cognitive therapy for addiction
DESCRIPTION
Training on MSc in Cognitive Psychotherapy Course at Trinity College, Dublin 24th October 2013TRANSCRIPT
Cognitive Behaviour Therapy for Addiction : Motivation and CHANGE
MSc in CBT Dublin, October 24th 2013
Frank Ryan
Overview of workshop
Welcome and introductions
Goals of workshop
Scientific perspectives on addiction
Role of cognition in addiction
Applications & competencies: Time for CHANGE
Introducing “4 Ms”
Motivation & engagement
Managing impulses and craving
Mood management
Mindful recovery
Time for CHANGE
Change
Habits
And
Negative
Generation of
Emotion(Ryan, 2006; 2013)
The Four Ms
Motivate (and engage)
Manage impulses to use
Mood management
Mindful recovery
Addiction is commonly co-morbid
75% had one or more co-occurring mental health condition
8% had a psychotic disorder,
40% had minor depression,
26% had severe depression,
37% had a personality disorder and
19% severe anxiety
(Weaver et al 2002)
4 Ms
Motivation and engagement
Manage impulsivity
Manage Negative emotions
Maintain Change (relapse
prevention)
Healthcare costs (in billions Euro)of emotional and addictive disorders in 30 European countries (27 EU Plus N, CH and Iceland) Gustavsson et al 2011
Depression Addiction Anxiety disorders0
10
20
30
40
50
60
70
80
Five things about addiction
ADDICTION IS COMPULSIVE HABIT
COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF CONSCIOUSNESS
ADDICTION IS ABOUT 50% HERITABLE
MOST PEOPLE WITH ADDICTIONS WHO PRESENT FOR HELP HAVE OTHER PSYCHIATRIC PROBLEMS AS WELL
ADDICTION IS A CHRONIC RELAPSING DISORDER
Five More things…
“COME BACK WHEN YOU’RE MOTIVATED” IS NO LONGER AN
ACCEPTABLE THERAPEUTIC RESPONSE!
DIFFERENT PSYCHOTHERAPIES APPEAR TO PRODUCE SIMILAR
TREATMENT OUTCOMES
THE MORE INDIVIDUALIZED AND BROAD-BASED THE TREATMENT A
PERSON WITH ADDICTION RECEIVES, THE BETTER THE OUTCOME
MIRACLE CURES RARELY HAPPEN
CHANGE TAKES TIME
Low Intensity Interventions
Giving accurate information about addiction, detoxification and relapse to service user & family Brief motivational interventions Contingency management Identifying triggers and cuesCoping skills for impulse control Facilitating engagement in AA/NA/CA/GA
High Intensity Interventions
Programmed cognitive behaviour therapy sessions such as Relapse Prevention Skills Training either on one to one or group basis.
Mindfulness based cognitive therapy Behavioural Couples Therapy
Emotions MatterWhen we experience negative emotions
drugs are more rewarding, as they are reinforced both positively and negatively.
But not the full story...
Psychodynamic tradition viewed drug addiction as: “a replacement for a defect in the psychological structure”. Kohut (1971,p 46),
The question of motivation……In groups of three, discuss what drives
or motivates drug use or compulsive gambling,.
Use examples from your own work if possible.
Cognitive therapy
Addiction motivated by need to cope with or suppress the consequences maladaptive core beliefs such as ‘I am helpless’ or ‘I am unlovable’ (Beck et al. 1993, p. 52)
Cognitive behaviour therapy
“Relapse Prevention Skills Training” model (Marlatt & Gordon,1985; Marlatt & Witkiewitz, 2005 ) tackled addiction using functional behavioural analysis (antecedents, behaviour, consequences) and induction of alternative coping skills.
Focus of CBT in Substance Misuse
Motivation, Motivation, Motivation!
Conceptualising, formulating and treatment planning
Identify high risk stimuli: internal and external
Correct maladaptive beliefs about substances e.g “people would ridicule me if I did not drink at the party”
Identify the involvement of early maladaptive schemas e.g. defectiveness or unloveability as contexts for misuse
Negative automatic thoughts: “Who cares if I drink?”
