The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4 - 5
Core Components
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of psychological difficulties. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one of these domains can impact other domains. CBT therefore identifies, challenges, and aims to change unhelpful thinking patterns and teaches new skills, facilitating emotional and behavioural changes.
In the context of substance use, CBT tasks are aimed at enhancing motivation to reduce substance use; broadening and strengthening the person’s range of coping skills; increasing non-substance use-related activities; managing difficult emotions; and enhancing interpersonal functioning and social support. Hence, CBT for substance use can include the following components;
- Functional analysis: This aims to identify persons’ thinking patterns and circumstances prior to and after substance use. This component helps to identify each person’s triggers (or precipitants) of substance use, and identify opportunities to develop new coping skills
- Cognitive strategies: This aims to alter unhelpful thinking patterns that maintain addiction. These strategies also work towards developing more helpful thinking patterns.
- Behavioural techniques: This aims to alter unhelpful behavioural patterns. It can consist of introducing new more helpful activities, carrying out behavioural experiments, in addition to developing new skills.
- Skills training: This component aims to improve coping skills. It relates to the control of substance use (including recognition of high-risk situations, coping with thoughts about substance use); coping strategies to address problems (e.g. problems at work, social isolation); as well as skills training for interpersonal (e.g. refusal skills) and intrapersonal problems (e.g. managing cravings or difficult emotions)
These core CBT components help people recognise situations that precipitate substance use; empowers them to avoid such situations where appropriate; and teaches coping strategies to more effectively address problems or behaviours associated with substance use. They focus on the cognitive, affective, and environmental precipitants of substance use, and skills training to increase capacity to manage high-risk situations (e.g. anxiety, depression, interpersonal problems) for relapse prevention. CBT may also focus on problems co-occurring with substance use.
CBT is largely present-centred and focuses on the “here and now” challenges. It involves setting realistic goals that have been mutually agreed between the therapist and service user. It therefore benefits from a collaborative therapeutic relationship between therapist and service user, as this facilitates achievement of the goals of the intervention (e.g. identification of problems, learning of relevant skills, and application of learned skills to manage identified problems). CBT delivered in this standard format is time-limited and is typically delivered weekly, over 12 to 16 sessions. CBT has homework components as these provide opportunities for people to challenge themselves between sessions, and to generalise the skills learnt to their everyday lives.
Fidelity
CBT should be delivered by competent practitioners with ongoing supervision. The intervention should be delivered as outlined in a validated manual or program. The stipulated content and structure should be adhered to in order to ensure consistency in delivery of intervention. The use of competence frameworks developed from the treatment manual should also be considered.
Treatment adherence and practitioner competence should be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions. Rating scales like the Cognitive Therapy Rating Scale- Revised (CTS-R, Blackburn et al. 2001) can be used to assess therapist fidelity. Raters should be trained in CBT and should consider the relevance of the formulation and change methods.
Modifiable Components
As outlined above, CBT is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. CBT can be delivered in a variety of settings, delivered face-to-face or virtually (via videoconference), in individualised or group formats. Delivery typically runs over 12-16 sessions, session generally lasting about 45-60 minutes, but can be lengthened for group delivery. CBT can be delivered to people with substance use disorders and comorbid mental health disorders including PTSD, depression, and anxiety (see other sections in the Matrix guide for more information). CBT can be delivered with cultural accommodations to increase cultural relevance.
CBT plus Motivational Interviewing (MI)/ Motivational Enhancement Therapy (MET):
CBT can be used in conjunction with other psychological interventions (e.g. CBT plus MET/MI). MI/ MET focus on eliciting behavioural change which can translate to increased awareness of substance-use problem and strengthened motivation for change. MI/MET in combination with CBT can increase treatment response by increasing individuals’ engagement with treatment. CBT plus MI/MET have been used in the treatment of substance/ alcohol use alone https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468498/pdf/nihms862494.pdf, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673563/, and in comorbid conditions (e.g. substance use and major depressive disorder (MDD)) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094504/pdf/nihms290205.pdf; https://pubmed.ncbi.nlm.nih.gov/21890213/. When delivered as dual treatment for comorbid conditions, the combined therapies are delivered to target both conditions.
