07-04-2026, 07:36 background module 3: Addiction and Compulsive Disorders

background module 3
Cognitive-Behavioural Therapy for substance use disorders
Cognitive-behavioural therapy (CBT) has its theoretical foundations in research on learning and
conditioning conducted by scholars such as Pavlov, Watson, Skinner, and Bandura (Craighead et
al., 1995). This body of work demonstrated that behaviour is shaped through associations
between stimuli, responses and appetitive/aversive outcomes, and through observational and
social learning. These principles have been highly influential in the development of psychological
interventions for substance use disorders, particularly approaches that target conditioned
responses to substance-related cues and reinforcement processes that maintain use.

Research into Pavlovian (classical) conditioning originated in the Soviet Union, where Pavlov
(1849-1936) demonstrated that previously neutral stimuli can come to elicit conditioned responses
after repeated pairing with an unconditioned stimulus. In addiction, this insight led to early cue-
exposure interventions, in which individuals are exposed to substance-related cues in the
absence of consumption. Although cue exposure was initially intended to weaken or extinguish
conditioned craving responses, later research has shown that such associations are difficult to
erase entirely. As a result, current CBT approaches focus less on eliminating conditioned
responses and more on developing alternative coping responses and behaviours that can
compete with substance-use urges when cues are encountered.

Skinner’s work on instrumental (operant) conditioning further advanced understanding of how

substance use is maintained, by showing that behaviours followed by reward or relief are more
likely to be repeated. In addiction, substance use is often negatively reinforced by reductions in
withdrawal symptoms, stress, or negative affect. Operant conditioning principles have informed
both aversive and reward-based interventions. Aversive approaches, such as the use of disulfiram
in alcohol use disorder, aim to reduce drinking by pairing alcohol consumption with unpleasant
physiological effects. More commonly in contemporary treatment, positive reinforcement
strategies are applied through contingency management, in which desired behaviours (e.g.,
abstinence verified by negative urine tests, attendance at treatment sessions, or engagement in
healthy activities) are reinforced with tangible rewards. Contingency management has
demonstrated strong empirical support, particularly for stimulant use disorders, although it is still
not routinely implemented in many addiction treatment settings.

Building on these learning principles, the central aim of CBT in the treatment of substance use
disorders is to help patients identify high-risk situations, triggers, and maladaptive cognitive and
behavioural patterns that contribute to continued substance use. Patients are supported in
learning how to avoid certain risk situations where possible and, crucially, how to respond
differently when exposure cannot be avoided. CBT assumes that individuals are capable of
change and are able to change their behaviour through increased self-awareness and the
acquisition of practical coping skills. Core techniques include self-monitoring, goal setting,
functional analysis, self-control measures, emergency measures (i.e., relapse prevention) and
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dealing with craving. CBT is highly adaptable to individual goals and circumstances and is
supported by substantial empirical evidence demonstrating its effectiveness in reducing substance
use and related harm.

Finally, CBT for substance use disorders is typically delivered within an integrated treatment
framework that extends beyond substance-focused behaviour change. Treatment often addresses
co-occurring psychological difficulties, such as anxiety, depression, and interpersonal problems,
which frequently interact with and maintain substance use (see Module 4). By combining learning-
based interventions with cognitive and skills-based strategies, CBT provides a flexible and
empirically grounded approach to the treatment of substance use disorders.

Motivational interviewing (MI)

Nowadays, MI is widely regarded as a important adjunctive intervention technique in the treatment
of substance use disorders. MI is defined asMI is “a collaborative, goal-oriented conversation style
with special attention to change language. It is designed to enhance personal motivation and
commitment to a particular goal by eliciting and exploring a person's reasons for change in an
atmosphere of acceptance and compassion” (Miller & Rollnick, 2015).

Behaviour change is often difficult, particularly in the context of addiction. Substance use typically
develops over many years and, in addition to its negative consequences, is associated with
immediate rewarding or relieving effects. As a result, individuals with addiction are often
ambivalent about changing their behaviour, simultaneously recognising the harms of use while
valuing its perceived benefits.

Within MI, the therapist explores this ambivalence through an empathic and structured dialogue.
Patients are invited to reflect on their current difficulties, their motivations for and against change,
their personal values, norms, and goals, and the discrepancy between their present situation and
their desired future. MI also aims to strengthen the patient’s sense of competence or self-efficacy
by identifying obstacles to change, exploring past successes, and encouraging reflection on
possible strategies for change. While MI is characterised by an accepting and non-judgemental
stance, it is also directional: the therapist actively guides the conversation toward change by
selectively reinforcing expressions that support movement away from substance use.

