If so helpful, why is CBT for addictions not more easily accessible in public mental health care? One reason may be the ubiquitous problem of the dearth of therapists trained in comprehensive CBT for addictions. Another reason may be found in the remnants of the long-standing debate over whether addiction is a moral failure or a disease with no cure, making total abstinence imperative. The opposing argument, consistent with the more recent controlled drinking or harm reduction approach (Inciardi & Harrisons, 2000), posits that any addiction is a complex mental health issue, rather than a disease one either has or does not have. Further, addiction is best understood as occurring on a continuum where relapse is expected but recovery possible. For some types of addiction, such as eating or shopping, abstinence is not even possible.¹ The harm reduction reasoning thus stands in contrast to the philosophy of Alcoholics Anonymous (AA), which advocates lifelong abstinence.

AA is the largest of several mutual help groups. These groups differ noticeably from professional-led treatment groups. AA groups rely primarily on the model of those who have recovered from an addiction helping others. AA supports the 12-step approach (the first step acknowledges one’s powerlessness over the addiction; subsequent steps focus on developing a relationship with a higher power and committing to the fellowship of helping others recover). Developed before the harm reduction paradigm, the 12-step AA program has for decades been the go-to place and authority, to the point of some communities offering no alternative. Perhaps this situation alleviated community mental health programs of the pressure to develop services for addictions. Senior psychologists today share my graduate school training experience where we were encouraged to simply refer any client with an addiction problem to the local AA group.

Unquestionably, AA, along with Gamblers Anonymous, Sexaholics Anonymous, Overeaters Anonymous, and Shopaholics Anonymous, and similar 12-step programs continue to help people with addictions around the world. The possible limitations of 12-step programs are, however, increasingly noticed. Most importantly, peer counselors in 12-step are not trained in mental health, which may be one of the reasons why several additional problems facing those with addictions go unrecognized and untreated. Many, if not most, people with addictions have additional psychiatric issues such as anxiety, depression, psychosis, and personality disorders (Swendsen et al., 2010). The addiction to substances or other activities, such as gambling or pornography, thus co-occurs with another mental health problem. Without attention to co-occurring problems, recovery from the addiction can be problematic. For example, people with anxiety disorders often use alcohol as a way of calming themselves before going into situations that are likely to trigger their anxiety. Because taking alcohol as a form of self-medication works to a point, it will be challenging to overcome an addiction without also being offered specialized help for anxiety.

Despite endorsing the effectiveness of CBT as a best practice approach to addictions, there is a persistent problem with high relapse rates past the first year of treatment. In a review article on understanding and preventing relapse, relapse rates for a range of addictions including substances, food, and smoking ranged from 50% to 90% (Brownell, Marlatt, Lichtenstein, & Wilson, 1986). However, there is a lack of agreement on what defines a relapse versus a lapse for various addictions. Moreover, relapse rates depend on characteristics of the addiction, individual variables related to a person’s environment, culture, and physiology, and the type of treatment (e.g., emphasizing coping skills and motivation especially help to prevent relapse). The authors caution that the percentages for relapse may be inflated given that the majority of people with an addiction recover through their own efforts (and we don’t know much about their relapse rates) with only the more severe cases receiving formal treatment.

Despite lack of exact knowledge about relapse rates, the need for improved treatment and relapse prevention remains. The end of the chapter will return to literature on ways to augment the more problem-focused CBT group for addiction with a paramount focus on strengthening the addicted person’s identity and self-definition. Mindfulness-based and spiritually oriented approaches to relapse prevention will be discussed as ways to support people in developing a new understanding of their addiction and a larger sense of life purpose.

Although this chapter is focused on adults, it is important to note that systematic reviews on the effectiveness of CBT and CBGT for adolescent substance use, including marijuana, indicate this as a well-established and responsible choice, although not superior to other treatment models including family therapy (Diamond et al., 2002; Waldron & Turner, 2008).

