Eight CBT practitioners (i.e., seven females and one male) were recruited for the present study. Their ages ranged from 27 to 43 years. Among them, one had a PhD in psychology, three had MS in psychology, and five had MSc and a postgraduate diploma in clinical psychology. Years of practising CBT ranged from three to 11 years, while the experience of working with people with SUDs ranged from four to seven years. Although, the data were collected from CBT practitioners/psychologists, they provided ample information regarding various aspects of society and systems affecting the delivery of CBT as a treatment for SUDs. See Table 1 for themes and subthemes that were identified during the analyses. However, its detailed description is illustrated below.
Mental health system
The mental health system was divided into the following subthemes:
Enormous discrepancy between workforce i.e., CBT practitioners and workload was reported. “On a daily basis, I see 20 patients on average. In addition, the workload is not even uniform. Some parts of the day, I see 4–5 patients in an hour and some parts of the day I only see one patient per hour, it depends on the arrival of the patients. It definitely affects my work badly. Sometimes I am not at all happy about it, as I am not able to utilize my ability fully.” (Female, 6 years using CBT).
It was highlighted that a greater workload leaves CBT practitioners with limited case preparation time, resulting in frustration. “It becomes very frustrating when you want to contribute to the mental health of people, but limited time does not allow you to.” (Female, 6 years using CBT). It was also reported that shared working space for CBT practitioners affects the privacy of the patients, which is a basic requirement for psychotherapy. “Patients with psychological illnesses always require confidentiality and privacy to share their personal issues, because these are their sensitivities and vulnerabilities and they don’t want to open up in front of everyone. It is unlike any general medical condition, but it is unfortunate that psychologists not only have to share their working space with their colleagues, but there are large number of patients also queuing for their turn, which makes it very difficult for our clients to entrust us with their problems.” (Male, 5 years treating SUDs).
It was also highlighted that access to treatment was challenging for people living far away from Islamabad, where better treatment facilities were available. “Family members sometimes bring their relative with substance issues to the hospital a day ahead of the appointment. They travel from various distant places, and it is not possible for them to be on time during the working hours. Therefore, they have to come a day ahead of the appointment. Then, they stay on the premises of the hospital the night before their appointment, as they cannot afford any private accommodation nearby for a night’s stay. Such odds in themselves are traumatizing for the whole family. Such issues make it hard for the majority to avail treatment for people with substance abuse.” (Female, 10 years using CBT).
Collaboration between psychologists and psychiatrists
Power imbalance between psychiatrists and psychologists at workplace and a lack of understanding of psychotherapy on part of psychiatrists was reported. “At times it becomes difficult to make CBT understandable not only for the patients, but also for your psychiatry colleagues.” (Female, 4 years using CBT). “I assist senior psychiatrists in the hospital. I am sometimes answerable to my boss for spending more time with certain patients, which affects my decision-making and independence to formulate therapy according to the requirements of the patients.” (Female, 3 years using CBT).
Some societal practices were highlighted that restrict the utilization of CBT for SUDs in Pakistan. The following subthemes were identified:
The interviews highlighted the effects of a deep-rooted belief system on the treatment approach towards SUDs. “I have seen patients with chronic substance abuse with family members stressing the point that their relative has been taken to various renowned spiritual healers and “Dargahs” (shrines), but to no avail.” (Male, 7 years using CBT). A family member’s saying was quoted, “he prefers staying in the nearby “Mazaar” (shrine). He doesn’t eat the meals we give him, and he doesn’t return home for days despite our requests. People who visit “Mazaar” ask him and others staying there to pray for them.” (Female, 5 years using CBT).
Influence of family and peers
It was reflected in the interviews that family support was essentially required for the success of therapy. However, the family can have a negative effect on therapy outcomes. “A lack of tough love on part of family members is what ruins all the efforts put into therapy for people with substance abuse. Family simply gives in to the begging of their relative and for their “release” from treatment.” (Female, 7 years treating SUDs). “There are many instances when I requested family for assisting patients in their homework, motivating them to change, or having a diary of automatic thoughts, cues and triggers for using drugs. However, family members appeared to be more controlling than supportive, which offended and discouraged the patients from becoming self-aware and self-reliant.” (Female, 5 years using CBT).