In this context, patients typically express both change talk (e.g., “I would like to quit” or “I need to
stop to keep my job”) and sustain talk (e.g., “I’ve tried before and I don’t think I can quit” or
“drinking is the only thing that helps me relax”). A central goal of MI is to elicit and strengthen
change talk while reducing sustain talk. This is achieved through the use of open-ended
questions, reflective listening, and exploration of the perceived advantages of change and
disadvantages of continued substance use. In the later phase of MI, therapist and patient
collaboratively develop a concrete plan for change. A common therapeutic pitfall is moving too
quickly into planning before sufficient motivation has been established, as a high level of
readiness for change is considered a key prerequisite for successful behaviour change.

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MI stands in contrast to more confrontational approaches, such as the Johnson Model

Intervention (see Module 5). Importantly, current scientific evidence provides stronger support for
MI and CBT than for confrontational interventions in the treatment of substance use disorders. As
a stand-alone intervention, MI is particularly suitable for individuals with mild substance use
problems, while in more severe cases it is most effective as an adjunct to CBT, where it can
enhance treatment engagement and adherence. Consequently, MI is regarded as a core clinical
skill by the majority of Dutch addiction treatment centers.

Pharmacotherapy
Although this module does not focus on pharmacotherapy, an understanding of the main
medication strategies used to support psychological interventions such as CBT is important in the
comprehensive treatment of substance use disorders. Pharmacotherapy is used not as a
standalone cure, but as an adjunct to CBT and other behavioural interventions to improve safety,
reduce physiological symptoms, decrease craving, and increase patients’ capacity to engage
effectively in these interventions.

Withdrawal management (detoxification). In patients undergoing withdrawal management,

pharmacological agents are used to reduce the risk of severe physiological complications: for
example, benzodiazepines remain a standard option to manage alcohol withdrawal symptoms and
prevent seizures or delirium tremens, whereas opioid detoxification is managed through carefully
monitored tapering or short-term use of medications such as buprenorphine or methadone.

Relapse prevention. For individuals with alcohol use disorder, medications that support relapse
prevention - notably naltrexone and acamprosate - have robust evidence for reducing craving and
harmful drinking when combined with psychosocial support. Naltrexone exerts its effect by
obstructing the mu-opioid receptor (indirectly involved in the regulation of dopamine), while
acamprosate has an inhibitory effect on the glutamatergic system. Long-acting injectable
naltrexone is an important option for patients with adherence challenges. It is interesting to note
that Naltrexone in some studies has also shown to be effective in supporting CBT for gambling
disorder.

Aversive drugs. Agents such as disulfiram are available and can support abstinence through
aversive conditioning, but in settings such as the Netherlands and specialised clinics like Jellinek,
their use tends to be selective and supervised rather than first-line, reflecting mixed evidence and
adherence requirements. Disulfiram prevents alcohol in the body of breaking down, resulting in
nausea, headache, dizziness, sweating and palpitations.

Maintenance (or 'medication-assisted') treatment. This treatment involves prescribing

medication that has the same chemical properties as the drug to which that person is addicted. In
this way, withdrawal symptoms and craving are prevented. In opioid use disorder, medication-
assisted treatment (MAT) with long-acting opioids such as methadone or buprenorphine/naloxone
is considered first-line standard care and may be continued long-term as part of a chronic-care

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model; these medications reduce withdrawal and craving, stabilise neural and behavioural
functioning, and provide a foundation on which CBT and psycho-social rehabilitation can build.

Prevention strategies
In contrast to CBT and pharmacological interventions that target established patterns of
substance use, prevention strategies focus on reducing risk and strengthening protective factors
before clinically significant impairment develops. Contemporary prevention approaches move
beyond simple information provision about drugs and focus instead on strengthening skills such
as emotional regulation, impulse control, refusal skills, and coping with stress, which are known to
reduce vulnerability to substance use, particularly during adolescence. At the social level,
prevention includes family-based interventions that improve parenting practices and early
detection, school-based programs that promote social competence and address peer norms
around alcohol and cannbis use, and community initiatives that aim to reduce risk behaviours,
such as peer-led outreach in nightlife and at festivals. Environmental and policy-level strategies
further shape behaviour by reducing exposure and opportunity. These strategies are widely
applied in the Netherlands, including age limits for alcohol sales, regulation of alcohol availability
in public spaces, pricing measures, and local prevention plans coordinated by Municipal Health
Services (GGD). Prevention approaches are commonly classified as universal (e.g. school-wide
prevention programs), selective (e.g. targeted programmes for children of parents with substance
use disorders or youth in high-risk neighbourhoods), and indicated (e.g. brief interventions for
adolescents already experimenting with substances but not yet meeting diagnostic criteria). From
a clinical psychology perspective, prevention programs underscore the importance of early
intervention, developmental sensitivity, and recognising that substance use disorders emerge from
dynamic interactions between individual vulnerabilities and social contexts.

Despite strong evidence for many preventive strategies, a key ongoing challenge lies in
translating research into sustainable, large-scale implementation, underscoring the need for
clinicians to engage not only in individual-level work but also in advocacy, program development,
and interdisciplinary collaboration with policy-makers, schools, families and community services to
reduce the overall burden of addiction.

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