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Kathleen Carroll, PhD
Cognitive behavioral therapy (CBT) is one of the most studied and most effective treatments for common mental health disorders like depression, anxiety and insomnia. It would make sense that CBT has the similar benefits for individuals being treated for substance use disorder, especially as many individuals with substance use disorders have mental health problems as well. “Comorbid substance use disorder and mental illnesses are common, with about half of people who have one condition also having the other,” according to the National Institute of Drug Abuse.
The CBT methodology is grounded in the idea that behavioral patterns that maintain substance use are strongly established over long periods of time. To change these patterns, individuals can learn new skills to understand and disrupt them. Just as particular feelings (affects), thoughts (cognitions) and behaviors can lead to substance use (the ABC model), analyzing and changing those thoughts, feelings and behaviors can help individuals stop substance use.
Teaching individuals with drug and alcohol problems to become aware of these patterns so that they can interrupt them is key. This allows an individual to transition from having mostly negative thoughts, upset feelings and risky behaviors toward healthier, more productive thought and behavior patterns that support positive behavior change. CBT enables sessions to be interactive, engaging, and positive.
Below, we explore the power of combining technology with CBT.
Over the course of seven randomized clinical trials spanning more than 15 years, the efficacy, durability and value of technology-enabled CBT programs have been proven for the treatment of substance use disorders.
For example, one recent study found that participants who received online CBT reduced their frequency of substance use significantly more than those who received CBT delivered by a clinician or traditional weekly group therapy (treatment as usual). Six-month follow-up outcomes indicated the continuing benefit of online CBT over treatment as usual as well as clinician-delivered CBT. Analysis of secondary outcomes indicated that participants assigned to online CBT demonstrated the best learning of cognitive and behavioral concepts, as well as the highest satisfaction with treatment. These outcomes have since been replicated.
Using technology to deliver CBT is a new approach that is being used to break down barriers of the past that confined treatment options to in-person therapy. Online programs allow individuals the ability to log in via tablet, smartphone or computer, which makes help more accessible than ever before, and these programs use videos and interactive exercises to demonstrate the CBT skills and provide a convenient means of practicing them. The professional responsible for overseeing the treatment plan monitors the program.
Technology-enabled CBT can be used in combination with other elements of treatment that include medication or other forms of talk-therapy. It is also a valuable resource for clinicians who may not have an in-depth knowledge of CBT. Programs like these allow clinicians to track progress for their patients. Online CBT also eliminates the need to send clients home with a worksheet and hoping they take action. CBT integrated into a robust technology platform offers real-time data to providers and allows clients to engage in the online sessions more effectively while supporting providers in making decisions about how to plan for one-on-one meetings.
Online telehealth programs are appropriate for a wide range of individuals, including those with comorbid mental health disorders. These programs have the potential to improve substance use outcomes when added to standard treatment or when used standalone. With regular clinician monitoring, there is a definite benefit when it comes to cost reduction for the clinic and the client. Programs offered online can cut down on office visits which save the client travel-related expenses, like money for gas or bus fare, while also reducing the impact of fees associated with regular office visits.
According to the National Council for Behavioral Health, “Mental health services in the U.S. are insufficient despite more than half of Americans (56%) seeking help. Limited options and long waits are the norm, but some bright spots with 76% of Americans now seeing mental health as important as physical health.” Online programs break down the barrier to mental health and substance use treatment due to reduced cost as well as the ability for clients to access the program despite facing obstacles such as the inability to travel long distances for office visits—a common barrier in rural areas. Additionally, some clients report feeling anxious or uncomfortable coming to the office when they begin treatment. However, programs that are primarily accessed via technology create a gateway for the clinician and client to begin developing a therapeutic relationship. For these reasons, interventions that are accessed through technology are more convenient for many clients.
Thus, if a technology-based, telehealth-enabled program is deemed more effective, durable, and less costly than standard outpatient counseling while effectively teaching the target skills, then the benefits certainly make this an appropriate potential treatment option depending on a client’s individual needs.
Skills to address SUD
Online CBT sessions address a range of other problems that often pose problems for individuals with substance use disorders. Thus, CBT also teaches individuals how to respond assertively, think through their decisions and become better problem solvers, all of which may contribute to better outcomes and less relapse.
Testimonials from people with varying demographics and backgrounds can also be featured as part of program modules. This is helpful because it provides an opportunity for individuals to hear from people who appear similar to themselves, which can increase engagement and motivation to practice new skills.
The time is now
There is overwhelming evidence that CBT is an effective, durable empirically validated SUD treatment. With the onset of a global pandemic, there is a greater need than ever to provide services in new formats. It is of extreme importance that we work collectively to take innovative and evidence-based ideas and push them out faster to those who need them.
Kathleen Carroll, PhD, is a professor of psychiatry at the Yale School of Medicine.