CBT WORKSHOP

1. CBT WORKSHOP The purpose of this exercise is to give delegates a general introduction to the basic principles of CBT as applied to Adolescent Substance Misuse. In addition to a basic theoretical review of CBT principles, delegates will get the opportunity to experience conducting an interview with the aim of (i) developing a functional analysis explaining the clients difficulties from a learning theory perspective and (ii) suggest the development and implementation of skills based interventions that will benefit the client. "By weaving together the patients history, constellation of beliefs and rules, coping strategies, vulnerable situations, automatic thoughts and images, and maladaptive behaviours, the therapist has a better understanding of how patients become drug dependent ... The therapist is guided to ask important relevant questions and to develop strategies that are most likely to succeed " (Beck et al, 1993, pg. 80)

2. General Introduction to CBT • A combination of Cognitive Therapy and Behaviour Therapy • Behaviour Therapy seeks to extinguish or inhibit abnormal or maladaptive behaviour by reinforcing desired behaviour and extinguishing undesired behaviour • Cognitive Therapy “a system of psychotherapy that attempts to reduce excessive emotional reactions and self defeating behaviour by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions” (Beck et al, 1991,pg. 10) • Abnormal thinking changed by verbal techniques • - Explanation, discussion, questioning of assumptions • Behavioural actions can also be used to change the way someone thinks • - “Learn from their experience”- challenge existing beliefs • At a “deeper level”, schema (fundamental core beliefs) which give rise to enduring assumptions, attitudes and thoughts which set in motion problematic behaviours may be a focus of attention • CBT- integrates ‘cognitive restructuring’ with behaviour modification techniques of behavioural therapy as well as skills development

3. Major Historical Figures Epictetus 55AC- 135 AC “People are not disturbed by things but by the view they take of them” Ellis- relationship between thoughts, beliefs, feelings and behaviour Past experiences shape one’s belief system and thinking patterns Illogical, irrational thinking patterns cause negative emotions and further irrational cognitions Ellis now talks about the four basic irrational beliefs as the “big MACS” :   “Mustabatory thinking” / demandingness = “my parents must love me” or “the world must be fair” Awfulising – “it would be awful (100% bad, nothing could be worse) if I could not smoke hash” Can’t stand it (low frustration tolerance) – “I can’t cope with other people thinking badly of me” or “I can’t stand the way they treat me” Self / other downing – “I’m a bad person” or “he’s a junkie” In REBT a belief is only irrational if it contains one of the MACS.

4. Ellis’s “A- B- C- D- E” Model A= Activating events B= Beliefs rBs (rational, flexible, realistic and undemanding) iBs (irrational, rigid, unrealistic and demanding) C= Consequence (A + B= C) Healthy negative emotions = sadness, concern, regret, disappointment, healthy anger Unhealthy negative emotions = depression, anxiety, shame, hurt, jealousy, envy D= Disputing irrational beliefs Empirically- “evidence?” or “universal law?” Logically (sense or logic in beliefs?) Pragmatic (helpful, solution focussed?) E= Effect (create rBs to replace iBs) thus producing new Emotions

5. Seligman’s “learned helplessness” and “learned optimism” Depressed people: learned to be helpless, believed responses would be futile, lack of control/ powerless Yet there were exceptions- people who did not get depressed even after many bad life experiences. What you think when faced with Adversity (“Failure is Permanent, Pervasive, Personal”) can change the way you feel. A = Adversity B = Beliefs (groups of thoughts, internal dialogue, reflexive, seldom based on reality, 'sacrosanct') C = Consequences D = Distraction, Disputation, Distancing E = Energization Learn to change the thoughts ('Pessrum') and change the feelings Meichenbaum Recurring thoughts of anxious people identified Individual actions arise from “self talk” Instructional or “self talk” (changing internal/ external dialogue with self) and teaching coping skills “Self instructional inner dialogue”- a method to talk oneself through a problem or situation as it arises, was developed

6. Beck’s discovery of two abnormalities with depressed patients: Repeated intrusive thoughts Low self regard Self criticism Self blame Ideas of deprivation Critical injunctions Wish to escape of die Cognitive distortions (“errors of logic”) Thinking errors- “unhelpful thinking” NATS- “extreme and unhelpful thinking” Personalisation- “taking things to heart” Arbitrary inference- “jumping to conclusions” Selective abstraction- “negative interpretations/ conclusions” Over- generalisation- “making extreme rules or statements” Magnification/ Minimisation- “focusing on (-); downplaying the (+) Unrealistic assumptions (related to previous experiences) (Williams and Garland, 2002) Arising from above he developed the notion of the “cognitive triad” Negative: View of the self Interpretation of current experience (world/ others) View of the future