The prevalence, process, and causes of substance abuse among the youth were reported by the respondents. “Youngsters normally start taking drugs for fun or for being accepted among their peers. Initially, it is kept secret from family or parents, as such behaviour is completely unacceptable in society. That is the reason the issue cannot be addressed in a timely manner. It [the addiction] gets full bloom before being discovered by the family.” (Male, 5 years treating SUDs). “It is correct that causes of drug abuse vary from person to person, but it’s my observation that adolescents with low self-esteem are more susceptible to peer pressure and indulging in problematic behaviours, such as substance abuse or drug addiction. Therefore, work on their self-esteem is an initial step in the therapy.” (Female, 7 years treating SUDs). Almost all the participants agreed that educated youth with substance abuse who became addicted due to peer pressure were easy to engage in CBT. Therapy outcomes were also positive with such individuals.
Illegal practices and the drug mafia
Certain illegal practices associated with drug misuse that hinder the treatment process for people with SUDs were reported: “it is not always the impulse or withdrawal effect for the patients which makes them relapse, but they are so deeply ensnared in drug mafias, including legal personnel or drug dealers, that they cannot be helped despite their own and their families’ desires.” (Male, 5 years treating SUDs). “I can feel how scared they [patients] feel, through their nonverbal cues when asked to talk about the high-risk situations for drug abuse. Most likely, it is the flawed law enforcement system that victimizes them instead of helping them.” (Female, 4 years treating SUDs).
Therapeutic issues involved the following subthemes:
Perceptions of the patients’ understanding of CBT
It was reported in the interviews that reliance on psychotherapy seemed impractical, unrealistic or illogical to the patients. “The patient asked me with surprise and a little bit of annoyance, do you think my problem is so light to be treated with talk only?” (Female, 4 years using CBT). Moreover, it was highlighted that lack of awareness about usefulness of psychotherapy hinders its acceptability. “People with substance abuse are full of uncertainties regarding CBT as a treatment option because it is a completely new idea for them. They do not seem to understand how talking about the problem or following some tasks or exercises can be helpful in treating their issues. They do participate in therapy half willingly, get bored with it very soon, and terminate therapeutic treatment shortly after.” (Female, 3 years using CBT).
The patients’ lack of understanding of the basic concepts of CBT was also reported. “One problem which I encounter most of the time is that the patients argue that their beliefs are based on their religion, which is perfect and without any distortions or flaws. Explaining it to them that the beliefs I am talking about are not religious, rather individual and personal, is time-consuming and tedious task.” (Female, 9 years of using CBT).
Likewise, difficulties in understanding the concepts of delaying, distracting, decatastrophising, and disputing were reported: “(patients) consider that delaying means delaying the urge to use the drug for some time as a formal requirement of therapy, after doing so they feel liberated from the task assigned to them and start thinking about the drug all over again, which is surely counterproductive.” (Female, 5 years using CBT). “Distractions are often misperceived. People with substance abuse try to distract themselves from the urge to use the drug with something or someone related to drug, which obviously is not helpful.” (Female, 8 years using CBT). “Sometimes there is lack of self-awareness among people with substance abuse. They believe that they are using the drug only for recreational purposes, and they do not consider it catastrophic if they resist the urge to use the drug or if the drug is not available. However, guided discovery often reveals the contributing role of the catastrophizing aspect of their thinking.” (Female, 7 years treating SUDs). “Disputing may be due to its negative connotation taken as something undesirable. I have had patients ask me if it is required to be aggressive towards the urge or thought to use the drug because it causes them more anxiety and guilt when they do so.” (Female, 11 years using CBT). In addition, it was reported that it was equally difficult to make the concept of irrational beliefs understandable to the patients. A patient’s response was quoted: “… why would I have an irrational belief? I am educated, and I know my problems are caused by my life circumstances and not by any external force.” (Female, 7 years using CBT).