Coping with craving: e.g. “delay and distraction”
Rationalisations “ permission giving beliefs” e.g. “I deserve one…”
Circumscribing lapses/slips: One swallow doesn’t make a summer!”
Or, just do two things!
Facilitate impulse control Facilitate affective regulation
Early adverse learning experiences
•Formation of dysfunctional schemas e.g "I am not as good as other people".
Exposure to euphoric orhedonic effects of drugs such as alcohol
and cocaine
•Formation of substance related beliefs e.g. "I feel better about myself when I use cocaine or alcohol; people seem to like me more".
Critical Incident: Failed job interview
•Schema about personal inadequacies is activated and triggers automatic thoughts "I am stupid", negative affect and substance related beliefs e.g. "I can't handle this without a drink; I'll feel better if I have some cocaine"
Current case
Maria: 30 yr-old female
Single, but lives with ex-partner
Experiences depressive and angry emotions
that trigger episodes of excessive drinking> impulsive
suicidal behaviour and intent.
Shows high level of insight and motivation
but still engages in problem behaviour 3-4
times per month
Vulnerability factors include parental abandonment and
Rigid parenting style; recently disclosed sexual violence.
New Perspectives
Treatment outcomes are often poor in addiction
Treatment specific effects not demonstrated (e.g. Project Match).
This suggests key variables are not being addressed specifically.
Recent findings implicate impaired cognitive control as a factor in the persistence of addiction.
This needs to be assimilated into CBT
Vulnerability factors in addiction
Implications for psychotherapy
Why Drugs are Addictive
Drugs of abuse such as alcohol, amphetamine cocaine act as primary reinforcers.
This operates directly or indirectly through reward circuit in the brain.
Some people find this hard to resist.
Two Pathways to emotion (& craving)
Information about emotionally salient stimuli and stimuli associated with drug availability reaches the amygdala directly from the thalamus (low road) and also via the cortex (high road).This is why sometimes we feel approach (appetitive)urges or avoidant (fear ) without knowing why. Stimuli are monitored continuously but “amygdala alerts” do not necessarily generate conscious awareness.
Overview of scope and aims of CBT in Substance Misuse
Engaging and motivating individuals into therapeutic programmes
Placing substance misuse in a personal context for the individual (formulating).
Facilitating the acquisition of skills to cope with impulses driving drug seeking and taking
Enhancing affect regulation
Relapse prevention and follow-up (maintenance strategies)
Cognitive control is impaired before during and after substance misusePre-existing –dispositional deficits
Acute effects of intoxication
Withdrawal effects
Carry-over effects
Associated risk factors due to injuries or self-neglect
Executive control is impaired
Up to six 6 years in after seeking treatment alcohol dependent people who are largely abstinent show deficits in executive control despite appearing to function normally in many settings
Detoxified alcoholic men with an average of over 26 weeks abstinence and with otherwise good psychosocial functioning can nonetheless register loss of grey matter in neural structures involved in higher cognitive function: Morphological changes were highest in the DLPFC (up to 20%) but were noted also in the temporal cortex, insula, thalamus, and cerebellum. (Chanraud et al, 2007).
Volumetric reductions in grey matter, in the region of 5%-11%, have been observed with long term abstinent heroin and cocaine addicted people Franklin et al, 2002; Yuan et al 2008.
Key Concepts from psychology
Reflective system and impulsive system govern behaviour – Reflective impulsive model (RIM) (Strack and Deutsch, 2004)
Reward learning is enduring and resistant to devaluation or extinction i.e. becomes stimulus driven rather than outcome driven
(Yin & Knowlton, 2006)
Motivational dynamics: conflict between impulse and control
Attention, Motivated !“people become consciously aware of
an act only after they unconsciously decide to engage in it. In addition, at least some volitional behaviour does not require any conscious awareness at all: Goals and motivation can be unconsciously primed.”
Motivated attention is the driving force of addiction.
