Advanced Psychotherapy Cognitive Behavioral Therapy CBT for SUD

Advanced Psychotherapy: Cognitive Behavioral Therapy

§CBT for SUD §Multiple manuals §Motivational Interviewing/Enhancement Therapy §Contingency Management § 12 -step Facilitation §Behavioral Couples Therapy

§Cognitive-Behavioral theoretical approach §Short-term manual driven treatment §Can be administered 1: 1 or in group §Each 1 hour session is focused on a specific topic §Treatment is education/skills based

§ Help client identify why he or she uses substances § Help client master skills needed to maintain abstinence (i. e. , identify high risk situations and how to deal with them) § Abstinence is the goal, but relapse is learning opportunity § Patient may or may not be involved in AA or NA

§Therapist must skillfully select and tailor CBT modules to clients §Manualized Treatment is NOT a cookbook §Basic skills for psychotherapy are extremely important (i. e. , accurate empathy, genuineness, and positive regard)

§ Maintaining structure is crucial § Different than supportive psychotherapy § Each treatment session has a pre-determined agenda § Focus on necessary changes to reduce chronic distress § Modeling a systematic, non-impulsive style

1. Coping with Cravings and Urges to Use 2. Managing Thoughts about Substance Use 3. Drug/Drink Refusal Skills 4. Seemingly Irrelevant Decisions 5. An All-Purpose Coping Plan 6. Problem Solving 7. Case Management 8. HIV Risk Reduction 9. Significant Other Session 10. Termination

1. Managing Thoughts about Drugs and Alcohol 2. Managing Negative Moods and Depression - I 3. Managing Negative Moods and Depression - II 4. Anger Awareness 5. Anger Management 6. Receiving Criticism 7. Increasing Pleasant Activities

§ Substance dependence from learning theory § Learned associations develop between substances and external and internal (thoughts, feelings) cues § See someone using may produce craving § Feeling anxious may be associated with using § Beliefs are developed about substance use § “Drinking is the only way I can deal with my depressed mood” § Explanation of high risk situations

§ Treatment from a learning perspective § The same principles that led to them learning to have a drug problem, will also be used to help them learn to lead a life without drugs § Skills will be taught to replace old habits § Nobody is born an addict or alcoholic

Coping with Cravings and Urges to Use

§ Cravings and urges § Not a sign something is wrong § Often triggered by external or internal cues § Time-limited (up to 10 minutes on average) § Physical signs (Changes in heart rate, muscle tension, nausea) § Psychological signs (Anxiety, tension, irritability)

§ Learn to recognize urge triggers (functional analysis) § When did it occur? § Where did it occur? § Who was I with when it occurred? § What was I thinking beforehand? § What did I think using would do for me at that moment? § What emotion was I experiencing?

§ Skills to cope with cravings § Avoid cue § Escape cue § Distraction § Talk it through § Challenge and change thoughts § Homework: monitor cravings and coping skills used

Managing Thoughts About Substance Use

§ Drug-related thoughts are normal in recovery, drug- related behavior is destructive § Should encourage patients not to beat themselves up because of drug-related thoughts § Normal because drugs work very well in short term

§ Learn to identify thoughts that may lead to resumption of using: § Nostalgia – remember positive events related to drugs use and forgetting negative consequences § Testing control – “I wonder if I can have just one? ” § Crisis – “I can only get through this with a drink” or “I need a drink” following a crisis § Socialization – feeling lonely because of stopping substance use § Not feeling comfortable with normal negative or positive emotions

§ Methods to manage thoughts about use § Challenge thoughts § E. g. “ I don’t need a drink. There are other ways to cope with this, and besides drinking will actually make me feel worse. ” § List and recall benefits of not using § E. g. , My mind is clearer, I’m proud of myself, etc. § List and recall unpleasant using experiences (i. e. , “thinking through the drink” in AA language) § Distractions

§ Homework § List Positive benefits of NOT using § List negative consequences of using § Transfer this information to 3 X 5 card § Encourage them to carry with then § Some will include pictures of children/spouses/loved ones on card § Identify drug/alcohol thoughts and coping skills used § Rather than simply journaling, be specific about recovery-based skills

Drug/Drink Refusal Skills

§ Very important session because some lack assertiveness skills § Over time, the social network begins to include more substance abusing peers and fewer nonabusing peers § Describe types of pressure § Overt pressure from friends, family, users, dealers § Subtle pressure of social situation (e. g. , wedding)

§ Helpful skills for drink refusal § Behavioral avoidance (just don’t go there!) § Nonverbal behaviors (e. g. , clear voice, eye contact) § Verbal behaviors (e. g. , “no” first word, suggest alternative, avoid excuses, etc. ) § Generalize refusal skills from other successful situations (e. g. , saying no to encyclopedia sales person) § Homework: Develop refusal responses to different categories of people § Friends, family, bosses, waiters, dealers, etc.