The Diagnoses of Substance-Related and Addictive Disorders

In the DSM-5 (American Psychiatric Association [APA], 2013), the Substance-Related Disorders encompass 10 separate classes of drugs, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, and anxiolytics, as well as stimulants such as cocaine, tobacco, and other substances. All drugs taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of addictive behaviors. Although the mechanisms work differently, all drugs produce feelings of pleasure, often referred to as “a high.” Individuals with lower levels of self-control may be especially predisposed to develop substance-related disorders.

In addition to Substance-Related Disorders, the DSM-5 has added Addictive Disorders. The nonsubstance-related disorders, or Addictive Disorders, are presently limited to Gambling Disorder, which has a distinct set of diagnostic criteria and activates reward systems similar to drugs. The DSM-5 recognizes other kinds of behavioral addictions such as Internet gaming, sex addiction, exercise, overeating, and shopping addictions, although these are not yet formal diagnoses given a lack of evidence to establish diagnostic criteria. Substance-Related Disorders are further divided into Substance Use Disorders or Substance-Induced Disorders. For example, the alcohol-related disorders include separate diagnoses for Alcohol Use Disorder, Alcohol Intoxication, and Other Alcohol-Induced Disorders. The latter captures how an anxiety or mood disorder can be induced by excessive alcohol use.

The essential feature of all Substance Use Disorders (I will not review the Substance-Induced Disorders but refer the reader to the DSM-5) is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. The DSM-5 Substance Use Disorder diagnosis focuses on an unhealthy pattern of use where the individual takes the substance in larger amounts or over a longer period than was originally intended (Criterion 1); expresses a desire to cut down or reports many unsuccessful attempts to decrease (Criterion 2); spends a great deal of time obtaining the substance, using it, or recovering from its effects (Criterion 3); and craves the substance (Criterion 4). The second group of criteria (Criteria 5–7) includes social impairment, such as failing to fulfill major role obligations at work, at school, or at home; continuing to use despite recurrent social or interpersonal problems; or withdrawing from friends, family, and interest and hobbies. The third group of criteria (Criteria 8–9) involves the risks associated with continued use, such as compromised physical safety and physical and psychological problems. Lastly, the final group of DSM-5 criteria (Criteria 10–11) is pharmacological and involves problems with building tolerance to the substance or problems with withdrawal. Substance use disorders can be specified as mild (two to three symptoms), moderate (four to five symptoms), or severe (six or more symptoms), and neither tolerance nor withdrawal is required for a diagnosis.² Other specifiers such as in early remission or on maintenance therapy are also available.

Prevalence rates for Alcohol Use Disorder in the United States is 4.6% among 12–17-year-olds and 8.5% among adults aged 18 and older. Rates are greater among men (12.4%) than women (4.9%). For Cannabis Use Disorder, the 12-month prevalence is 3.4% for 12- to 17-year-olds and 1.5% among adults aged 18 and older. Prevalence rates for other substances can be found in the DSM-5 (APA, 2013).

CBT for Addictions

The behavioral and cognitive parts of CBT have each, separately, contributed to the larger framework within which the majority of clinicians offer their integrated CBT for addictions. Behavioral approaches are influenced by both classical conditioning (Pavlovian) and operant conditioning (Skinnerian; O’Brien, Childress, McLellan, & Ehrman, 1992). Classical behavioral theory operates under the assumption that learned behaviors can become unlearned. One example of a behavioral technique for the treatment of substance abuse is counterconditioning, sometimes referred to as aversive conditioning. For example, someone who has become conditioned to reach for the whiskey bottle and pour into a glass upon returning home from work can engage in a counterconditioning behavioral program. This could involve taking a medication such as Antabuse (disulfiram), which induces vomiting at the first sip of whiskey. Over time, the taste, or even smell of, whiskey no longer becomes paired with feelings of pleasure and relaxation but instead with unpleasant feelings of nausea and vomiting.³

Operant conditioning involves promoting behaviors that lead to lesser drug abuse or abstinence. Such behaviors can be positively reinforced and strengthened. For example, a voucher program for purchase of goods was used in the treatment of cocaine users (Silverman et al., 1998). The value of the voucher increased as the number of consecutive cocaine-free urine samples increased. Other forms of contingency management include extensions of employment contracts, offers of subsidized housing, and any form of reward that is meaningful to the person. Behavioral contracts with family members can be helpful in influencing behaviors (e.g., “If I attend my treatment sessions regularly, my husband and I will celebrate by going on a weekend trip; if I miss more than 25% of sessions, my husband has the right to delay any talks about a weekend trip for another 6 months”).