The key variable is motivated attention
Attention triggers action even in the absence of awareness.
Dual processing; fast and slow.
Cue detected
Controlled processing(slow)
Activation of addiction related beliefs. e.g "I will have more fun if I use cocaine"
Automatic processing(fast)
Conditioned cue reactivity : somatovisceral arousal and approach tendency
Cognitive appraisal
Level of processing
Prelude to passion:Limbic activation by “unseen” sexual and drug cues. Childress et al 2008
Neural response at 33ms exposure specific to drug and sexual cues.
Implications of recent cognitive neuroscience findings
Addiction is maintained by enduring changes in priorities and deficits in information processing.
Therapies that infiltrate and modify this, i.e. increase cognitive control, are more likely to be effective.
There is therefore a potential role for “neurocognitive rehabilitation” using the prototype described here
Conversely, changes in attentional and mnemonic functioning, especially implicit processes, will index and predict therapeutic gain.
Accordingly....
Result is distinctive “cognitive signature” and behavioural dysregulation.
Remediation needs to overcome automatic tendencies that are often implicit.
The neural networks subserving drug seeking and taking endure (excessive “wanting”) long after the pleasure or liking is gone.
Exposure, the most potent weapon in CBT is ineffective, or at least inconsistent.
Work in progress…..
Working Memory
Top downProcesses
(goals and coping strategies)
Bottom upProcesses
“Reward Radar”
Cycle of pre-occupation
Attentional bias
Contents of
Working memory
Attentional bias
Attribution of incentive salience
Any Questions?
Themes applied
Importance of goal maintenance
Rehearsal+ repetition+ reinforcement =
Reversal.
Importance of identifying alternative goals and pursuing these in a systematic manner
Cognitive biases are linked to craving
Cognitive biases are associated with increased craving.
Increased craving leads to increased cognitive bias.
Increased cognitive bias leads to increased craving.
Bias predicts outcome.
Field, Mogg & Bradley, 2006 Attention to drug-related cues in Wiers, R.W., & Stacey, A.W Handbook of implicit cognition and addiction.(Eds)
Sage. London.
But “reward radar” is always on!
Emphasis on reversal of implicit cognitive biases.
Focus on enhancing cognitive control (STM and attention ) mechanisms via goal maintenance
Prioritises impulse control strategies
Assessment and engagement
Begin with current concerns
Explore personal history
Elicit history of substance misuse:
Functional analysis (ABC)is helpful
Work towards formulation
Formulation
Building resilience
Conclusion:You know most of it already! (but please stay until end of workshop just to make sure)
From a CBT perspective, there are no entirely novel mechanisms or compensatory strategies involved in the acquisition, maintenance or regulation of
addictive behaviour.
The first M: Motivation and how to foster it
Treatment barriers:The possible effects of repeated setbacks
Scenario 1: Client blames themselves: “I’m lacking will power and I’m useless anyway…”
Scenario 2: Therapist blames client ( sometimes with their full agreement/collusion : “ You are not motivated or committed, come back when you’re ready (i.e. stop wasting my time!)
Scenario 3: Therapist blames themselves: “I’m no good at this, my clients never seem to improve”
Scenario 4: Client blames therapist : “ You don’t understand me or my problems and the treatment is useless”.
Motivational Interviewing 1
Opening strategy: ask about lifestyle, stresses and problem behaviourA typical dayThe good things and the less good things about the current drug useCurrent concerns
Motivational interviewing 2
Elicit self-motivational statements:
e.g.” Its sounds like your partner is worried about your drinking, but I was wondering how you feel about it?”
Listen with accurate empathy:
“It sounds like you want to quit but when you tried treatment before you went back to using cocaine”
Motivational interviewing 3
Roll with resistance: “you’re not sure you want to make a commitment to quit today”
Point out discrepancies: “ You’re not sure your drinking is a big problem, but people who care about you seem to be concerned”
Clarify free choice: “In the end, its down to you to make the decision….”
Brief motivational encounters….