Seemingly Irrelevant Decisions

§ People do not just “end up” in crack houses or bars § George was on his way home and decided to take the “scenic route” home. As he was driving, he reached for a cigarette and realized he was out and needed some more. As he was driving, he saw a bar and knew there would be a cigarette machine inside so he figured he would pop in and grab some cigarettes. He went in and saw the machine. He reached into his pocket and realized he needed change. He went to the bar to ask for change and heard someone call his name, “George!”; it was his boss. “A beer for George, ” his boss said. (Marlatt & Gordon, 1985, p. 273)

§ Increase awareness of decisions that increase probability of sobriety § Learn to analyze each decision in terms of how it may affect sobriety; see the “red flags” § Examples: what route to drive home, who to give a ride to, where to go to get snack food, whether to tell people you quit using, carrying cash § Identify “safe” choices in recent or upcoming decisions

An All-Purpose Coping Plan

§ Teaching clients to anticipate high-risk situations, but recognize that life is unpredictable § Have patients identify 3 -4 stressors likely to occur after treatment discharge (e. g. , social separation, new responsibilities, work stress, job promotion) and what their reactions might be § Ask them to anticipate anything that might happen to shake commitment to recovery § Develop a coping plan for each situation

§ Because life is unpredictable, clients should also develop an all-purpose coping plan containing: § A set of emergency phone numbers § Negative consequences of returning to use § Positive thoughts that can be substituted for high-risk thoughts § A set of reliable distracters § A list of safe places to ride out temptation

§ We know that substance use disorders are chronic, relapsing conditions (particularly when relapse is defined as any use after treatment) § Defining relapse too rigidly can set clients up for the “abstinence violation effect” § Within the CBT framework, relapses are viewed § As learning experiences § As red flags for the future § As choice points

§ Slips (a single isolated use) vs lapses (greater use, but without a return to regular use) vs relapses (return to regular use and re-emergence of symptoms) § This is very useful for many clients, however, clients who have been through 12 -step programs may be very resistant with this distinction § You can build an effective relapse prevention plan, including what to do if they use again, without using these terms

Problem Solving

§ Over time, clients’ coping and problem solving skills have likely narrowed to drug use only § We take this skill for granted § Clients are taught how to problem solve and given opportunities to practice § There are likely opportunities to foster clients’ use of this skill throughout treatment as they come to you with problems (my kids are upset with me, I need a driver’s license, I don’t have transportation, etc. )

§ The Steps of Problem Solving 1. Recognize the Problem 2. Identify and specify the problem 3. Consider various approaches to solving the problem 4. Select the most promising approach 5. Assess the effectiveness of the selected approach

Case Management

§ Many clients come to treatment with a host of problems awaiting them upon discharge § Therapists can engage clients in problem solving to try to begin to address these issues during treatment § The therapists does not advocate on behalf of the client § The therapist teaches the client to get his or her own needs met

§ Steps in case management include: 1. Identifying problems (unemployed, living with parents, no transportation) § This usually occurs early in treatment 2. Goal Setting (get a job, find stable housing) § Identify and prioritize goals 3. Resource identification § Brainstorm together possible solutions 4. Follow-up and provide praise and encouragement

HIV Risk Reduction

§ Identify ways of transmitting HIV § Identify ways to reduce HIV risk § Risk to partners § Identify barriers to HIV risk reduction (e. g. , partner does not like condoms, client does not like condoms, lack of clean needles, sex trade associated with cocaine use) § Risk reduction model § Identify ways to overcome barriers

Significant Other Session

§ § This is not at all like traditional marital therapy; there is not enough time to resolve long-standing marital problems The goals are 1. Help the significant other understand treatment 2. Explore strategies through which the significant other an help clients stay abstinent after discharge

§ The significant other session is not a gripe session § The CBT model should be briefly explained to the SO § The patient should identify ways the SO can help them maintain abstinence § The SO may also request changes of the patient § The Client and SO can be asked to develop a contract specifying desired behavior changes

§ Review treatment plan and goals to identify successes and areas for continued work § Review coping plans, support plans, etc. § Try to get client to reiterate commitment to doing things differently § Provide feedback on progress made § Allow client to provide feedback on treatment and post-treatment concerns

Managing Negative Moods and Depression

§ Addresses depression and negative moods by changing negative thoughts and behavior § Three A’s § Aware – become aware of the symptoms of depression, especially automatic negative thoughts § Answer – confront negative thoughts with more realistic thoughts § Act – change behavior, act on the thoughts

§ “Automatic” thinking § Second level of awareness: catching thoughts that come to your mind before your symptoms § Thinking Errors (e. g. , magnifying, minimizing, jumping to conclusions) § Homework: step-by-step approach to following the three A’s

Anger Awareness and Management

§ Fairly standard CBT anger management § Correct “good vs. bad feelings” beliefs § Identify constructive and destructive effects of anger § Become aware of external anger triggers § Become aware of internal anger reactions § Events Thoughts Anger

§ Skills § Calming phrase § Analyze situation § Think about options § Employ constructive option § Homework: Monitor anger and behavioral and cognitive response to anger

§ A Cognitive-Behavioral Approach: Treating Cocaine Addiction National Institute on Drug Abuse Clinical Toolbox § http: //www. nida. nih. gov/TB/Clinical. Toolbox. html § Cognitive Behavioral Coping Skills Therapy Manual Project MATCH Monograph Series § http: //pubs. niaaa. nih. gov/publications/match. htm