Cognitive Behavioral Therapies

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Cognitive Behavioral Therapies Practicum
Course 39457 Current Professionals
Track Substance Abuse Studies Training
Program UNM Continuing Education
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Behavior Therapy

• Behavior therapy is a method of counseling that
  focuses on modifying the patients learned
  behavior that are negatively affecting his or
  here life.

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Cognitive Therapy

• Cognitive therapy holds that the principal
  determinant of emotions, motive and behavior is
  an individuals thinking, which is a conscious
  process.
• Change perception, alter emotions changes in
  lifestyle.

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Classical Conditioning

• A model where a particular response to a stimuli
  can be elicited overtime by association with a
  related stimulus.

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Unconditioned stimulus(UCS)

• A component of classical conditioning an event
  that produces an unconditional response when
  present.

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Unconditioned Response (UCR)

• A natural reaction to an unconditioned stimulus

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Conditioned Response

• A response that is identical to an unconditioned
  response, yet it is elicited by the conditioned
  stimulus, not the unconditioned stimulus.

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Operant Conditioning

• This model is based on the theory that where
  behavior is reinforced and learned based on the
  consequences of the behavior.

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Reinforcement

• Something that is added to a situation that
  increased the likelihood of that even or behavior
  of occurring again.

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Negative Reinforcement

• Something that is taken away or removed from the
  situation that increase the likelihood of the
  behavior occurring again.

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Modeling

• A principle where a behavior is learned by
  observing the consequences of someone elses
  experience.

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Shaping

• The procedure of rewarding successive
  approximations to the desired response.

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Coping Skills TrainingInterpersonal

• Coping skills deficits are considered a major
  cause of drinking/using, which is likely to
  continue in the absence of adequate skills for
  coping with the events that trigger and follow us.

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Introduction to Assertiveness

• Passive
• Aggressive
• Passive-aggressive
• Assertive
• See handout 1

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Receiving Criticism about Drinking

• Type of Criticism
• Constructive
• Destructive
• See handout 2

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Refusal Skills

• Learned in the CRA Class

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Developing Social Support Network

• There are many stresses associated with problem
  drinking and drug use. (relationships, illness,
  job loss, etc.)
• Often, people who stop using still have friends
  who drink and use drugs.
• Many people feel that drinking and using helps
  them to socialize.
• See handout 3

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Other Coping Skills

• Communications skills
• Nonverbal communications
• Listening skills
• Refusal skills
• Resolving Relationship problems
• See Monti et al., (2002)Treating Alcohol
  Dependence, Guilford Press.

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Coping Skills TrainingIntrapersonal

• Managing urges to drink/use
• Problem solving (CRA)
• Increasing pleasant activities (CRA)
• Anger Management (CRA- FA)
• Managing negative thinking
• Seemingly irrelevant decisions
• Planning for emergencies

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Managing urges to drink/use

• See handout 4
• Positive Thinking worksheet
• Urge control information sheet

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Urge Control

• Urges and Cravings are normal
• They happen more in the early part of tx.
• They have triggers, physical, environmental and
  psychological.
• Urges are time Limited

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Urge Control

• Teach client to recognize triggers.
• Exposure to cue
• Watching others drinking or using
• Contact with people, places, activities.
• Elicit emotional states (anger, stress, etc)
• Examine physical feelings (shakes, etc.)

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Urge Control - Steps

• Avoid identified urges
• Find competing behaviors
• Talk to a friend
• Surf it (discuss urge surfing)
• Challenge and change the thought
• Review positive things since stopped using
• Wait 15 minutes before you act
• Use self talk. What is the worst that can happen?

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Managing negative thinking

• Triggers (event, person, place)
• Thoughts (I cant do this)
• Feelings (Scared, depressed, angry)
• How do you change each one of the above?
• See handout 5

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Seemingly irrelevant decisions

• Many events are seemingly unrelated to a relapse
  but lead to one, Right?
• What is a behavioral chain of events?
• Can we change the outcome and where do we
  intervene?

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Planning for emergencies

• See handouts 6 for exercise

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Contingency Management

• The theoretical foundation of CM was derived from
  principles of operant conditioning.
• Behaviors are controlled by its consequences, and
  is amenable to change by altering its
  consequences.

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Contingent

• Dependent on something conditional
• Something that may or may not happen.

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Contingency Management

• Patients are offered some attractive options,
  including tangible goods and services,
  immediately contingent on demonstrating objective
  evidence (i.e., drug-free urine samples).

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Voucher Program

• For every clean Urine, client gets monetary
  rewards
• First drug-free urine 2.50, each consecutive
  drug-free urine the amount given was increased by
  1.50.
• For every 3 consecutive drug-free urines the
  client received a 10.00 bonus.
• In 12 weeks the client could earn up to 1000.00

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Voucher Results

• 75 of the clients who received the vouchers
  completed 24-weeks of abstinence compared to
  only 40 in the non-voucher group.