Establish rapport through empathy
Focus on raising the issue (i.e. substance misuse)
Build commitment
Agree goal
Use self-monitoring and reinforcing feedback
Assessing readiness and building commitment to change
Importance
Readiness
Confidence
Ask: How important/ready/confident are you on a scale of 0-10? Then “Why not lower/higher …? ”
Identify and challenge negative thoughts about change
Encourage re-attribution of past failures (prevent the cultivation of internal, global and general attributions of impulsivity)
Express accurate empathy
Dealing with ambivalence
Identify an issue or situation about which you are ambivalent about taking steps to change.
In pairs: One to explore the pros and cons of changing
Tried & Tested:Summary of useful CBT techniques
Recognising or “capturing” automatic thoughts
Goal setting
Reality testing/behavioural experiments
Cognitive rehearsal
Identifying underlying beliefs and assumptions
Coping skills (e.g. relaxation therapy; “distancing”)
Problem solving skills
Relapse prevention skills: identifying high risk situations and rehearsing how to cope with them.
Five facets of impulsivity
Negative urgency: the tendency to act rationally when experiencing negative emotions e.g. “When I am upset, I often act without thinking and sometimes reach for a drink”.
Lack of Perseverance: the tendency to give up on a task more easily, in effect a lack of willpower. The manifestation of this personality trait could be endorsing the item “I tend to give up easily” strongly discounting the statement “Once I start something I'm determined to finish it”
Lack of Premeditation: the tendency to act without considering the consequences, especially those in the medium to long-term, e.g. strongly disagreeing with a statement such as “before deciding to do something I carefully weigh up the “pros and cons”.
Sensation seeking: essentially the same as the FFM construct reflecting a preference for novelty seeking, risk-taking and openness to new experience.
Positive urgency: this disposition refers to the tendency to act rashly when experiencing positive affect feeling excited in response to positive life events (see also Lynam, 2011)
Structuring the session
• Update on developments since previous encounter, with particular emphasis on any expression of addictive behaviour, negative mood states and current concerns.
• Setting the agenda, possibly asking the client to specify the priorities if the list of concerns or problematic issues is extensive. Specifying the stage of CHANGE (one of the 4Ms) of treatment e.g. managing impulses, managing mood maintaining change
• Reviewing any between session assignments homework• Introducing and then elaborating on the primary topic of the session e.g. coping
with impulses• Negotiating homework for coming week e.g. an implementation strategy or a
behavioural experiment• Summary and feedback • Schedule next appointment, reinforcing the importance of attendance even if
the therapeutic objectives are met by the homework is not accomplished.
In summary: the “20 20 20” rule
20 minutes: Review substance misuse, give motivational feedback, note current concerns
20 minutes: Introduce session topic (e.g. coping with craving) & relate to current concerns
20 minutes: assign homework /practice exercise for coming week & anticipate high risk situations
Overall, always apply social reinforcement to “shape “ behaviour. A client who presents for an appointment is always welcomed warmly!
Session by session monitoring: COMET
Continuous
Outcome
MonitoringDuring
EngagementIn
Treatment
Outcome Monitoring
Percentage days abstinent (PDA)
e.g. Client reports alcohol use on 4/7 days
(3/7)X100= 43% approximately=PDA
This can be applied to various time intervals such as change since baseline.
Feedback to clients can be provided in a motivational context.
Contingency management
Identify target behaviour e.g. supplementary drug use; testing or treatment for hepatitis C. Emphasise collaborative dimension.
Reinforce frequently and according to pre-ordained schedule.
Maintain for up to twelve weeks
Just say no!
When offered drugs:Say no first
Make direct eye contact
Don’t be afraid to ask the person to stop offering
Don’t leave the door open to future offers (e.g. I don’t feel like it today)
Be assertive, not aggressive!
Manage impulses (urges) and craving: the “Reward Radar” never switches off!
