According to the 2019 National Survey on Drug Use and Health (NSDUH), 14.5 million people aged 12 or older have an alcohol use disorder (AUD), also known as alcoholism.1 Engaging in harmful drinking behaviors not only can have social consequences, such as car accidents or violence, but the health costs can also be severe, ranging from blackouts and falls to liver damage, alcohol poisoning, and cancer, and death. Alcohol is the third leading cause of preventable death in the United States, trailing behind tobacco and poor diet and physical inactivity. 2,3
Fortunately, effective treatment is available for alcohol use disorder. Cognitive behavior therapy (CBT) is one of the most popular psychotherapy approaches for treating alcohol use disorder. This article will explain CBT in relation to alcohol use disorder, its effectiveness and what to expect during a counseling session.
What is CBT?
Cognitive-behavioral therapy (CBT) is widely considered the preferred psychotherapy treatment modality for alcohol use disorder.4,5,6 CBT, also called talk therapy, combines therapeutic techniques from both aspects of cognition and behavior to help individuals recognize and resolve distorted patterns of thought, which often influence their behavior, leading to their alcohol use disorder.5,7,8 The key assumption of the CBT model is that your thoughts, emotions and behaviors are all connected. For example, if you think poorly about your yourself then you tend to feel alone and depressed which can lead you to drink alcohol to numb your internal pain. CBT is a problem focused therapy approach meaning that the goal is to find healthy solutions to your current problems rather than focusing on the underlying reasons of why you are having these problems.4,8
CBT was first discovered in the 1960s when psychoanalyst Aaron Beck detected a pattern of cognitive distortions amongst his patients with depression.8 He noticed that many of his patients expressed patterns of irrational and exaggerated thoughts, which he observed were attributed to cognitive deficiencies.8 With these findings, Beck began to view depression as a cognitive disorder rather than a mood disorder. Ultimately, his research led to the development of cognitive theory, which is now known as CBT.8
The CBT Model
The CBT model is used as a framework to gain an understanding of a person’s problematic behavior.9 Its core principles are centered on a person’s cognitions, or beliefs, about themselves, the world, and those around them. The 3 levels of cognition in the CBT model are:8,10,11
- Core beliefs, or schemas: Core beliefs are underlying beliefs, or schemas, that a person holds about oneself, others, and the world. Typically, they are influenced by early childhood experiences and viewed as factual and absolute. When triggered, negative core beliefs often lead to cognitive distortions and automatic thoughts.
- Cognitive distortions, or dysfunctional beliefs: Cognitive distortions are defined as the irrational misbeliefs that people maintain. These assumptions are likely unreasonable and flawed. For example, you might feel that asking for help is a sign of weakness.
- Automatic thoughts, also called negative automatic thoughts (NATs): Automatic thoughts, specifically negative automatic thoughts, are those that are unintentionally brought on in certain situations. These thoughts intensify problematic behavior. For instance, if you have an AUD, negative automatic thoughts may cause you to underestimate your ability to cope with a difficult situation and likely drive you to engage in problem drinking.
Based on the relationship among core beliefs, cognitive distortions, and automatic thoughts, studies have shown that problematic behavior can be changed through cognitive restructuring.9 In other words, you can modify unhealthy behaviors by changing unhealthy thought patterns.12
During CBT, your therapist helps you classify your problems into basic categories, such as:11
- Physical feelings.
Each of these categories can directly impact one another.11 In other words, your thoughts and feelings about a specific experience may influence how you emotionally interpret it and actively respond to it.11 During behavioral therapy, you and your therapist will be able to identify and reconstruct unhealthy patterns in these areas.9,10
How Do I Start Treatment?
How Does Behavioral Therapy Work?
Behavioral therapy is based on the concept that human behavior can be learned, unlearned, and relearned in a new way.4 The first step of behavioral therapy is to determine whether a specific behavioral pattern has a negative impact on your life.4 If it does, the second step would involve you working to change the problematic behaviors associated with the identified pattern of thoughts and feelings.4
Used in tandem with cognitive therapy, which helps you gain more control over your thoughts, behavioral therapy aims to minimize and replace problematic behaviors through skills training.13 For treating alcohol use disorders, behavioral therapy might involve learning how to manage cravings and adopt healthier coping strategies.5
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How Long Is CBT?
Unlike other psychotherapies that may have a broader focus, the length of CBT treatment is typically brief and can be effectively carried out over 5-20 sessions.11 However, treatment time varies from person to person. Factors to consider regarding the duration of treatment include:4,10,11,14
- Nature of the problem or disorder.
- Severity and complexity of the problem.
- Progression and comfort with the treatment plan.
How is CBT Different from Other Therapies?
The following attributes set CBT apart from other psychotherapies:4,11,12
- Accessibility, with many mental health care professionals being trained in CBT.
- Self-driven, aiming to help you identify and resolve your own problems.
- Present-day focused, concerned with current thoughts and actions instead of past issues.
- Problem-oriented, structured to focus on specific problems and set practical goals.
- Collaborative, in which you and your therapist work together to resolve your current issues.
Cognitive behavioral therapy is also different from other therapies in that it uses a variety of interventions in its approach, such as:11,13
- Exposure therapy.
- Motivational interventions.
- Contingency management.
- Relaxation and stress reduction.
