SAMHSA (1999) defines Cognitive-behavioral theory as “the integration of the principles derived from both behavioral and cognitive theories, and it provides the basis for a more inclusive and comprehensive approach” to treatment (p. 69). Attribution, appraisals, self-efficacy, expectancies, and substance-related effect expectancies are “broad range cognitions” (p. 69) included in cognitive-behavioral theory. An attribution is an “individual's explanation of why an event occurred…and plays a major role in the cognitive-behavioral theory of substance abuse disorders” (p. 69). An example of attributional styles are whether the client believes events and their cause are attributed to himself or to others. Another is whether behaviors continue to affect the future or can they change or stop.

Cognitive appraisal is an individual's “appraisal of stressful situations and his ability to cope with the demands of these situations” (p. 70). An individual's coping skills and coping strategies are described as secondary to the individual's cognitive appraisal. Self-efficacy expectancies have been “thought of as both the client's temptation to use in substance-related settings and his degree of confidence in his ability to refrain from using in those settings” (p. 73). Those with lower levels of self-efficacy are more likely to abuse substances. Substance-related effect expectancies are the individual's “expectation that certain effects will predictably result from substance use” (p. 73). Positive expectancies usually relate to euphoria, relaxation, enhanced sexual facilitation among others. Over time, negative expectancies may develop such as aggression, risk taking, impairment, and hangovers for alcohol use. Cocaine use may cause anxiety, depression, and paranoia.

SAMHSA (1999) continues by describing a 3-way relationship among factors that maintain behaviors in cognitive and behavioral models. “Antecedents” are activating events in a client's life. “Cognitions…represent the client's beliefs, thoughts, or attitudes that serve to filter or distort the perception” of the activating events (p. 62). The third factor is the behavior – “the observable actions and emotional reactions that result from his beliefs and emotions” (p. 62). The relationship among the antecedents, cognitions, and behavior is reciprocal. The client may experience and “antecedent” such as getting paid on Friday. He believes (cognition) that since he now has money, it is okay to just spend $20. The behavior is that he buys the $20 worth of cocaine and ends up spending his whole paycheck and possibly gets into some type of trouble on top of being broke. Depending on his attributional style, he may either say that his boss was so demanding that he had no choice but to use (blaming others). Or he may say that he decided to use because he has messed his life up so badly that it does not matter anyway (blaming self, unable to change).

Cognitive-Behavioral Therapy Techniques

“Cognitive therapies have been aimed fundamentally at restructuring the belief systems assumed to be of motivational significance” (McCusker, 2001, p. 47). Grant and Haverkamp describe Cognitive Behavioral Therapy as an “umbrella term for a variety of approaches and interventions aimed at changing a person's internal experience by changing cognitions and behavior” (p. 29). Beck (1979) states that there are two important differences between cognitive-behavioral therapy and “conventional therapy” (p. 6). The therapist is much more active and engaged with the client than in psychodynamic or client centered therapies. The session is structured according to a particular design “which engages the client's participation and collaboration” (p. 6). Cognitive behavioral therapy focuses on problems in the present. Exploring the psychological and behavioral experiences of the client during and between sessions is more important than exploring what has happened in the client's past.

In substance abuse treatment, clients must learn new coping skills to help them through situations in which they normally use drugs or alcohol. The coping skills include identification of situations in which the addict of alcoholic typically uses. Instruction, modeling, role-plays, and rehearsals are used to teach the needed skills. Relaxation training and stress-reduction methods are included in the model to help the client discover that he or she can relieve some of the pressure of day-to-day life without using alcohol or drugs (Longabaugh and Morgenstern, 1999). Longabaugh and Morgenstern describe a type of CBT called Cognitive-Behavioral Coping-skills Training (CBST), which is aimed at improving the client's cognitive and behavioral skills and changing the clients drinking and drug-using behaviors. This helps the client “identify specific situations in which coping inadequacies typically occur” (p. 78).

SAMHSA (1999) lists other necessary coping skills are the ability to cope with negative emotional states, conflict, physical pain, temptations or cravings to use, social pressures and even positive states and emotions. Another core element of CBT is relapse prevention. “Relapse prevention approaches rely heavily on functional analyses, identification of high-risk relapse situations, and coping skills training but also incorporate additional features…[that] deal directly with a number of the cognitions involved in the relapse process and focus on helping the individual gain a more positive self-efficacy” (SAMHSA, 1999, p. 81). Clients who are new in recovery often experience “passivity and a sense of helplessness that often accompany low self-efficacy” (p.81). To overcome this clients are taught things they were previously unable to accomplish. Through the use of homework assignments and coaching, clients gradually expose themselves to situations that would previously been too stressful to manage without relapse. As he becomes more comfortable in these situations, he begins to generalize his learning to other situations thereby reducing the sense of helplessness (SAMHSA, 1999).