Issues relating to patient engagement with CBT and attrition rates
Engaging patients in therapeutic sessions was reported to be challenging. “There are more male patients with substance abuse compared to females, while most CBT practitioners or psychologists are females. Perhaps the male patients are not comfortable engaging in a long therapy session with a female practitioner due to cultural norms or hesitation. That’s why they try to end the session quickly. This has no positive effect on their treatment though.” (Female, 7 years treating SUDs). “People coming to hospitals in Islamabad for treatment normally travel long distances in the public transport, which involves a lot of time and effort. This probably causes a rush, as they have to travel back a long distance again. They think therapy should be like getting a doctor’s prescription quick and crisp, which is not the case.” (Female, 5 years treating SUDs).
“Only those patients who are very desperate to share the underlying causes of their addictive problems have higher acceptability for CBT. It provides them the opportunity to be heard and share, which is an initial step towards success of the therapy.” (Female, 6 years using CBT).
“Females are more willing to accept CBT as a treatment option compared to male patients.” (Female, 4 years using CBT).
Limited capacity for payment, and uncertainties regarding CBT as a treatment option, also affected patients’ engagement in CBT. “If a patient has to pay 100 rupees for a session and the same amount for the doctor’s appointment, he’ll prefer the doctor’s appointment and refuse to participate in the therapy.” (Female, 5 years using CBT). “One of the patients argued I’d prefer taking some edibles home with the money instead of giving it away for mere talk.”(Female, 5 years using CBT).
The attrition rate was reported to be lower among people with substance abuse who were residing in the rehabilitation centres compared to those who visited the outpatient department in the hospitals: “most of the substance abuse clients discontinue therapy after two or three sessions, taking it nowhere,” (Female, 7 years treating SUDs).
“Patients in rehabilitation centres have to follow a certain routine, and they take therapeutic sessions as part of their routine activities, so it is easy to engage them in sessions of CBT during their stay in the centre.” (Female, 4 years treating SUDs).
“Commitment to therapy is a heavy responsibility requiring persistence, but there is a great risk of relapse in substance abuse of clients. It makes it hard for them to continue their therapy.”(Female, 6 years treating SUDs).
“Patients think psychotherapy is some sort of magic which will eradicate substance from their lives without any of their input or effort.” (Female, 4 years treating SUDs). “Patients often have a long history of substance abuse but they want a quick fix. Such unrealistic expectations can take them anywhere from disappointment to discontinuation of therapy.” (Female, 7 years treating SUDs).
Perceptions of patients’ compliance with CBT therapeutic processes
Compliance with CBT homework tasks was reported to be low in the present study. “I can see from the face of the patient that they are not going to do their homework as they seem not to be interested in taking it. Therefore, I repeatedly explain to them how important it is for them to cooperate if they truly want to improve.” (Female, 5 years using CBT). “When I feel that the patient is not going to follow what they have been asked for as homework, I involve their family members to facilitate completing their homework.” (Female, 4 years using CBT).
“Patients sometimes expect an immediate remedy for the deep-rooted and prolonged disorder, which is why they find it hard to work on a weekly basis to achieve relief. Maybe it is the despair, impulsivity, or finding it absurd to do homework, which is at work when not complying with the suggestions.” (Female, 11 years using CBT).
Moreover, in the present study, CBT practitioners highlighted some confusion, which patients experienced during the therapy, which if not addressed appropriately, resulted in dropouts or relapse. “I have found patients worrying and guilty about quitting the drug not because it was hard for them to quit, but they were, in fact, equating it with leaving their friends and company in which they used to do drugs. In such cases, proper guidance is necessary for differentiating between quitting the drugs and leaving the friends or the company of peers.” (Female, 4 years treating SUDs). “It is not unusual for people with substance abuse to have occasional lapses during therapy, but sometimes patients consider it their failure and become discouraged and demotivated. Such demotivation, if not resolved in a timely manner, can result in a complete relapse. We encourage patients to view lapses as opportunities to identify the weaknesses, cues, and triggers, which led to a lapse to avoid relapse.”(Female, 6 years treating SUDs).
In addition, patients’ conformity bias and misreporting were reported to be counter effective for CBT: “at the start of the therapy patients tend to be very cooperative and motivated, maybe they are trying to be accepted and to be more presentable. They are keeping their masks tight. They probably try to guess what will be appreciated in the therapy so they fake report the positives and negatives about substance abuse. Such overreporting affects the whole process and progress of therapy negatively.” (Female, 5 years using CBT).