Electronic CBT options (eCBT): eCBT interventions are delivered remotely as self-help interventions (without therapist guidance), or as guided self-help interventions (with varying levels of therapist assistance). eCBT interventions can be delivered as web-based interventions (via internet browser); computer-based interventions (accessed offline, e.g. CD or DVD); and mobile apps. These methods can increase access to treatment which could be limited due to shortages of available therapists, individuals’ attenuating circumstances, and insufficiencies in available resources for delivery of traditional face-to-face therapies. eCBT modules / lessons also adhere to traditional CBT content.
Self-Management and Recovery Training (SMART) Recovery Programme: This training programme equips individuals with skills to abstain from substance use and addictive behaviours, and to cultivate a lifestyle that supports sustained recovery. SMART recovery is not a therapy but is based on cognitive behavioural and motivational tools and techniques that are focused on four points; building and sustaining motivation; enhancing coping skills; managing thoughts, feelings, and behaviours; and living a healthy, balanced lifestyle. These tools and techniques are taught via several courses that include;
- Introduction to SMART recovery course: A 1-hour course that provides an overview of the SMART recovery programme. It consists of video’s, reading, and a short quiz
- Getting SMART: An 8-10-hour course that introduces the SMART Recovery tools, methods and theories, as well as the application of these strategies. It contains videos, reading materials, worksheets and quizzes
- SMART Recovery Meetings: These are weekly structured meetings that focus on addictive behaviours and goal setting.
As well as the online courses, this training programme can be accessed through mutual aid community meetings and via partner agencies (including the NHS and third-party charities). SMART is also available in adapted formats e.g. for family members, in criminal justice settings, for those in the military/veterans.
Adults – technology delivered CBT - Rating: 4
Usable - this intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Adults – SMART recovery programme - Rating: 4
Usable - this intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Supports - Rating: 4 - 5
Implementation Support
Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology workstreams, including webinars, CPD and supervisor training. CBT is a core therapeutic modality within the NHS and many other settings. As such, access to supervision and implementation support is widely available.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
To deliver CBT as a therapy, staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level). People from other backgrounds can build up a portfolio of evidence (a Knowledge, Skills and Attitudes portfolio) to gain entry to postgraduate training and gain accreditation. Some CBT interventions outlined above (electronic options and SMART recovery, and some of the CBT techniques described) can be delivered by a wider range of staff working in substance use settings, with access to appropriate training and supervision.
Training Requirements
Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT is available through the NES Psychology workstreams. The British Association for Behavioural and Cognitive Psychotherapies (BABCP) provides accreditation for training courses. Training for SMART recovery programme can be accessed online via the UK SMART recovery's training site (https://training.smartrecovery.org.uk/).
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).
The therapist should access regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
There is additional training available that specifically supports CBT supervision skills.
Practitioners delivering CBT skills as part of other packages (e.g. SMART recovery) will benefit from coaching or reflective practice sessions to support their delivery.
Adults – technology delivered CBT - Rating: 4
Supported - some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention.
Adults – SMART recovery programme - Rating: 4
Supported - some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention.
Evidence - Rating: 4 - 5
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Evidence
Theory of Change
Cognitive Behavioural Therapy is based on theories that include:
- Cognitive theory: this theory recognises the inter-relationship between thoughts, feelings and behaviours, and the role of unhelpful thinking patterns in the development of unhelpful behaviours and difficult emotions. Cognitive theory therefore proposes identifying, challenging and altering unhelpful thinking patterns, which can then help change difficult feelings and behaviours.
- Behavioural theories. Classical behavioural theories suggest that behaviour is learnt as a result of classical or operant conditioning. Social learning theory suggests that behaviour is also learnt from people’s environment by watching and observing others. Behavioural theories view substance use as a learnt way of coping with difficult situations, thoughts, and feelings.