Stimulus Control
Implementation intentions
Be aware of and attempt to correct cognitive biases
Identify alternative rewards
Self monitoring
Distance /de- centre / mindfulness meditation
Challenge expectancies and implicit cognitions via behavioural experiments
Support self-efficacy
Goal specificity
Managing craving
Recognise thinking about drugs e.g “life is boring without cocaine” or “I deserve a drink”. Include categories of testing personal control and permission giving beliefs.
Avoid situations rich in drug cues e.g. parties where drugs are ubiquitous- setting alternative goals is often a good strategy
Identify and rehearse coping strategies e.g. drink refusal skills; distraction; challenging your thoughts ; review negative consequences focus on benefits of restraint; talk to supportive friends or associates on programme
Implementing intentions to change
If situation X occurs I will perform behaviour Y e.g.
“If I have money I will do my shopping before visiting the cocaine dealer”
If I am offered alcohol to drink at the party I will say “no thanks, but I would love a mineral water”.
Prestwich et al (2006)
The Third M:Manage mood
Conventional CBT techniques: correcting cognitive distortions; problem solving; exposure & behavioural experiments
Pharmacotherapy
Three vulnerabilities
-genetic loading contributing to neurobiological vulnerability;
-exposure to adversity in childhood and at early developmental stages;
-subsequent exposure to negative life events.
Assessment should explore these in detail.
Three sources of negative emotion
• pre-existing negative affect due to dispositional traits and/or exposure to adverse life events both historically and concomitant with recovery;
• negative emotions stemming from the after effects of drug intoxication; • negative emotions arising from setbacks or lapses when self-control
fails.
Assessment should aim to distinguish between these.
Mindfulness
Mindfulness disrupts automatic flow of cognitions < contrasts with ironic or paradoxical effects of effortful suppression>
Mindful acceptance should influence outcomes by reducing intrusion
Sober breathing space
S top
O bserve
B reathe
E xpand
R espond (not react!)
Four components
Educate about emotions
Antecedent cognitive appraisals° Probability errors° Catastrophising
Prevention of emotional avoidance° Behavioural avoidance e.g . avoiding eye contact° Cognitive avoidance e.g. thought suppression ,
rumination° Safety signals e.g. Carrying a bottle of water or a pill
Modification of emotionally driven behaviours° Hypervigilance° Health anxiety behaviours
Mindful Recovery
Relapse Prevention Skills Training: identify high risk situations and how to deal with them.
Goal Maintenance (therapies that foster this are more effective)
Attend Twelve Step based groups such as AA/NA
Use self-help materials
Practice mindfulness meditation or other meta-cognitive techniques
Remember that addiction casts a long shadow: appetitive responses are enduring and can be re-established by exposure to stress, small amounts of the drug of choice (possibly accidental?) and slight or ambiguous stimulation associated with drug.
“Road to recovery……is paved with good rehearsals.”
Successful execution of any task requires both controlled and automatic processing- Treatment for addiction requires that automatic processes are recruited through practice, implementation intentions, programmed cue exposure and stimulus control.
Robust practice has been shown to increase automatic inhibition of competing goals (Palfai, p 416, Wiers & Stacey 2006)
The Future:Neuro-Cognitive Behaviour Therapy?
Emphasis both on remediation of cognitive deficits and reversal of cognitive biases.
Focus on goal maintenance and working memory mechanisms.
Prioritises impulse control strategies.
Summary
Impulse control and emotional control strategies should be addressed sequentially, but as part of a formulated treatment plan in a framework that accentuates cognitive control.
Particular attention must be given to enhancing therapeutic alliance: Continuous feedback is used to motivate the client to remain engaged in treatment despite the inherent treatment resistant nature of addiction.
Addiction, once established, is an enduring condition because of the powerful learning mechanisms it subverts. Help seekers and their carers need to remain mindful of this in the years following treatment.
References
Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R. and Wanigaratne, S. (2010) Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: a Practical Treatment Guide, Wiley-Blackwell, Chichester.
Miller, W.M. & Rollnick, S. (2013) Motivational Interviewing, Third Edition: Helping People Change. Guilford Press, New York.
Ryan, F. Cognitive therapy for Addiction: Motivation and Change (2013). Wiley Blackwell.