Other behavioral techniques focus on self-control by developing new coping skills. These include how to assertively refuse offers of drinks, how to slow down rate of drinking, or how to develop an engaging interest to immediately turn to when the craving is strong. Not that any of this is easy, but clients in groups inspire each other to consider new ways of coping so as not to give in to their cravings. A 65-year-old woman in our depression group who had a co-occurring serious gambling addiction became able to call her daughter, or grandchild, as a way of countering her urge to get in her car and head for the local casino. The group supported her with how to disclose her gambling problem to her daughter. Fortunately, the daughter took it well and became more than willing to help.

Cognitive approaches to substance use and other addictions assume that, similar to depression, unhelpful, untrue beliefs play a significant role in both the onset and maintenance of an addiction (Beck, Wright, Newman, & Liese, 1993). Our understanding and treatment of addiction is greatly enhanced by awareness of the many cognitive variables mediating between the stimulus (opportunity to engage in the addiction) and the behavior (actual engagement with the addiction).

Cognitive theory emphasizes three main types of thoughts that increase the likelihood of choosing to engage with an addiction: outcome expectancies, negative automatic thoughts, and facilitating thoughts (Wenzel, Liese, Beck, & Friedman-Wheeler, 2012). Outcome expectancies are highly related to relapse and involve positive anticipatory and relief-oriented expectancies. Positive anticipatory expectancies involve expecting an increase in well-being (e.g., “I can’t wait to have some drinks and have fun after a tough week at work” or “My new clothes will make it easier to feel confident in all the meetings coming up next week”). Relief-oriented expectancies involve expecting reduced discomfort and distress by engaging in the addiction (e.g., “With a few drinks, I’ll get through this family event better” or “Playing a few rounds of Black Jack at the casino will be a nice break from my ex-wife harassing me again for financial support”). The more traditional negative automatic thoughts, which are common in depression, also figure prominently in people with addictions who experience them as an ongoing “commentary” exerting a powerful influence on the likelihood of giving in to an addiction behavior. Examples may be “I deserve a drink,” “It’s Friday, time to relax and party,” or “I see a sale sign in my favorite clothing store.” Lastly, facilitating thoughts play a powerful role in giving permission to engage with the addiction and are characterized by minimizing the harmful effects and denying the extent of one’s problem. Examples may be “After my divorce is finalized, I’ll not need to gamble anymore” or “Everybody will be drinking at the wedding, so what’s the big deal if I, too, enjoy myself?”

Although the ultimate outcome measure for addiction treatment is the degree to which people are able to reduce their addictive behaviors measures of the thoughts that promote an addiction are also helpful indicators. Chapter 6 recommended such specific outcome measures for addiction, the Drinking Expectancy Questionnaire (DEQ; Young, Oei, & Crook, 1991).

CBGT for Addictions

CBGT for addictions comes in various flexible forms. There are groups targeting primarily the addiction and groups targeting both the addiction and co-occurring mental health issues. We will first look at the latter before reviewing the components comprising CBGT primarily for addictions.

CBGT protocols for addictions

A number of core components comprise the protocols clinicians use in their CBT groups for substance use. There seems, however, to be only a few protocols specifically developed for a group setting. The group protocol by Monti, Kadden, Rohsenow, Cooney, and Abrams (2002) is often used as a basic framework with its emphasis on identification of high-risk situations, coping skills, challenging unhelpful thinking, problem solving, and relapse prevention. A recent CBGT manual, Group Cognitive Therapy for Addictions, for different kinds of addiction emphasizes psychoeducation, coping skills, and cognitive restructuring. In this protocol, each session begins with a review of the Cognitive Model of Addiction as a springboard for discussion about situational triggers, thoughts, and lapses (Wenzel et al., 2012) (Figure 17.1). This manual is based on an open group where new members enter and leave on a continuous basis.