CBT therefore proposes working with the individual to develop a shared formulation of their difficulties and identify goals for therapy. Goals generally address the individual’s broad range of problems, as opposed to having a targeted focus on substance use alone. The emphasis is placed on developing skills (e.g. coping skills, refusal skills, identification of triggers), and increasing coping capacity for high-risk situations (to prevent relapse). This is expected to enhance individuals’ active behavioural or cognitive coping techniques to better address their problems as opposed relying on substance use as a coping mechanism.
Children and Young People - Rating: 5
Research Design & Number of Studies
Children and Young People (CYP) CBT Evidence
Some studies have reported the effectiveness of CBT in CYP with substance use disorders, with or without co-occurring mental health disorders. These are described below and include RCTs and two meta-analytic reviews.
One meta-analytic study evaluated the effectiveness of different psychological therapies in adolescent substance use treatment (1). It included studies, conducted in USA or Canada, that recruited CYP aged 12 to 18 years with current or recent substance use disorder diagnoses. Research designs included were randomised studies and quasi-experimental designs. 10 studies evaluated CBT in pre-post analysis, and 8 studies evaluated CBT plus MET (CBT/MET) in pre-post analysis.
Another study was an RCT that assessed the efficacy of an integrated CBT protocol (I-CBT) for co-occurring alcohol or other drug use disorder (AOD) and suicidality in adolescents (2) Integrated CBT therefore included CBT techniques that address unhelpful cognitions and behaviours underlying adolescent suicidality and AOD. The study included 40 participants, aged 13 to 17 years, who were recruited from a psychiatric inpatient unit in USA. Participants had made a suicide attempt within the prior 3 months or reported clinically significant suicidal ideation during the past month, and had been assessed as having an alcohol or cannabis use disorder. CBT was delivered over 12 months, with weekly classes delivered in the first 6 months, fortnightly in the next 3 months, and monthly thereafter for the last 3 months.
Lastly, one meta-analysis evaluated the effectiveness of psychosocial treatments for adolescent substance abuse (3). The review included 17 studies that involved 2307 adolescents aged 12-19 years. Of the 17 studies, 7 studies (n=367 participants) evaluated CBT delivered in individual format, and 11 studies (n=771 participants) involved CBT delivered in group format. Participants in this review met diagnosis for substance use disorder or reported low to heavy substance use.
CYP Outcomes for CBT
Compared to enhanced treatment as usual, minimal treatment, or in pre-post analysis, the following outcomes were observed;
- Significant reduction in substance use at post-treatment. Significant results reported for CBT and CBT/MET in within-group analysis (1) ,and for group CBT in between-group analysis (3)
- Significant reduction in substance use (i.e. heavy alcohol use days and days of marijuana use) during the 18 months of treatment (2)
- Significant reduction in suicidal behaviour during the 18 months of treatment (2)
Adults – CBT in a standard therapy format - Rating: 5
Adult CBT Evidence
A number of studies have reported the effectiveness of CBT in addressing the substance use of adults. Some of the best available evidence include Randomised Controlled Trials (RCTs) and meta-analyses. Studies that have evaluated the effectiveness of CBT in substance use and co-occurring mental health difficulties have also been included.
Adult Evidence for CBT Delivered in a Standard format
The best available evidence demonstrating the effectiveness of CBT (delivered in standard therapy format) in substance use includes meta-analytic studies. This is an established area with fewer studies published recently. The key meta-analyses are described below.
NICE carried out a meta-analysis to determine the effectiveness of CBT in the management of alcohol use (4). The review included 20 RCTs with 3970 participants aged 18 years or over. 80% of the study participants met the criteria for alcohol dependence or harmful alcohol use. Of the 20 RCTs, 3 RCTs compared CBT to treatment as usual or inactive controls. CBT was delivered in face-to-face format, over a treatment period that ranged from 0.5 to 6 months.
