Cognitive Therapy: What You Need to Know

The use of cognitive therapy to treat substance use disorders (SUDs) has been in play for a long time. Cognitive therapy was first used in the treatment of mental health disorders and is part of cognitive behavioral therapy (CBT). Research articles boast of its effectiveness as a method of drug abuse treatment, but none of these articles speak of its effectiveness in different races. However, the questions raised remain, does cognitive therapy work? And if it does, is it effective and applicable to all races? 

History of Cognitive Behavioral Therapy 

To understand the concept of cognitive therapy, it is important to first look at its history. This section will highlight the first use of cognitive behavioral therapy, any other form of therapies that were used before it and how they influenced the introduction of cognitive therapy. This section will also highlight the person behind the concept of cognitive therapy, the link between cognitive and behavioral theories, and its use in the treatment of substance use disorders (SUDs). 

Cognitive behavioral therapy (CBT) came into use after it was determined other available options in the 1960s were ineffective (Benjamin et al., 2011). At the time, behavior therapy gained popularity, but this method was controversial and only limited to the treatment of behavioral disorders among children (Benjamin et al., 2011). In the 1970s, behavioral therapies began to expand to clients who were considered high functioning and were eventually integrated with cognitive processing. 

Cognitive therapy (CT) was first introduced by Aaron T. Beck, an American psychiatrist. Cognitive therapy is a part of cognitive behavioral therapy (CBT). According to Benjamin et al. (2012), CBT is the combination of cognitive and behavioral theories of human behavior and psychopathology. It also includes the blending of emotional, peer and familial influences. This definition highlights one key concept that there is a link between cognitive and behavioral theories. The discussion below will highlight this link. 

The cognitive theory states that chemical dependence is a result of interaction between cognitions, emotions, familial relationships, and behavior (Silva & Serra, 2004). On the other hand, behavioral theory suggests that chemical dependence is because of certain behaviors and focuses on social learning theories such as modeling. The link between these two theories is that cognitive theory attempts to unify the two theories. It addresses both behavior and cognition, and this is how it influences cognitive therapy (CT). 

Cognitive therapy (CT) can be defined as the application of the cognitive theory to an individual’s psychopathology (Silva & Serra, 2004). However, the set of techniques used in CT adapt behavioral and psychopathological cognitive models. This relationship between the cognitive and behavioral theories is the reason it is recommended that a combination of both cognitive and behavioral theories be used in the treatment of substance use disorders (SUBs). The application of both theories is however limited to professionals. 

Techniques of Behavioral Theories Used in Treating Substance Use Disorders (SUBs) 

As stated before, behavioral theory focuses majorly on social learning theory. Studies have shown behavioral theory is effective in treating drug addiction and its associated problems. According to Silva & Sierra (2004), behavioral theory can be applied in different settings and modalities. It can be applied in the hospital or home and can be applied to an individual or a group. There are several techniques of behavioral theory that can be used in treating SUBs all which aim to change the drug users’ lifestyle. These techniques are discussed below. 

Social learning theory is the focus of behavioral theory, and therefore its techniques are used to treat SUDs. Social learning theory is the systematic study of learning in human beings (Silva & Serra, 2004). It looks at how they act, think or feel under different circumstances. It is based on the fact human beings still possess instinctive processes. Learning in human beings occurs in many levels. However, in this paper, we will discuss two of those levels instrumental learning and classical conditioning. 

Instrumental Learning 

This theory is based on the fact that all human beings always look for pleasure and avoid situations that are not satisfactory (Silva & Serra, 2004). SUDs deprive the affected a meaningful life. In the absence of these drugs, individuals have also faced withdrawal symptoms that are unpleasant. In instrumental learning, there are two types of reinforcers, positive, which is satisfactory, and negative, which is that of displeasure. This is known as operant conditioning. In the case of SUDs, drugs are short-term positive reinforcers. 

This approach involves encouraging patients to seek alternative sources of pleasure which helps these patients deal with their withdrawals. They also choose to seek satisfaction through other avenues that do not involve the abuse of drugs. However, this approach has two limitations. One limitation is that some individuals seek pleasure from risky behaviors and may deem substance abuse as one way. The second limitation is that patients may think the pleasure they derive from their new activities will equal that of drug abuse which is not the case. 

The second approach to instrumental learning is psychosocial (Silva & Serra, 2004). In this approach, the positive reinforcer is vouchers. Patients have their urine samples screened for drug use every week (Silva & Serra, 2004). If the drug test is negative, the patients then receive vouchers, which they can exchange for drug-free activities such as movies or sports. Studies conducted in 1991 and 1993 showed that this approach resulted in higher abstinence and retention rates compared to other forms of treatment. 