7. According to Beck et al there are levels of cognitions salient to drug misuse: 1) Deep- Core beliefs or Maladaptive Schema- "templates" (See too Jeffrey Young, former Director of Aaron Beck's CBT Institute in Philadelphia) Examples: I'm a failure/ inferior/ incompetent helpless unlovable/ unattractive/ undesirable powerless/ ineffective/ trapped weak/ vulnerable rejected/ unwanted/ uncared for I am bad Life/ The world is/ My future is ... (Various sub- derivatives and correlates) Conditional assumptions/ rules (+ or -) (Help clients cope with their core beliefs) “If I am perfect in all respects I will not be a failure” “If I am not found to be attractive by all it means I am unlovable” Compensatory strategies (Compulsive, rigid, inappropriate, destructive, unbalanced behaviours to cope with painful core beliefs) “Cocaine use makes me competent and witty” “Smoking hash brings out my creativity” “When I drink I socialise much better”

8. 2)Intermediate- Addictive or Drug beliefs (Pleasure/ problem solving/ relief and escape) Need for substance to maintain psychological/ emotional balance Expectation substance will improve social and intellectual functioning Expectation of pleasure and excitement from use Belief that drug will provide energy and increased power Expectation drug will have a soothing effect Belief drug will relieve boredom, anxiety, tension and depression Conviction that if nothing is done to satisfy craving/ neutralise distress it will last indefinitely/ get worse 3) Shallow- Automatic thoughts Spontaneous 'thoughts or pictures in the mind' that stem from activation of deeper beliefs (core, conditional and drug) Permission giving- related to justification, risk taking and entitlement "Just a little won't hurt.......... "I deserve it.......... "It's the only pleasure I have......... "I cannot stand the urges and cravings........... "As I'm feeling bad its OK to use............ "If I give in now, I promise to resist next time......

9. 4) Emotions- associated with automatic thoughts and beliefs - clients often unaware of preceding cognitions 5) Vulnerable situations/ Triggers- activate core, conditional and drug related beliefs - potentate urges and cravings, motivate procurement plans Automatic thoughts- stem from activation of core and drug related beliefs 6) Behaviours - preoccupation with, planning, procuring drugs - irresponsible actions - avoidance of help The end product of the above process How do CBT- Based Practitioners Approach Adolescent Substance Misuse Behaviours Drug use and related problems are learned behaviours Initiated and maintained in a particular environmental context As drug use behaviours are learned so they can be “unlearned”/ modified

10. Learning Principles salient to the genesis/ treatment of addiction: Operant conditioning- focus on important and particular reinforcers (+ and -) Drug taking behaviours very responsive to reinforcement contingencies Drug use behaviours develop and maintained in context of antecedents/ consequences of behaviour Physiological effects are powerful reinforcers (hedonistic and suppressive) Euphorogenic Dampening of rage Tension reduction- sedating/ relaxing Regulation of negative affect Enhanced social/ interpersonal interaction (perceived) Classical conditioning- pairing: paraphernalia, places, people, times, feelings associated with drug use Research has explored acquisition of Preferences/ Aversion/ Tolerance/ Urges/ Cravings Above model has given rise to development of interventions which: Help clients anticipate and avoid high-risk situations (Settings, times, places which serve as triggers or stimulus cues) Help client manage resultant urges and cravings (Techniques to promote self control, promote rewards from competing behaviours, coping skills training)

11. Social Learning Model- Imitationand Modelling/ - “copying and watching others” Incorporates classical and operant learning principles Recognises influence of environment on behaviour acquisition Acknowledges role of cognitive processes (how environmental influences are appraised and perceived) Adolescent substance misuse behaviours are thus influenced by: Observation and imitation of parents, siblings, peers Social reinforcement Anticipated effects/ Expectancies Direct experience of drugs effects as being rewarding Self efficacy beliefs Beliefs about refraining from use Beliefs about dependence Modelling drug use as a means of managing stress Repertoires of alternative coping skills

12. Whilst CBT is not a single unitary approach a Functional Analysis and Skills Training are hallmarks A) Functional Analysis “Why” are clients using? (Learned behaviour?) What do they need to do to recognise, avoid and cope with triggers? Deficiencies and obstacles to abstinence/ reduction?(Skills) Existing skills and strengths? Determinants of Use (Current and Habitual) Social Environmental Emotional Cognitive Physical B) Skills Training (e.g)- develop strategies and interventions Generalisable in nature Basic Individualised Repetition (“practice makes permanent”) Practice ‘Mastering Skills’ in situ

13. General Treatment Techniques: “What is in the Tool Box?” Self Monitoring/ Diaries/ Logs/ Mood monitoring Graded Task Assignment/ Activity Scheduling/ Behavioural contracting Avoidance of Stimulus Cues/ Distraction/ Engagement in incompatible actions Modelling/ Role play/ Response and Behaviour Rehearsal/ Refusal Skills Coping Skills to manage/ resist urges to use Focus on drug effects/ expectancies/ consequences of use Decisional analysis/ Use of Flash Cards Communication Skills/ Conflict resolution skills/ Social skills training/ Assertiveness Skills Problem Solving Skills Self Image Mood Regulation/ Relaxation training/ Anger Management Clarification of role of cognitions in challenging situations/ In situ and in vivo practice to manage threatening situations Examine inaccurate/ distorted thoughts/ maladaptive core beliefs/ schema (self, world, others, future) (Re) lapse analysis (preparation, prevention and feedback) Psycho- education Progressive Muscle Relaxation/ Autogenics Training