A comprehensive Cochrane review that evaluated the effectiveness of psychosocial interventions for reducing harmful benzodiazepine use, abuse or dependence in opiate and non-opiate dependent adults (5). The review included 25 studies with 1666 participants aged 16 years or over. Participants presented with dual diagnosis or co-morbidity of a substance problem and another mental health difficulty, e.g. anxiety or depression. The meta-analysis for CBT included 11 studies and 575 participants. The studies compared CBT to pharmacological intervention, no treatment, placebo, or a different psychosocial intervention.
A comprehensive Cochrane review that evaluated the effectiveness of psychosocial interventions for reducing cannabis use was carried out by (6). The review included 23 RCTs with 4045 participants aged 18 or over, who met the criteria for cannabis use or dependence. This review looked at the effectiveness of CBT, MET, and the 2 in combination. The studies compared CBT to no treatment, minimal intervention, delayed intervention, or a different psychosocial intervention.
(7) conducted a meta-analysis of 30 RCTs looking at the effectiveness of CBT for alcohol or other substance use. Studies were included if participants were over 18 years of age and met the criteria for alcohol or other substance use disorder, or problematic use. The median sample size was 102 participants (range 39 - 952 participants). The studies compared CBT to minimal intervention, non-specific therapy, or a specific alternative therapy. Interventions were delivered in individual or group format.
Adult Outcomes for CBT Delivered in Standard Format
Compared to participants in control groups who did not receive CBT, the following outcomes were observed;
- Significantly reduced number of participants with reported lapse or relapse to alcohol at 6- month follow-up (4)
- Significant discontinuation in benzodiazepine use at post-treatment and 3-months follow-up (5)
- Significantly reduced frequency of cannabis use at 6-month follow-up (6)
- Significantly reduced frequency and quantity of alcohol or substance use at 6 month follow up (7)
Adults – technology delivered CBT - Rating: 5
Adult Evidence for technology delivered CBT
The best available evidence demonstrating the effectiveness of technology delivered CBT for substance use management includes 2 meta-analyses. These are described below.
One meta-analytic study reported on the short- and long-term effects of digital prevention and treatment interventions for cannabis use reduction (8). The meta-analysis included 21 RCTs, consisting of 6 prevention studies and 15 treatment studies. Motivational interviewing (MI) plus CBT was delivered to participants in 5 of the 15 treatment studies, in guided or unguided formats. Subgroup analysis for MI plus CBT was conducted and reported. Participants receiving treatment were cannabis users aged 16 to 40 years.
Another meta-analytic study reported on the effectiveness of technology delivered CBT-based interventions for the management of alcohol use (9). The study included fifteen RCTs conducted in people identified as at-risk or heavy drinkers. The content of CBT tech programs varied, and ranged from 4 to 62 sessions/exercises. Participants were adults aged 18 years and over.
Adult Outcomes for CBT Delivered Digitally or Remotely
Compared to minimal treatment control or inactive controls, the following outcomes were observed;
- CBT and MI combined evidenced significantly reduced cannabis use at post-treatment (8)
- Significantly improved alcohol measures of quantity or frequency at post-treatment follow-up, and at early follow-up, i.e. 1-3 months (9)
Adult Evidence for CBT plus Motivational Interviewing (MI)/ Motivational Enhancement Therapy (MET)
The best available evidence for integrated or combined CBT and MI/MET for substance use management in adults include a meta-analytic review and RCTs (in addition to the study in relation to digital interventions, above).
As described above, a comprehensive Cochrane review that evaluated the effectiveness of psychosocial interventions for reducing cannabis use was carried out by (6). The review included 23 RCTs with 4045 participants aged 18 or over, who met the criteria for cannabis use or dependence. This review looked at the effectiveness of CBT, MET, and the 2 in combination. The studies compared CBT/MET to no treatment, minimal intervention, delayed intervention, or a different psychosocial intervention.
A meta-analytic study was conducted to evaluate the effectiveness of CBT and MI in the management of comorbid alcohol use and depression (10). The review included 12 studies that involved 1721 participants, aged over 16 years, who met diagnostic criteria for depression and alcohol use disorder or scored above a cut-off point on self-report scales. The studies compared CBT and MI with either treatment as usual or an alternative psychosocial intervention.
