Introduction to counseling theories applicable to addiction

Daily Thought Record is completed in this order: 

1. Recognize a trigger – strong emotional reaction (e.g., stress, anger, anxiety)
2. Briefly describe the situation, thoughts, and feelings that followed it. 
3. Once automatic thoughts are identified, take time to reflect on and challenge them, using evidence and logic.
4. After reframing recorded thoughts, note if emotions have shifted. This demonstrates the how thoughts have power to change emotions.

Automatic thoughts might not be so clear at first, a client might say, that their head was empty at the particular moment. Then it is easier to start with emotions and then ask some questions about thoughts:

• What was going through your mind when you felt upset (anxious, sad, angry)?
• What do you fear might happen?
• What conclusion did you jump to? 

Next step is to formulate an alternative (realistic, more balanced) thought. In order to do that counselor challenge automatic thoughts by looking for evidence for and against them.

Questions to challenge the thought:

• What evidence do you have that supports this thought?
• What evidence contradicts this thought?
• Are you jumping to conclusions or making assumptions without all the facts?
• Have you been in similar situations before? How did they turn out?

It is important to find evidence against negative automatic thoughts even if it seems that they are minor. It might be not easy at first, client might find more evidence that supports negative automatic thoughts. Automatic thoughts sound true and clients are used to believing them, even if they are not rational. The goal for the client is to start monitoring them and give them some doubt. 

Questions for creating an alternative thought:

• Given the evidence we collected, what is a more balanced way to think about this situation?
• How would you view this if you were less emotional or upset?
• What would you tell a friend in the same situation?
• Can you look at this situation from a different perspective?

Examples of alternative thoughts:

• Automatic Thought: “One drink won’t hurt; I deserve it after a tough day.”
• Alternative Thought: “Even one drink could lead me back to old habits. I deserve to treat myself in a way that supports my recovery, like taking a relaxing bath or going for a walk.”
• Automatic Thought: “I slipped up once, so I might as well give up on staying sober.”
• Alternative Thought: “One slip doesn’t mean I’m back to square one. Recovery is a journey, and I can learn from this experience to avoid future slips.”
• Automatic Thought: “If I don’t use, my friends will think I’m boring and won’t want to hang out with me.” 
• Alternative Thought: “True friends will support my decision to stay sober. I can find new activities to enjoy with them that don’t involve using.”

Practice. Complete Automatic Thought Record in pairs or for yourselves (remember any recent situation when you experienced a strong emotional reaction)

Table 3. Automatic Thought Record – Practice

Discussion with a group

What was difficult for a “client” and a “counselor”? Did the “client‘s” emotion change after creating an alternative thought? What challenges would you expect doing this exercise with your real clients?

Working with automatic thoughts can lead to discovering the client’s permission-giving beliefs. They are typically activated in high-risk situations where the individual feels the urge to use substances. These beliefs serve as justifications or rationalizations that lower the person’s resistance to substance use, making it easier for them to engage in the behavior despite knowing the potential negative consequences (Beck et al., 1993). They can be viewed as a mental shortcut to reduce cognitive dissonance between the person’s knowledge of the harms of substance use and their desire to use (Beck et al., 1993). For example, if a belief surfaces like, “I’ve been good all week, so one pill is okay,” it becomes much easier to decide to use a drug (Wright et al., 2006). Permission-giving beliefs also lower the individual’s defenses by downplaying the risks or consequences, making it easier for them to proceed with substance use (Beck et al., 1993).

The goal is to identify these beliefs and challenge their validity. Clients are taught to recognize when these beliefs are activated and to develop alternative, more adaptive thoughts that support their goals for sobriety (Wright et al., 2006). An automatic thought record can help identify these beliefs, and it may be useful for clients to create a list of recurring beliefs to notice which appear most often. Once an active belief is detected in a certain situation, counselors help clients examine the evidence for and against these beliefs, challenging their logic and fostering more balanced thinking (Beck et al., 1993).

Examples of alternative responses to permission-giving beliefs:

• Only weak people get addicted, it won’t happen to me.

I’m like anyone else. No one sets out to be addicted to drugs. It could easily happen to me.

• My drug use is out of control.

My drug use may sometimes feel out of my control but that’s just a feeling. I know how to slow it down and stop it.

• I’ll never be able to control my cravings without using a drug.

Cravings come and go regardless of whether I use.

• Everyone is using.

It sometimes seems that everyone is using but that’s probably not true. That also does not mean that I should use.

• The satisfaction I’ll get from this is worth the risk.

Don’t test myself. I’ve got too much to lose and it’s not worth a few minutes of pleasure.

It is very important to take notes not only for the counselor but for the client as well. The client can go through them at home and make reading notes a coping strategy when feeling less motivated or upset. 

Flashcards

Flashcards is a practical tool used in CBT for many issues, including substance abuse. They help clients reinforce learning, manage cravings, and maintain focus on their recovery goals (Beck et al., 1993). Here’s how flashcards can be utilized in this context:

• to help clients cope with cravings by reminding them of strategies to use when they experience the urge to use substances
• to counteract permission-giving beliefs that might lead to substance use.
• to reinforce positive self-beliefs and motivation to stay sober.
• to remind clients of the negative effects of drug use. 
  
