Cognitive

1
CognitiveBehavioral Therapy

• An Evidence-Based Approach to Relapse Prevention
• Philip J. Pellegrino, Psy.D.

2
Participants will be able to

• 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

3
Brief Biology of Drug Use

• Reward/Reinforcement Pathway
• Neurotransmitter release
• Keep this in mind when discussing classical and
  operant conditioning
• Brain neuroplasticity

4
Scientific Principles Behind CBT

• Social Learning Theory
• Classical Conditioning
• Operant Conditioning
• Core Beliefs and Schemas

5
Social Learning Theory

• 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

6
Classical Conditioning

• 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
• UCSDrug UCR Drug Effects/Compensatory
  reactions.
• CS Environmental stimuli associated with the
  drug CR Compensatory reaction/drug effects.

7
Operant Conditioning

• 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

8
Operant Conditioning (contd)

• 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

9
Core Beliefs and Schemas

• 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 cant handle this without drug use
• Drugs help me focus
• Drugs make me more sociable/creative
• Cognitive Model
• Handout

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Overview of CBT Model
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CBT Model (contd)

• 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

12
Philosophy of CBT

• 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)
13
Short-Term Brief Therapy

• 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

14
Flexible and Individualized

• 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

15
Collaborative Relationship

• 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. Lets take a
  look, together, at how you were thinking in this
  situation.

16
Collaborative Empiricism

• Student and therapist work together to find
  solutions to students 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.?

17
Focus on Present Circumstances

• CBT focuses on the students 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!!

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Focus on Present Circumstances

• We use the past to inform are current
  conceptualization of how the individual is
  behaving or perceiving their world.

19
Guided Discovery

• 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?vsG0P6TlbYOw
• Examples

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Guided Discovery (contd)

• 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

21
Homework

• 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

22
Be Your Own Therapist

• 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!!

23
Mood Check/Agenda

• 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

24
A Typical CBT Session

• 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)

25
CBT Treatment Strategies

• 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)

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Functional Analysis

• 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 (BBehavior)
• 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?

27
Functional Analysis (contd)

• Use the FBA to identify triggers and high-risk
  situations
• Allows individual to avoid/change triggers and
  provide new consequences for positive behaviors

28
Coping with Cravings

• Normalizing cravingThe goal is not to get rid of
  them, but to make sure they dont lead to
  relapse.
• Identification of cues
• Using Pavlovs dogs as an analogy
• Cues being like the bells for hunger
• Emphasize the time-limited nature of cravings.

29
Coping with Cravings (contd)

• 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

30
Assertiveness/Refusal Skills

• 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
  students situation, e.g., friends, SO, dealer,
  etc.)

31
Assertiveness (contd)

• Passive, aggressive and assertiveness
• Using I statements
• Being specific

32
Seemingly Irrelevant Decisions

• 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.

33
SIDs (contd)

• Recognizing
• Avoiding
• Coping
• Provide concrete examples
• Explore past personal experiences

34
Positive Reinforcement

• Teaching students how to reward themselves for
  success
• Chips in AA/NA meetings

35
All Purpose Coping Plan/Relapse Prevention

• 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

36
Relapse Prevention

• 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?

37
Relapse Prevention (contd)

• Lets develop our own relapse prevention plan.

38
Problem Solving

• 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)

39
Problem Solving (contd)

• Identify the problem
• Most important part
• Generate alternatives (Ways to solve the problem)
  
• Brick exercise
• Withhold judgments
• Assess the cost and benefits of alternatives
• Choose a solution
• Act on solution
• Evaluate outcomes and return to step 2

40
Challenging Negative Thinking

• 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

41
CBT and Recovery

• Smart Recovery
• CBT-based recovery group
• http//www.smartrecovery.org/

42
References

• 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.