Adult Outcomes for CBT plus MI/MET
Compared to control groups (including placebo control and treatment as usual), the following outcomes were observed;
- Significant reduction in symptoms of cannabis dependence within 6-month follow-up (6). This effect was greater than the effect of either CBT or MET in isolation.
- Significantly reduced frequency of cannabis use within 6-month follow-up (6). This effect was greater than the effect of either CBT or MET in isolation.
- Significant reduction in alcohol consumption at post-treatment, maintained at up to 6-12 months follow-up (10)
- Significant reduction in depression symptoms at post-treatment (10).
Adults – SMART recovery programme - Rating: 4
Adult Evidence for SMART Recovery
The best available evidence for SMART recovery in the management of substance use disorders includes 1 RCT with follow up:
A RCT evaluated the effectiveness of SMART recovery in 189 participants new to SMART Recovery (8), (11). Participants were adults, aged at least 18 years, aiming to reduce their alcohol use, and having an Alcohol User Disorders Identification Test (AUDIT) score of 8 or higher. The study was conducted by researchers in USA.
Adult SMART Recovery Outcomes
In pre-post or control group analysis, the following outcomes were observed;
- Significantly increased abstinent days at 3-months follow-up (11), and at 6-months follow-up (12)Results were for within-group analysis
- Significantly decreased mean drinks per drinking day and alcohol/drug-related problems at 3-months follow-up (11), and at 6-months follow-up (12). Results were for within group analysis.
Need
Comparable Population
CBT has been shown to be effective in the treatment of substance use. Effectiveness has been demonstrated across a range of substances (e.g. alcohol, benzodiazepines, cannabis), in children, young people and adults.
Desired Outcome
CBT has been shown to effectively reduce substance use, and symptoms of co-morbid mental health disorders (e.g. anxiety and suicidal behaviours) at post-treatment and follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Fit
Values
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. It draws upon behavioural and cognitive theories. In the context of substance use, CBT focuses on understanding how thoughts, feelings and external triggers might lead to substance use. CBT aims to help people deal with these triggers in more helpful ways by learning new skills. Practitioners using CBT are recommended to work collaboratively with the individual to develop a shared formulation of their difficulties and identify goals for therapy. Practice is person-centred and holistic, and goals generally address the individual’s broad range of problems, as opposed to having a targeted focus on substance use alone. The emphasis is placed on developing skills (e.g. coping skills, refusal skills, identification of triggers), and increasing coping capacity for high-risk situations (to prevent relapse). This is expected to enhance individuals’ active behavioural or cognitive coping techniques to better address their problems as opposed relying on substance use as a coping mechanism. Although practitioners often consider how difficulties have developed over time, the focus of therapy is usually the “here and now” and making changes for the future.
Priorities
CBT identifies, challenges, and modifies unhelpful thinking patterns, facilitating emotional and behavioural changes. CBT can help people using various substances (e.g. alcohol, cannabis, benzodiazepines), when delivered alone, or in conjunction with other psychological interventions (e.g. CBT plus MET/MI). CBT can be offered in individual or group formats, either in-person or as remotely delivered interventions (with varying levels of therapist’s assistance).
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) or other professionals who have built up relevant experience. These professionals will have then undergone training in CBT to support its delivery. CBT can be delivered to people weekly, typically over 12-16 sessions. CBT can also be delivered digitally, but therapist support generally improves efficacy. Access to supervision is also necessary to support practice.
Technology Support
Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
Cognitive Behavioural Therapy (CBT) is typically delivered weekly, over 12-16 sessions. Sessions can last about 45-60 minutes for delivery in individual format, or over 90 minutes for group delivery. Face-to-face therapy sessions can be held in various settings including community mental health centres, outpatient clinic settings, hospitals, and schools. It is good practice to be able to offer trauma-informed and psychologically-informed therapeutic environments (see https://transformingpsychologicaltrauma.scot/ ). Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost. As CBT is a core therapeutic modality within the NHS and many other settings, access to supervision and implementation support is generally widely available.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