Likewise, a poorly reported history of drug abuse and relapses was reported to be another factor that negatively affected the outcome of the therapy: “knowledge of the history of substance abuse, number of times the patient sought the treatment or psychotherapy, and instances of relapses in the past are crucial for the psychotherapist to determine the goals of therapy and the selection of appropriate therapeutic techniques for the patient, but patients do not realize how important it is for their treatment. Their distorted reporting hinders the process of abstention.” (Female, 6 years treating SUDs).
Similarly, it was reported that some facts patients did not report correctly may facilitate the therapeutic process:. “patients have a hard time exploring the internal factors responsible for their substance abuse behaviour. As a therapist, we can only guide them through such introspection, although it depends completely on their own sincere efforts to explore.” (Female, 7 years treating SUDs).
Psychologists’ perceptions of personal challenges
Furthermore, practical issues constraining the use of CBT were also highlighted in the interviews: “standardized CBT manuals are available for different types of substance abuse, but there is no standard translation available in Urdu [Pakistan’s national language] for any one of them. This limitation restricts us [psychotherapists] from implementing the techniques of CBT and accomplishment of homework forms.” (Female, 6 years treating SUDs). “It becomes a great challenge to translate all assessment tools and worksheets for homework for patients. We [psychotherapists] have a short amount of time due to massive workload and limited therapists available.” (Female, 3 years using CBT).
Making CBT terms understandable for patients was reported to be challenging as well: “when I tell my clients that you have to work on your absolutistic thought patterns. You have to start changing “should” and “musts” patterns in your thinking. My patients, most of the time, argue that they are very compromising, and they never insist on having anything. They do not understand that it’s not about having material gains, but it is about changing the attribution processes.” (Female, 4 years using CBT).
In addition to challenges pertaining to patients and the system, certain limitations on the part of the therapists were reported to have a negative effect on the therapeutic process and outcomes: “I understand that empathy is vital in the treatment of people with substance abuse. I also admit that when I am overburdened, as I am the only psychotherapist working in my organization, it becomes extremely difficult for me to empathically involve my patients, which definitely affects therapy outcomes negatively.” (Female, 3 years using CBT).
Additionally: “due to time constraints and being overworked, it is hard to keep updated the therapeutic knowledge. I feel bound to use traditional CBT techniques.” (Female, 5 years using CBT). Furthermore: “CBT takes a collaborative approach, while patients expect directions or advice from us (therapists). They request it until they understand that therapy has to be collaborative. I do suggest and direct them on certain issues in order to move on in therapy.” (Female, 4 years using CBT).
Useful CBT techniques
In the context of Pakistan, certain CBT techniques were reported to be more effective: “providing CBT in group format has resolved many issues for me, like time constraints, patients’ discomfort and inhibition to share their problems, rapport building, and ambivalence to change or lack of motivation to start therapy. Group format probably gives them confidence that they are not alone in their situation.” (Female, 11 years using CBT).
“I spend a lot of time motivating those patients who are brought to therapy by their family or referred by law enforcement agencies. Motivation is key to change; once patients are motivated to change, it becomes easy to proceed with therapy and succeed.” (Female, 8 years using CBT).
“I found role play as one of the most effective therapeutic techniques. It is equally useful for patients with a low educational background. This is similar to real life situations. The participants were usually people with substance abuse under therapy. It facilitates learning life skills of assertiveness, resistance, and confidence simultaneously for all the participants, hence is very efficient.” (Female, 5 years using CBT).
“Successfully educating patients about their automatic thoughts, irrational beliefs, misconceptions about therapy, exploration of triggers and cues for drug usage, and possibility of quitting the drug by changing their thought patterns helps a lot in making therapy a success.” (Female, 7 years treating SUDs). “Training and practice of progressive muscular relaxation is very useful in distracting and relaxing patients during cravings for drugs. It takes time to train patients but once learned it has greater benefits.” (Female, 4 years treating SUDs).
“I do some modifications in the homework worksheets and forms on my own to make them understandable for patients who cannot read or understand it in English. I make sheets more illustrative and interactive by adding pictures and images to make the homework understandable.” (Female, 4 years using CBT).