requires conscious effort and self-reflection. The first step is awareness – recognizing the repetitive patterns that hinder our progress. This awareness allows us to question and challenge the validity of these patterns in our lives.

Thus, CBT may include behaviorist techniques such as operant and classical conditioning to change behavioral patterns. Operant conditioning involves the application of reinforcements both positive and negative to influence behavior, while classical conditioning involves pairing two stimuli ( a thing that causes a thing) together. The goal is to break the cycle of negative behaviors, thoughts, and emotions by replacing it with positive alternatives (Magill et al., 2019).
Operant Conditioning Techniques
Operational Conditioning focuses on how behaviors are learned through the consequences they produce. Positive reinforcement adds to the behavior and negative reinforcements take away or remove from the negative behavior. Classical conditioning is based on associations in which a stimuli(a thing that causes a thing) causes an unconditioned response. An unconditioned response occurs automatically and naturally a conditioned response is not natural and is learned behavior. Understanding how a client is responding is crucial as it allows therapist to identify and modify conditioned responses that are contributing to the maladaptive behavior.
A positive reinforcement is the introduction of an adverse circumstance, while a negative reinforcement involves the removal of a favorable circumstance. For instance, giving a child an extra hour to play on their Xbox for completing chores is a positive reinforcer, while removing time from playingon the Xbox completing chores is a negative reinforcement; with negative reinforcement you are removing something desirable.
The challenge with those who have addiction issues is that their current behavior is already reinforced with established behavioral patterns (Bador & Kerekes, 2020). Breaking this cycle requires addressing not only the physical aspect of addiction but also the underlying cognitive and emotional patterns that contribute to its continuation.
Addiction produces withdrawal symptoms, from a cognitive perspective, withdrawal symptoms negatively impact one’s emotions. Because the behavior of consuming more drugs has already been reinforced, the most likely behavior that will follow feelings of withdrawal is the intake of more drugs contributing to cyclical drug use.
Drug use becomes a defense mechanism against these unpleasant thoughts and feelings, and the goal of taking drugs is to remove these adverse feelings. They act as a shield, allowing individuals to cope with stressful situations or conflicts. However, defense mechanisms can also become repetitive cognitive and emotional patterns that influence our behaviors. When working with clients, it is essential to recognize and address these defense mechanisms in order to facilitate meaningful change. By breaking the cycle of behaviors, thoughts, and emotions that clients have normalized over time, therapists can help them develop healthier coping strategies and promote personal growth.
As an example, counseling a patient experiencing addiction might reveal that the client’s drug use originates from feelings of boredom and social isolation, which in turn trigger feelings of loneliness and low self-esteem. Compulsive drug use may also be the result of cognitive distortions, which are perceptions of reality that are often untrue or incomplete (Sripada, 2022). For instance, one might assume that continued drug use is not harmful or that they can fully manage their addiction without any adverse effects. These are examples of cognitive distortions because they are beliefs not grounded in reality. At the same time, they might believe that they are immune to the negative effects of continued drug use while also feeling that drugs simply make them feel better whenever they experience negative feelings.
The counselor’s goal, therefore, would be to find ways to disrupt this pattern of thoughts, emotions, and behavior. This could occur at several points, if the client’s feelings can be redirected to a more positive state, for instance, then the client might feel less compelled to take drugs as a way to subvert negative feelings. However, if this is unlikely due to the physical symptoms of withdrawal, then finding alternative behaviors to manage unpleasant emotions would be more appropriate. In this instance, suggesting vigorous exercise whenever one feels unpleasant emotions would be a viable alternative, as the exercise would ideally provide an additional reward once completed.
The threat of punishments can also contribute to breaking the cycle, these would not be punishments imposed by the counselor but rather punishing circumstances that can occur in real life due to drug addiction. For instance, the loss of a job or relationship would be negative punishments associated with continued drug use, while the imposition of legal fines or incarceration would be positive punishments to consider.

Classical Conditioning Techniques
Classical conditioning involves pairing one stimulus with another. For those who struggle with addiction, the addictive behavior may be already paired with a common activity, such as drinking alcohol while sitting on the couch after a long day of work. Because this might be a daily activity that lasts for several hours, the paired association between relaxing and drinking alcohol results in excessive alcohol intake. The action of sitting down on the couch immediately compels thoughts of alcohol. Over time, the act of going to the refrigerator to get a beer becomes automatic, without any cognitive effort or reasoning taking place.
Classical conditioning can be utilized in CBT by pairing stimuli with healthier behaviors. If the client uses drugs whenever they are feeling anxious, for instance, suggesting that they go for a walk instead would be a way to introduce an alternative behavior. This would need to be a repeatable behavior, but it would become increasingly habitual over time. The eventual goal would be for the positive behavior to replace the negative behavior entirely. When feeling anxious, the client will want to go for a walk instead of using drugs.
In order to help clients identify cognitive distortions, it is essential to first establish a safe and trusting therapeutic environment. Once this foundation is set, the therapist can then guide the client in exploring their thoughts, emotions, and behaviors in a non-judgmental manner. By encouraging self-reflection and promoting awareness, the therapist can assist the client in recognizing any cognitive distortions that may be present. This may involve challenging irrational beliefs or negative self-talk, and highlighting any patterns of thinking that are not based on reality or evidence. Once the client is consciously aware of these distortions, they can proactively take steps to alter their negative thought patterns. If they recognize that a negative thought about themselves is a manifestation of an anxious emotional state and not an accurate reflection of reality, they will have more control over their subsequent behaviors.
CBT is intended to provide clients with more control over their impulsive behaviors by making them more aware of how their thoughts and emotions influence their behavior. The counselor then provides the client with various strategies they can use to alter their behavior. If drugs are used as a coping mechanism, for example, the counselor should provide the client with alternative coping mechanisms, like exercise or social activity, to replace harmful behaviors. The process will most likely take time, and there are often additional factors to consider, such as the type and severity of the addiction overall (Magill et al., 2019). CBT is also not guaranteed to work for everyone, so alternative therapies should be considered if CBT is ineffective. Nevertheless, CBT has shown promise when treating addiction as it can disrupt the cycle of negative thoughts and emotions that often compel addictive behaviors.
References
Bador, K., & Kerekes, N. (2020). Evaluation of an integrated intensive cognitive behavioral therapy treatment within addiction care. The Journal of Behavioral Health Services & Research, 47(1), 102–112. https://doi.org/10.1007/s11414-019-09657-5
Ciccarelli, S. K., & White, J. N. (2020). Psychology (6th ed.). Pearson.
Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M., Tonigan, J. S., & Carroll, K. (2019). A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition. Journal of Consulting and Clinical Psychology, 87(12), Article 1093. https://doi.org/10.1037/ccp0000447
Sripada, C. (2022). Impaired control in addiction involves cognitive distortions and unreliable self-control, not compulsive desires and overwhelmed self-control. Behavioural Brain Research, 418, Article 113639. https://doi.org/10.1016/j.bbr.2021.113639