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Implementing a Voucher Program

• Describe the program to patients
• Target Abstinence
• One drug at a time works best
• Set up a reinforcement schedule
• Escalating pay
• Reset the pay for non-compliance

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Implementing a Voucher Program

• Frequent Urine Monitoring
• Provide Feedback
• Minimizing delay in Voucher exchange
• Frequent and regular voucher spending
• Voucher Redemption
• Abstinence Reinforcement Summary

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Give examples of CM

• Being on Probation?
• Ultimatum from spouse?
• Boss says next time you come in late your fired?
• Condition of Probation is not going to bars?
• How else can you use CM in your practice?

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Behavioral Contracting

• This is a means of scheduling reinforcements
  (verbal, behaviors, events) between two or more
  people.

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Behavioral Contracting

• Involve all relevant parties.
• Write contracts, do not leave it to memory.
• Have all parties sign the contract, which in
  effect is a review process.
• Be sure contracts are understood by asking each
  party to describe what they have agreed to.

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Behavioral Contracting

• Role-Play the contact .
• Clarify each parties responses.
• There must be a benefit for each party.
• No value judgments.
• What is the pay-off or the desirable long term
  goal of the contract?
• There should be some reinforcer sampling

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Behavioral Contracting

• There should be flexibility, if one party refuses
  an agreement suggest alternatives.
• Always teach how to compromise.
• Small agreements will lead to larger agreements.
• You can build in sanctions for failure to follow
  through.

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Behavioral Contracting

• The therapist should eventually let the clients
  take the lead on making agreements.
• Use positive wording making out contracts.

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Behavioral Contracting Guide

• Select one or two behaviors that you want to work
  on first.
• Describe those behaviors so that they may be
  observed or measured.
• Identify rewards that will help provide
  motivation to succeed.
• Monitor or make sure someone monitors the
  contract and rewards success.

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Behavioral Contracting

• Write the contract so everyone understands it
  fully.
• Troubleshoot if needed.
• Rewrite the contract whether there is improvement
  or not.
• Continue to monitor the contract over time.
• Select new behaviors to work on.

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Aversion Therapy

• Aversion therapy attempts to interrupt the
  drinking behavior by creating a aversion or
  distaste for alcohol.
• Alcohol is repeatedly paired with an US which is
  extremely unpleasant. That unpleasantness then
  generalized and becomes associated with alcohol.

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Aversion Therapy

• Alcohol is paired with drugs, electrical shock,
  imagery, smell or other very unpleasant stimulus.
• Began in 1935 with injections of emetine, which
  cause nausea and vomiting.
• Drank alcohol injection sick, sick, sick

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Aversion Therapy

• Aversion therapy has mixed results.
• Some treatment centers wont release their
  results.
• Treatment (inpatient) usually lasts for 5, 30
  minutes sessions with 2 booster sessions after
  discharge.

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Aversion Therapy

• There have been other drugs used including a
  curare like drug that actually caused total
  paralysis, including breathing.
• Whos next? Would you try it?

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Aversion Therapy

• Imagery and smell has been used as well with
  mixed results. The success rate varies from 50
  maintaining abstinence to 9 remaining abstinent.
• Not used much anymore for obvious reasons.

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Cue Exposure

• CE is derived from learning and social learning
  theory models.
• Cues can include sight, smells, places, people
  and emotional feelings (anger, stress, depressed,
  happy etc.).
• Cues may play a role in resumption of using.

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Cue Exposure

• Since cues play an important part in triggering
  using behavior cue exposure training (CET) gives
  the client a chance to practice new coping skills
  to effectively handle those cues (triggers).

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Cue Exposure

• First, repeated exposure to a cue should result
  in habituation, (decreasing the strength of the
  cue).
• Second, practice using coping skill in the
  presence of cues should make it easier to use
  them in a real situation.

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Cue Exposure

• Urge Control is part of cue exposure
• Use Daily record of Urges to help clients
  identify urges and how strong an urge becomes.

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Behavioral Self-Control Training

• BSCT can be used for moderation or a goal of
  abstinence.
• Most likely to work for clients who are at the
  beginning of treatment, and are experiencing less
  severe problems.

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Why use BSCT?

• Those who refuse a goal of abstinence.
• Attracts a broader range of drinkers.
• In may cases moderation leads to abstinence.

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Description

• Setting limits.
• Self-monitoring of drinking behaviors
• Changing the rate of drinking.
• Practice refusal skills
• Setting up a reward system for achievement of
  goals.
• Learning which triggers result in overdrinking
• Learning new coping skills to resist drinking

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Practice Exercise

• Develop a Treatment Plan, just pick one or two
  areas to work on, (one or two goals)
• Then develop a strategy to accomplish these
  treatment goals using one of the strategies weve
  discussed in this class.
• Dont play the client from Hell. This is a
  learning experience.
• Debrief with group

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Recovery Maintenance Strategies Marlatt and
Gordon (1980) Cognitive-Behavioral Model

• Distinguished lapse from relapse.
• Creation of a Relapse Prevention (RP) model based
  on Cognitive-Behavioral principles.