14. A Proposed Model- (based on NIDA foundations and Beck et al. 1993) Goal of treatment- To achieve and maintain abstinence from substance use Recognise the Importance of the Therapist- Client relationship Good rapport Support/ “Hiker and the Guide” metaphor Balance between being directive and allowing the client to be self- directive Balance: Respect for where the client is versus direction in terms of goals of recovery Alliance/ Collaborative partnership Client is true expert in explaining their life Socratic questioning/ Accurate listening/ “Guided Discovery” Empathise effectively The development of relationships with clients who have endured chaotic lifestyles and poor attachments may take time. Without relationship - “a collection of gimmicks” (Beck, 1993)

15. “Stages of Treatment” 1) Starting treatment/ Engagement NIDA manual on CBT recommend MI strategies (Miller et al, 1992) to assess risk and elicit change: Empathy Affirm Reframe Roll with the resistance Point out discrepancies Explore consequences of action and inaction Communicate free choice Elicit self-motivational statements William Miller (2006) has argued that MI significantly adds value to the later implementation of other evidence-based treatments. Educate clients in the CBT model Foster teamwork and collaboration Ask the client for their views or formulations of the problem Understand the client's internal reality Establish a collaborative set for engagement Set and agree on realistic measurable, behavioural goals Establish goals in positive terms Two standard goals are: 1) Reduce drug use by developing techniques to better cope with urges and cravings 2) Learn more adaptive skills and methods for coping with life problems

16. 2) Early Abstinence- Recognise, avoid and cope Recognize, avoid and cope with high-risk “trigger situations” “People, places, things”- strong associations Activity and time scheduling (manage risk, regain order over a chaotic lifestyle dominated by drugs) Understand and manage cravings Coping with social/ peer pressure to use Understanding Post acute Withdrawal Symptoms- made worse, not better by drug use Risks posed by other drugs- esp. THC and Alcohol Encourage participation in Groups 3) Maintenance of abstinence- Relapse Prevention (Marlatt & Gordon, 1985) Encourage a respectful attitude towards the power of the addiction 3 strategies: Coping Skills Cognitive therapy Lifestyle Modification

17. Highlight and take steps to guard against the 3 high-risk situations associated with 75% of relapses (Marlatt & Gordon, 1985): Negative Emotional States Interpersonal Conflict Social Pressure - role of cognitive distortions (denial and rationalisation) - covert antecedents leading to exposure to high risk situation Emphasis on self management Rejection of labelling Understand relapse as a process Re frame change as a learning process Recognising own cognitive, psychological, emotional, triggers (internal”) Avoiding triggers (identify and cope) Manage urges and sudden expected cravings Implement “damage control procedures” during a slip/ lapse Stay engaged in treatment after a relapse Accept errors and setbacks contribute to mastery

18. 4) Life after Drugs Development of healthy behaviours/ more balanced lifestyle Meditation Nutrition Exercise Spiritual practices Guard against transfer of Addictive Behaviours Development of healthy positive relationships Co- dependency Enabling behaviour Identification and fulfilment of Needs Anger Management Encourage Relaxation/ Leisure Activities Issue related to Employment/ Management of Money Decision making skills Communication/ Assertiveness skills Stress management Self esteem

19. 5) Life's Problems Clients rarely enter treatment for addiction unscathed by other life difficulties Realization that "pre morbid" demands, responsibilities and troubles of life have not disappeared Secondary relationship, educational, health, legal, financial problems arising from drug use Life problems triggering drug abuse which in turn exacerbating negative life (cycle) "When positive life changes follow the patient's success in achieving and maintaining a drug free existence, it behoves the therapist to make certain that the patient understands the nature of this positive feedback loop" (Beck et al. 1993, pg. 210) Increases motivation and bolsters relapse prevention 6) Underlying/ related co- morbid conditions (>60% of adolescents dual diagnosed: Bukstein et al. 1992) Depression Trauma Personality issues Anxiety Gender identity ADHD Conduct Disorder CBT regarded as effective for both addiction and co- morbid conditions (Waldron and Kaminer 2004)

20. 7) Employment of skills to effectively manage (ad hoc) crises relationship break- ups arrests exposure to traumatic incidents/ assaults (esp. by family members) pregnancy/ deaths of family members suicidal behaviour “Substance abusers will almost certainly present with more crises than other patients” (Beck et al, 1993, p. 225 ) "Being available to patients in times of crisis is one the therapists most important responsibilities" (Beck et al, 1993, pg. 211 ) Warning signs include: Missing sessions, marked change in mood or behaviour, concern expressed by significant others Address as soon as possible "skilled mixture of accurate empathy and frank confrontation" (Beck et al, 1993, pg. 213 ) Stabilisation Address source of crisis in constructive manner 'Tarasoff Principle' if applicable "Failures" can be “re- framed” as opportunities (therapeutically relevant to producing change or positive shifts) - Opportunity to practice skills without resorting to drugs - A "test", if passed, indicating true progress Identify common dysfunctional beliefs and behaviours inherent to seemingly disparate crises