Classical Conditioning 

This method is based on Pavlov’s experiment in 1904 (Silva & Serra, 2004). The experiment involved transformation of a neutral stimulus into a conditioned stimulus. In his experiment, the neutral stimulus was the bell he rang, and the non-conditioned stimulus was the meat he offered to the dog whenever he rang the bell. After a while, the dog would salivate whenever he rang the bell. He had transformed the bell ringing into a conditioned stimulus associated with food, and the dog’s salivation became the conditioned response. 

Pavlov’s experiment can also be used to influence human behavior. A study in 1993 showed that there is a relationship between patient exposure to situations and the patient’s reaction to these situations (Silva & Serra, 2004). Using this knowledge, behavioral theorist can help patients cope with drug use. With the help of patients, behavioral theorists can determine situations and places that are likely to result in drug use. They can then help the patients to identify these situations and places and help them develop new behaviors that end their drug use. 

Techniques of Cognitive Theory Used in Treating Substance Use Disorders (SUBs) 

Behavioral theory focuses on drug use behavior and situations that lead to them. On the other hand, cognitive theory focuses on the cognitions, that is beliefs, thoughts, and schemas, that result in craving and on the beliefs that enable the behavior of drug use and search (Silva & Serra, 2004). Cognitive therapy is “a structured or semi-structured, directive, active and short-term approach” (Silva & Serra, 2004). It analyzes the relationship between the structure of a patients’ world and the patients’ behavior and affections. 

The aim of cognitive therapy is to determine the dysfunctional cognitions and find solutions to making them flexible. This flexibility allows the patients to make decisions depending on the situations they are in. Cognitive therapists will, therefore, determine the patients’ thoughts and beliefs about and how they influence their perception of themselves. All this is done through hypotheses which are then tested to determine their validity. The following section highlights the structure if a typical CT session. 

Structure of a Cognitive Therapy Session 

As stated before cognitive therapy is structured and short-term. It has a minimum of 12 sessions and a maximum of 24 sessions (Silva & Serra, 2004). For it to work, both the patient and the therapist must have a relationship that is collaborative and genuine. According to Silva & Serra (2004), the first session should follow the structure below: 

1. The therapist should set the session’s agenda in written form. 

2. The therapist should determine how to start a sympathetic relationship with the patient. 

3. The therapist should also determine the therapy’s focus. 

4. The therapist should gather information such as the history of the patient’s problem. 

5. The therapist should then use that information to determine a goal that they can both share. 

6. The therapist should then educate the patient on the therapy’s methodology. 

7. The therapist should then build cognitive conceptualization from theoretical reasoning. 

8. The therapist can then establish a doctor-patient contract that ensures privacy and includes therapy cost and homework. 

The rest of the sessions should follow the structure below: 

1. The therapist should set the session’s agenda based on the patient’s demand, the week’s events and the focus of the therapy. It should also be based on the goals that have been set. 

2. The therapist should create a link to the previous session. 

3. The therapist should then do a review of any homework given to the patient. 

4. The therapist and the patient should then discuss the topics in the set agenda. 

5. The therapist should then set the new homework. 

6. The therapist should then summarize the session and seek feedback from the patient or give it to the patient. 

Techniques of Cognitive Therapy used in Treating Substance Use Disorders (SUDs) 

Cognitive therapy techniques must always be discussed with the patient. This is often done to ensure the patient’s understanding of the therapeutic process. In this way, the patient can also become his/her own therapist. According to Silva & Serra (2004), the following techniques are always used: 

1. The patient’s negative automatic thoughts are monitored by keeping a diary. 

2. The therapist can also determine the connections between the patient’s cognition, and behavior and affection. 

3. The therapist can also examine the dysfunctional automatic thoughts and find solutions to deal them. The aim of this examination is to help the patient face these thoughts and distance himself or herself from them. 

4. The therapist can map any cognitions that are biased to make them flexible. 

5. The therapist can also identify and change the patient’s beliefs that influence their experiences assessment. 

6. The therapist can also determine dysfunctional images and alter them. 

Effectiveness of Cognitive Behavioral Therapy (CBT) in Different Races 

As stated before, CT is a form of CBT, and therefore its efficacy in different races is measured on the basis of all other forms of CBT. The efficacy of CBT in treating SUDs is supported by several trials. A study conducted on cocaine dependence, found that psychosocial treatment was effective in helping 60 percent of the addicts remain clean for up to 52 weeks (McHugh et al., 2010). Another study conducted by McHugh et al. (2010) also found that CBT had a larger treatment effect on cannabis. 