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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• Effective coping in high risk situations leads to
  enhanced self-efficacy
• Enhanced self-efficacy less relapse
• Ineffective coping in high risk situations leads
  to decreased self-efficacy and increase in
  positive outcome expectancy
• Low self-efficacy increased positive outcome
  expectancies more relapse

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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• High risk situation ? Effective coping response ?
  Increased self-efficacy ? Less risk of relapse
• High risk situation ? Ineffective coping response
  ? Decreased self-efficacy Positive outcome
  expectancy ? Lapse ? AVE and perceived positive
  effects ? Increased risk of relapse

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Marlatt and Gordon RP Model

• .

High Risk Situation
Effective Coping Response
Ineffective Coping Response
More Relapse Risk
Increased Self- Efficacy
Decreased Self- Efficacy
Increased AVE
Less Lapse/Relapse Risk
Positive Outcome Expectancy
More Lapse Risk
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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• Characteristics of a high risk situation
• Unpleasant emotions
• Physical discomfort
• Pleasant emotions
• Testing personal control
• Urges and temptations
• Social problems at work
• Social tension
• Positive social situations

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Outcome Expectancy orWhat the IP expects from
using

• Global positive changes
• Sexual enhancement
• Physical and social pleasure
• Social assertiveness
• Relaxation and tension reduction
• Arousal and power
• Expectancy plays a major role in the control and
  prediction of relapse

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Expectancy Effects
Received Alcohol Received No Alcohol
Told they Received Alcohol YES YES
Told they Received no Alcohol NO NO
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Biphasic Effects of Alcohol

• Description of the usual physical effects of
  drinking alcohol
• BAC of 0.01 to 0.06, experience positive mood
  effects (mostly due to expectancy)
• BAC gt0.06, experience negative mood effects

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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• Abstinence Violation Effect (AVE)
• an individuals cognitive and affective response
  to a lapse.
• (Disease model focuses on physiology-driven loss
  of control)

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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• AVE increases when cause of use is seen as
• Internal (I have a disease)
• Stable (My slip is about me, so it will happen
  again)
• Global (My slip will happen in other places)
• Uncontrollable (I have no willpower)
• AVE decreases if use seen as discrete event and a
  function of their behavior

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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• Additional AVE Factors
• Degree of commitment to sobriety
• Effort exerted toward sobriety
• Length of sobriety (highest relapse rate within
  first 90 days of sobriety)
• Degree of progress to maintain sobriety

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Recovery Maintenance StrategiesMarlatt and
Gordon RP Model

• Less Obvious Relapse Factors and Opportunities
  for Intervention
• Lifestyle imbalance ? Desire for indulgence ?
  Urges and cravings ? Rationalization, denial,
  AIDs ? Lack of coping response ? Decreased
  self-efficacy positive outcome expectancies ?
  Initial use (lapse) ? AVE ? Relapse

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Recovery Maintenance StrategiesSelf-Efficacy

• Enter high risk drinking situation
• Cognitive appraisal
• Reach judgment (efficacy expectation) about
  ability to cope
• Drink/use or not drink/not use

(Helen Annis)
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Recovery Maintenance StrategiesSelf-Efficacy

• Analysis of clients high-risk situations
  (Inventory of Drinking Situations - IDS-100)
• Creation of Client Profile
• Generalized
• Positive
• Negative
• Mixed
• Develop hierarchy of risky situations
• Identify strengths, resources and coping
  responses
• Monitor self-efficacy (Situational Confidence
  Questionnaire - SCQ-39)

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Recovery Maintenance StrategiesSelf-Efficacy

• Effective Homework Assignments
• Challenging tasks
• Moderate effort
• Little external aid
• Pattern of improvement
• Increase in personal control
• Success directly relevant to recovery

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Recovery Maintenance StrategiesFunctional
Analysis

• Emphasis upon lapse/relapse as learning
  opportunity
• Reasons for becoming sober/clean may not be the
  same as the reasons for staying sober/clean
• Assumes that lapse/relapse makes sense
• Examines the before, during and after of
  lapse/relapse behavior
• Done in a non-judgmental attitude
• Want to get the story
• Remember to go far enough back in time

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Behavioral Chain

• Bored need a walk
• go towards the park go into park
• Go near friends house go into house
• Friend asks you to get high give in

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Exercise

• Develop a relapse plan for your client
• Role play developing a relapses plan using the
  relapse strategies discussed, and then discuss
  with the group your plan.

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Cultural Issues

• Cultural Barriers to treatment
• Lack of gender specific programming
• Cultural structures, beliefs or values that
  discourage acknowledgment of alcohol or drug
  related problems or seeking formal treatment.
• Language barriers.

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Cultural Issues

• Lack of culturally specific programming.
• Lack of effective culturally specific outreach
  and advertisement.
• Lack of treatment to meet special needs of the
  culture.
• Lack of training in cultural issues

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Cultural Issues

• Respect for Culture
• Give Dignity to all
• Never think you know the culture