  

Flashcards are easy to carry, allowing clients to review them anytime, anywhere. Regular review helps reinforce coping strategies and positive thinking (Wright et al., 2006). Clients can create their own flashcards, making the tool more personalized and relevant to their specific challenges.

Imagery techniques

Imagery techniques involve replacing negative, triggering images (or mental scenarios) with healthier, more positive imagery. This method helps individuals manage cravings and cope with stress by reshaping mental scenarios and replacing negative images with more constructive ones (Hollon et al., 2008). Individuals with substance use issues often experience vivid mental images that trigger cravings or the urge to use substances. These images may be related to past drug use or situations that lead to substance use (Woolf, 2013). For example, a person can imagine themselves experiencing euphoria after using drugs or drinking, which intensifies their cravings. Identifying these images is the first step in addressing them. The counselor can ask the client what images come to their mind when they feel a craving or when talking about drug-related experiences. It is advisable always to ask clients not only about their thoughts but also about images that pop into their heads (Hollon et al., 2008).

Once the triggering imagery is identified, the therapist helps the individual question its accuracy by focusing on the negative aspects often ignored in these mental pictures. This process involves highlighting the real consequences of substance use, such as withdrawal, guilt, or the long-term impact on health and relationships (Woolf, 2013). The counselor might ask the person to recall how they actually felt after using—perhaps hungover, anxious, or ashamed—and reflect on the real emotional toll of their substance use.

After identifying the flaws in the initial mental imagery, the therapist encourages the individual to replace it with positive or realistic alternatives. This might involve visualizing success in resisting cravings, engaging in healthy activities, or coping with stress in a constructive way (Hollon et al., 2008). Instead of imagining the temporary pleasure from drugs, the individual may visualize confidently turning down an offer to use and experiencing pride and empowerment. They might also imagine themselves engaging in fulfilling activities like exercising, spending time with loved ones, or achieving career goals (Woolf, 2013).

Imagery rehearsal involves repeatedly practicing the new, healthier images to reinforce them in the individual’s mind. Over time, these positive images become more accessible during moments of stress or temptation, reducing the intensity of cravings (Hollon et al., 2008). Coping imagery involves preparing for high-risk situations by mentally rehearsing how to handle them without resorting to substance use. This technique equips individuals to face difficult scenarios confidently. Motivational imagery focuses on visualizing the long-term benefits of sobriety. By imagining a future free from substance abuse, individuals can strengthen their commitment to recovery (Woolf, 2013).

Example of Imagery Technique in Practice

Consider someone struggling with alcohol cravings, particularly when they think about relaxing after work with a drink. The therapist helps the individual first identify this image as a trigger. They then work together to challenge this image by recalling the negative consequences of drinking, such as a hangover or guilt the next day.

The next step involves replacing the image with a healthier one—perhaps the person coming home and relaxing through a hobby or spending quality time with family. They might visualize waking up refreshed and productive the following morning. Rehearsing this new imagery can reduce the power of the craving over time (Hollon et al., 2008).

Activity scheduling

Activity scheduling involves planning positive and meaningful activities that help individuals manage their emotions, reduce cravings, and rebuild a structured lifestyle without reliance on substances (Beck, 2011). Substance abuse often leads to a cycle of negative behaviors like isolation, idleness, and risky activities. Scheduling constructive activities helps break this cycle by replacing harmful behaviors with positive ones (Wright et al., 2006). Substance abuse can lead to chaotic, unpredictable daily routines. By scheduling activities, individuals can regain control over their time (Miller & Rollnick, 2013). Engaging in rewarding or pleasurable activities helps improve mood, which is essential because negative emotions like boredom, stress, or depression can trigger cravings (Beck et al., 1993).

Participating in positive activities helps clients rediscover their interests, passions, and talents, aiding in the development of a new, sober identity (Marlatt & Gordon, 1985).

Components of Activity Scheduling:

• Identifying enjoyable and meaningful activities: Clients are encouraged to explore activities that they used to enjoy before substance use or discover new ones. These could include hobbies, social events, exercise, or self-care practices (Beck, 2011).
• Balancing short- and long-term goals: The schedule includes daily routines, leisure activities, and long-term goals like education, job training, or repairing relationships (Wright et al., 2006).
• Addressing avoidance: Clients often avoid situations that remind them of failure or discomfort. Activity scheduling helps them gradually face and overcome these challenges by engaging in healthy behaviors (Beck et al., 1993).
• Enhancing social connections: Activities are often planned to foster positive social interactions, helping clients rebuild supportive relationships and avoid social isolation (Woolf, 2013).

Steps in Activity Scheduling:

• Assess current activities: The therapist and client assess how much time is currently spent on productive vs. unproductive or harmful activities, including substance use (Miller & Rollnick, 2013).
• Create a daily or weekly plan: The therapist works with the client to create a realistic and balanced schedule. This includes both mandatory tasks (like work or therapy) and optional activities (like hobbies, relaxation) (Wright et al., 2006).
• Monitor progress: Clients track their activities and reflect on their emotional and physical responses to scheduled activities. This feedback helps adjust the schedule to enhance its effectiveness (Beck et al., 1993).
• Address challenges: The therapist helps clients overcome obstacles that may arise, such as lack of motivation, feelings of hopelessness, or unanticipated triggers for substance use (Marlatt & Gordon, 1985).