The efficacy of treating SUDs using CBT does not account for racial demographics. In fact, most CBT trials have patient samples that are always White (Windsor et al., 2015). Therefore, one cannot conclude that it is effective for all races. This section will discuss the effectiveness of CBT in patient samples that are made up of non-Hispanic Whites, Black and Hispanic. Literature to be used will be from Windsor et al. (2015) who conducted a study using sample groups that were predominantly comprised of each race to be discussed. 

The aims of the study by Windsor et al. (2015) was to determine the inclusion of all races in CBT trial and to determine if it was indeed effective for all races. The whole study was based on analysis of articles that discuss CBT efficacy. A total of 322 articles were used in which all the studies were conducted in the United States between 1990 and 2012 on adult populations (Windsor et al., 2015). The experimental designs also used in the articles were controlled and randomized. 

In their study, Windsor et al. (2015) were able to determine that majority of studies on CBT were not racially inclusive. These studies also did not compare CBT efficacy across all racial demographics. However, the study determined that CBT efficacy among non-Hispanic Whites was higher than in Blacks and Hispanics when a pre-posttest comparison was made. The study also confirmed the efficacy of CBT in treating SUDs. However, it revealed that there is a need for researchers to exercise racial inclusion in their CBT trials. 

Limitations of Cognitive Behavioral Therapy (CBT) in treating Substance Use Disorders (SUDs) 

Despite its efficacy as method of treatment in SUDs, CBT has some limitations. Contingency management techniques such as instrumental learning is faced with the unavailability of funds (McHugh et al., 2010). The funds are needed for the provision of reinforcers in hospital settings. Challenges may also arise among the patients as it is difficult for them to shift from a particular setting to another. These patients are often left with no choice but to abandon relationships that meant a lot to them to recover from their addictions. 

Another challenge is the inclusion of all races in CBT. The highlighted study found that not all races were represented in most CBT trials. This limits the scope of these trials to the non-Hispanic White communities. There is, therefore, a need for researchers to determine if CBT trials are effective in all races and if there is a need to employ culturally relevant forms of CBT also known as adapted forms of CBT (ACBT) (Windsor et al., 2015). These interventions are more effective and have higher retention rates than non-adapted forms of CBT. 

Conclusion 

Evidently, cognitive behavioral therapy (CBT) is an effective method of treating substance use disorders (SUDs). Its efficacy is not limited to a particular modality or setting as it can be done in hospitals or homes and also among individuals or groups. Therefore, it should be highly recommended for the treatment of SUDs. However, its effectiveness cannot be determined in other races. Therefore, one can conclude it is not effective in all races. For this reason, it should not be used in all racial and ethnic communities until more research is done. 

Recommendations 

Researchers should conduct more racially inclusive CBT trials if its efficacy is to be determined across all races. The use of culturally relevant forms of CBT should also be embraced. By doing so, the scientific community will go a long way in ensuring the SUDs are eradicated to stop the continued moral deterioration among the adult population of not only non-Hispanic Whites but also Hispanics and Blacks. 

References  

Benjamin L. C, K. R., Puleo C. M., Setipani C. A., Brodman D. M., Edmunds J. M., Cummings C. M., Kendall P. C. (2011). History of Cognitive-Behavioral Therapy (CBT) in Youth. Child & Adolescent Psychiatric Clinics of North America , 20(2), 179-189. Retrieved 13 February 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3077930/ . 

McHugh, K. R., Hearon B. A., Otto M. W. (2010). Cognitive-Behavioral Therapy for Substance Use Disorders. Psychiatric Clinics of North America , 33(3), 511-525. Retrieved 13 February 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897895/ . 

Silva, C. J., Serra A. M. (2010). Cognitive and Cognitive-Behavioral Therapy for substance abuse disorders. Revista Brasileira de Psiquiatria , 26(1). Retrieved 13 February 2018, from http://www.scielo.br/scielo.php?pid=s1516-44462004000500009&script=sci_arttext&tlng=en . 

Windsor, L. C., Jemal A., Alessi E. (2015). Cognitive Behavioral Therapy: A Meta-Analysis of Race and Substance Use Outcomes. Cultural Diversity and Ethnic Minority Psychology , 21(2), 303-313. Retrieved 13 February 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589258/ .