- Relapse prevention.
How Is CBT Used in Therapy?
CBT can be carried out in solo sessions or in group sessions with other individuals who are struggling with similar issues, such as an AUD.11 Solo sessions may last for about 30-60 minutes and can take place either weekly or semi-weekly.11 During your first CBT session, you and your therapist may go over background information and discuss whether CBT is the right course of treatment for you.11
For example, if you are receiving CBT treatment for an AUD, typical questions might center around:10,11
- Work, family, and social life.
- Alcohol and other drug use.
- Internal and external triggers.
- Intensity and frequency of cravings.
- Former treatments.
- Goals for therapy.
- Alternative treatment options if CBT is not an appropriate option.
If you and your therapist decide to move forward with CBT, initial sessions may be spent working together to deconstruct problems that may be contributing to your alcohol use disorder.4, 11 During this time, you may be asked to use a journal to keep track of your thoughts, feelings, and behaviors.4,11
You and your therapist will work together to identify any irrational or obstructive patterns that are contributing to your alcohol use and develop strategies to resolve them.5,11 As treatment continues, sessions may involve:8,9,11
- Check-ins on your mood and comfort level with the pace of therapy and progress.
- Feedback on homework assigned during the previous session.
- Discussions about changes made.
- Plans for setting new goals.
Though CBT is often carried out in a clinic or office space, treatment may also be offered in settings such as the outdoors, in your home, or online.11
How Effective is CBT?
CBT is highly effective.8,9,12 Not only is it universally recognized as being evidence-based by most clinical guidelines and backed by a sizable amount of scientific data, CBT is also considered the gold standard of psychotherapy, especially for treating addictions such as alcohol use disorder.5,10,15 It has the potential to majorly improve an individual’s quality of life by empowering them to:5,9,10,11
- Identify and change distorted thinking patterns.
- Recognize external and internal triggers.
- Develop coping strategies to deal with difficult situations.
- Use critical thinking skills to solve problems.
- Determine their own healthy path to treatment.
- Address fears rather than avoid them.
- Build confidence in their abilities.
- Develop better ways to communicate.
Using CBT for Alcoholism Treatment
Many people engage in heavy alcohol use to cope with emotions linked to cognitive distortions, problematic events, or other mental health disorders.7,16 Over time, as an individual’s excessive drinking increases, despite the harmful consequences it may have on their health, relationships, and/or career, they may develop an alcohol use disorder.7 An AUD can worsen symptoms associated with a person’s underlying triggers, especially when these triggers co-occur with other disorders such as depression or anxiety.7
CBT is a leading choice in addiction treatment.5,12 CBT has been shown to help reduce relapse rates for an alcohol use disorder and other addictions and overall, has been shown to be effective in all aspects of substance use disorder treatment.5,7,10 CBT is effective as a standalone therapy and it is also used in combination with other treatment strategies.10,13,17
CBT uses a variety of coping skills to help you recognize and restructure unhealthy thought and behavioral patterns.5,13 During your initial assessment for alcohol use disorder, your therapist will help you to identify underlying triggers and unhealthy coping skills that are connected to your alcohol use.
Additionally, the problem-oriented structure of CBT builds on your ability to foresee problems before they arise and better manage difficult situations.5 As you continue your treatment for an AUD, you and your therapist will:5,13
- Discuss the positive and negative outcomes of continuing alcohol use.
- Keep a record to track cravings in order to recognize circumstances that increase the risk of alcohol use.
- Identify the triggers that lead to cravings and compulsive behaviors.
- Develop a plan for managing cravings and avoiding risky situations.
- Learn skills to improve self-control.
The effectiveness of CBT may improve when combined with other treatment approaches, such as medication and mutual support groups, such as Alcoholic Anonymous or Narcotics Anonymous.7,17 Research has shown that skills developed through CBT treatment are often sustainable and remain with an individual long after completing their therapy.5
. Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States.
. National Institute on Alcohol Abuse and Alcoholism. (2020). Alcohol facts and statistics.
. Quigley, J. (2019). Alcohol use by youth. Pediatrics. 144(1): e20191356
. InformedHealth. (2016). Cognitive behavioral therapy.
. National Institute on Drug Abuse. (2020). Cognitive-Behavioral therapy (alcohol, marijuana, cocaine, methamphetamine, nicotine).
. Daniel David, Ioana Cristea, and Stefan G. Hofmann. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Front Psychiatry; 9:4.
. National Institute on Alcohol Abuse and Alcoholism. (2020). Understanding alcohol use disorder.
. Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2021). Cognitive behavior therapy. In StatPearls. StatPearls Publishing.
. National Alliance on Mental Illness. (n.d.). Psychotherapy.
. Centre for Addiction and Mental Health. (n.d.). Cognitive behavioural therapy.
. National Health Services. (2019). How it works: Cognitive behavioural therapy (CBT)
. American Psychological Association. (2017). What is cognitive behavioral therapy?
. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disorders. The Psychiatric Clinics of North America, 33(3), 511–525.
. American Psychological Association. (2017). How long will it take for treatment to work?
. David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4.
. National Institute on Drug Abuse. (2014). Drugs, brains, and behavior: The science of addiction.
. Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M, Magill M. Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders: A systematic review and meta-analysis. JAMA Netw Open. 3(6):e208279