Making an activity plan should be a collaborative work of the client and the counselor. The counselor can boost the client’s motivation by encouraging them to remember every hobby, activity, or interest they had when they were younger. If the client finds it hard to remember much, they can be invited to think of something they admire seeing other people (friends, influencers) passionate about (Beck, 2011). Depicting it as an opportunity to do something exciting and interesting in their lives might work as a valuable source of motivation.

Activity categories that might be offered as inspiration for the client:

• Exercise (e.g., walking, yoga, gym workouts)
• Creative hobbies (e.g., painting, music, writing)
• Social engagement (e.g., meeting with friends, attending support groups)
• Educational or skill-building activities (e.g., reading, attending classes)
• Self-care (e.g., relaxation techniques, meditation) (Woolf, 2013).
  
  

Clients may initially resist the process, feeling overwhelmed or unmotivated, especially if they have been struggling with substance use for a long time. It requires consistent monitoring and adaptation, as the client’s needs and emotional states change over time (Miller & Rollnick, 2013). Support from others (like family or social groups) may be necessary to encourage adherence to the schedule, especially in the early stages of recovery (Marlatt & Gordon, 1985).

 Difficulties with clients who engage in substance abuse

Clients may enter therapy with resistance or ambivalence about change (Miller & Rollnick, 2013). A strong therapeutic relationship can help identify and address these barriers, facilitating a smoother path to therapeutic progress (Norcross, 2011). Working with clients who have substance abuse problems is often challenging. Many clients feel apprehensive about opening up and sharing their innermost thoughts and feelings (Miller & Rollnick, 2013). This fear of vulnerability can lead to avoidance of seeking help. Clients may not feel ready to confront their issues or may lack the motivation to engage in the hard work required for therapy (Perry et al., 2014). They also may minimize the extent of their use or dismiss the idea that it’s problematic. Denial of the problem or its extent can serve as a defense mechanism, protecting clients from the emotional pain or anxiety associated with acknowledging their substance use (Woolf, 2013). It helps them avoid confronting uncomfortable truths about their behavior and its impact on their lives.

CBT requires some cognitive capacity, and for some clients, it can be too difficult (Beck, 2011). They might lack insight, which refers to an individual’s ability to recognize the effects of their substance use on their life, relationships, and overall well-being (Perry et al., 2014). Without insight, clients may resist interventions that challenge their beliefs or encourage them to reflect on their behavior.

Resistance to help (or therapy) can manifest in communication as arguing against therapeutic suggestions or doubting the counselor’s competency (Norcross, 2011). Clients can regularly miss appointments or arrive late. They might refuse to do assigned tasks or forget homework. Refusing to take responsibility and concentrating on how others are to blame can also be a sign of resisting change (Miller & Rollnick, 2013).

When clients try to commit to seeking help, their dysfunctional beliefs are most likely activated. If unnoticed, these beliefs can interfere and block the therapeutic process (Woolf, 2013). Examples of these beliefs:

• “I am incapable of doing anything new and different.”
• “If I make changes, I will lose my identity.”
• “If I talk about things that upset me, I will collapse.”
• “If I try to change myself and my life, things will get worse.”
• “I am too weak and vulnerable to help myself.”
• “If I make positive changes, I will lose the attention and nurturance of others.”
  
  

When therapists and clients work together to uncover and address these beliefs, it strengthens the therapeutic alliance (Norcross, 2011). This collaboration can create a more open and trusting environment, facilitating deeper work (Miller & Rollnick, 2013). Understanding a client’s beliefs can inform the therapeutic approach. For example, if a client believes therapy is only for “weak” people, the therapist can work on reframing that belief and demonstrating the value of seeking help (Beck, 2011).

When counselors identify and work through clients’ dysfunctional beliefs, they gain deeper insights into their clients’ experiences. Understanding clients’ struggles can deepen therapists’ empathy and engagement (Perry et al., 2014). It helps to build resilience and experience navigating difficult moments with clients (Woolf, 2013).

Self-reflection on therapists’ beliefs about clients who abuse substances is crucial for fostering empathy, reducing stigma, and enhancing the therapeutic alliance. By examining and challenging your beliefs, you can create a more supportive and effective environment for your clients, ultimately contributing to their recovery and well-being.

Questions to answer for the counselor about working with substance-abusing clients:

• Would you like to work with them?
• Do you expect them to be “difficult”?
• Do they feel like “hopeless”?
• Do you think they are responsible for their problems?
• Can you empathize with them?
• Are you at risk of becoming overly involved, or do you find it challenging to connect?
• Do you view substance abuse as a mental disorder, a choice, or a combination of both?
• …
  
  

Now try to reflect on (and share with the group) how your views may influence your expectations and interactions with clients:

• Are you more empathetic, or do you harbor judgments that could affect the therapeutic relationship?
• How do your beliefs affect your approach to treatment?