cognitive–behavioral therapy an evidence-based approach to relapse prevention philip j....
TRANSCRIPT
COGNITIVE–BEHAVIORAL THERAPYAn Evidence-Based Approach to Relapse Prevention
Philip J. Pellegrino, Psy.D.
1
Participants will be able to:2
Describe the principles behind CBT approaches to addiction and relapse prevention
Articulate the elements involved in a CBT approach to relapse prevention
Apply and implement CBT relapse prevention strategies
Brief Biology of Drug Use3
Reward/Reinforcement Pathway Neurotransmitter release Keep this in mind when discussing
classical and operant conditioning Brain neuroplasticity
Scientific Principles Behind CBT
4
Social Learning Theory Classical Conditioning Operant Conditioning Core Beliefs and Schemas
Social Learning Theory5
Albert Bandura Modeling/Vicarious Learning
Examples We learn and develop beliefs and behaviors
through our families and cultural norms (Reciprocal Determinism)
Self-efficacy The belief that we are capable of doing something Creating accurate thinking
Expectancies
Classical Conditioning6
Pavlov Unconditioned and Conditioned Stimulus
UCS is paired with CS and elicits the UCR CS then elicits the UCR, which becomes CR
Application to drug use UCS=Drug – UCR= Drug Effects/Compensatory
reactions. CS – Environmental stimuli associated with the drug –
CR – Compensatory reaction/drug effects.
Operant Conditioning7
B.F. Skinner Behavior that is rewarded tends to be
repeated Rat studies on drug use
Repeated use of cocaine/stimulating brain Relation to self-efficacy and control over
environment Negative reinforcement
Avoidance of negative feeling states
Operant Conditioning (cont’d)
8
People have their own preferences when it comes to drug use
People then develop drug-seeking behaviors that are reinforced by drug use
Alternative behaviors are not reinforced Importance of developing alternative
behaviors that are reinforced Contingency management studies
Rat studies
Core Beliefs and Schemas9
Aaron Beck et al., (1993) Expectancies
Users develop beliefs and expectancies about their use of drugs.
Irrational thoughts on drug use It will only be one time I can’t handle this without drug use Drugs help me focus Drugs make me more sociable/creative
Cognitive Model Handout
Overview of CBT Model10
CBT Model (cont’d)11
Drug use is viewed as a learned behavior Relapse is the result/combination of
exposure to cues limited positive reinforcement for sobriety positive thoughts/expectancies for use negative beliefs/thoughts about sobriety limited self-efficacy for coping
Philosophy of CBT 12
Short-term brief therapy Flexible-individualized approach Collaborative relationship Collaborative empiricism Focus on present circumstances Guided discovery Use of homework Teaching students to be their own therapist (recovery) Mood check/agenda setting Outline of a CBT session
Freeman et al., (2004)
Short-Term Brief Therapy13
CBT is meant to be directive and goal oriented
Does not waste time getting to the core of the problem and providing symptom relief
Does not mean that it is always short term
Flexible and Individualized14
We can apply the philosophy and principles to each clients own needs
Choice of interventions is based on specific client needs/problems
We learn along with client and change treatment strategies based on client feedback and change feedback
Collaborative Relationship15
Therapy is not one sided Both therapist and student come
together to work on treatment goals and choose treatment approaches
Frequent us of the term “We.” “We are going to help you change your behaviors.” “Let’s take a look, together, at how you were thinking in this situation.”
Collaborative Empiricism16
Student and therapist work together to find solutions to student’s difficulties
Student and therapist learn and explore to find the answers and challenge student beliefs and predictions. “I wonder what would happen if you went to an AA meeting?” “What are your predictions about what might happen if you….?”
Focus on Present Circumstances
17
CBT focuses on the student’s current thoughts, emotions, and behavior patterns. Focus is on actively changing student lifestyle patterns.
Past is not ignored, used to inform conceptualization and plan present interventions.
No deep exploration into the past, only relevant to how it is affecting current problem!!
Focus on Present Circumstances
18
We use the past to inform are current conceptualization of how the individual is behaving or perceiving their world.
Guided Discovery19
Socratic Dialogue Using exploration and questioning to help
patients see new perspectives. Similar to MI (directive, while letting the
client come to their own conclusions.) http://www.youtube.com/watch?v=sG0P
6TlbYOw Examples
Guided Discovery (cont’d)20
Examining the evidence Hypothesis testing Advantages and disadvantages Prompt clients to consider consequences
of undesirable behavior Display to client how they are selectively
focusing on certain criteria
Homework21
CBT emphasizes opportunity for learning between sessions
Research shows that use of homework increases therapeutic outcomes
Types of homework in CBT Behavioral experiments Tracking behaviors, thoughts, and feelings Self-monitoring cravings/triggers Challenging thought distortions
Be Your Own Therapist22
CBT works to have students be able to be their own therapists
Similar issues will arise for students in the future, so CBT stresses prevention strategies
Teaching students not to depend on the counselor
Change is about being your own therapist!!
