Cognitive–Behavioral Therapy

1. Cognitive–Behavioral 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 • UCS=Drug – 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 (cont’d) • 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 can’t handle this without drug use • Drugs help me focus • Drugs make me more sociable/creative • Cognitive Model • Handout

10. Overview of CBT Model

11. CBT Model (cont’d) • 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.” “Let’s take a look, together, at how you were thinking in this situation.”

16. Collaborative Empiricism • 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….?”

17. Focus on Present Circumstances • 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!!

18. 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?v=sG0P6TlbYOw • Examples

20. Guided Discovery (cont’d) • 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)

26. 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 (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?

27. Functional Analysis (cont’d) • 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 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.

29. Coping with Cravings (cont’d) • 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 student’s situation, e.g., friends, SO, dealer, etc.)

31. Assertiveness (cont’d) • 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 (cont’d) • 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 (cont’d) • Let’s 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 (cont’d) • 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.