Mood Check/Agenda23
CBT monitors moods at the beginning of sessions
CBT emphasizes collaboratively setting an agenda Allows a focus on general themes and
behaviors Allows student to be involved in the process
A Typical CBT Session24
Agenda setting Mood check, review events of past week Review homework from last session Discuss main agenda items (bulk of
session) Develop new homework Solicit feedback about current session
(Very important; builds alliance)
CBT Treatment Strategies25
Functional analysis Coping with cravings Refusal skills/assertiveness Seemingly irrelevant decisions Developing a long-term coping plan Problem-solving skills Challenging negative thinking
NIDA (2008)
Functional Analysis26
A tool for monitoring triggers, thoughts and feelings before use and before cravings. In other words, what goes on when students use?
Questions for an FBA (B=Behavior) Where were you the last time you used, what were
you doing and who were you with? What happened before you used, what were you
feeling? When were you aware that you wanted to use?
What were the positive and negative consequences?
Functional Analysis (cont’d)27
Use the FBA to identify triggers and high-risk situations
Allows individual to avoid/change triggers and provide new consequences for positive behaviors
Coping with Cravings28
Normalizing craving—The goal is not to get rid of them, but to make sure they don’t lead to relapse.
Identification of cues Using Pavlov’s dogs as an analogy Cues being like the bells for hunger
Emphasize the time-limited nature of cravings.
Coping with Cravings (cont’d)
29
Getting clients to describe their cravings Making a list of triggers Emphasizing avoidance Distraction Talking about craving Going with the craving Self talk Recalling negative consequences of use
Assertiveness/Refusal Skills30
How available is the drug to the student? Have they informed people that they are
stopping? How to handle people you are close to? Refusal skills
Rapid response Good eye contact Clear and concise response that is firm
Role play (important to make it relevant to the student’s situation, e.g., friends, SO, dealer, etc.)
Assertiveness (cont’d)31
Passive, aggressive and assertiveness Using “I” statements Being specific
Seemingly Irrelevant Decisions
32
Decisions that appear unrelated to use of substances Rationalizations and decisions that put the
individual in a high-risk situation. Teaching students to interrupt the chain
of decisions that lead to use Easier to disrupt earlier in the chain
Identifying distortions in thinking I have to go see my friends.
SIDs (cont’d)33
Recognizing Avoiding Coping Provide concrete examples Explore past personal experiences
Positive Reinforcement34
Teaching students how to reward themselves for success
Chips in AA/NA meetings
All Purpose Coping Plan/Relapse Prevention
35
Identifying future high-risk situations Developing a plan of action to address
those situations Emphasizing that even positive events
can be situations that put the individual at risk
Relapse Prevention36
Collaboratively planning with the student Student input is very important Only lip service if it is just your plan
Any relapse plan must be tested for success
What do you think would go into a CBT relapse prevention plan?
Relapse Prevention (cont’d)37
Let’s develop our own relapse prevention plan.
Problem Solving38
A systematic approach to solving any problem that emphasizes brainstorming and cost-benefit analysis
First the individual has to believe that they are able to solve the problem (i.e., self-efficacy and hopelessness are addressed)
Problem Solving (cont’d)39
1. Identify the problem Most important part
2. Generate alternatives (Ways to solve the problem)
Brick exercise Withhold judgments
3. Assess the cost and benefits of alternatives
4. Choose a solution
5. Act on solution
6. Evaluate outcomes and return to step 2
Challenging Negative Thinking
40
Teaching students to identify distortions in thinking
Connecting those thoughts to emotions and behaviors
Strategies to challenge thinking Evidence for and against Cost/benefit analysis Is the thought logical? Thoughts are not FACTS
CBT and Recovery41
Smart Recovery CBT-based recovery group http://www.smartrecovery.org/
References42
Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive Therapy of Substance Abuse. New York: The Guilford Press.
Carroll, K., Rounsaville, B., and Keller, D. Relapse Prevention Strategies for the Treatment of Cocaine Abuse. American Journal of Alcohol Abuse 17: 249-265, 1991.
Freeman, A., Pretzer, J., Flemming, B., & Simon, K.M. (2004). Clinical Applications of Cognitive Therapy (2nd ed.). New York: Plenum Publishers.
The National Institute on Drug Abuse. (2008). www.drugabuse.gov/TXManuals/CBT/CBT3.html. 12/11/09.