CBT WORKSHOP

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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)
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• 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

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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 ones 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 Cant stand
it (low frustration tolerance) I cant cope
with other people thinking badly of me or I
cant stand the way they treat me Self /
other downing Im a bad person or hes a
junkie   In REBT a belief is only irrational if
it contains one of the MACS.
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Elliss 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
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Seligmans 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
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Becks 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
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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
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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 "Ju
st 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......
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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 Initiate
d and maintained in a particular environmental
context As drug use behaviours are learned so
they can be unlearned/ modified
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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 Physiolog
ical 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)
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Social Learning Model- Imitationand Modelling/ -
copying and watching others Incorporates
classical and operant learning principles Recogn
ises 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 Anticip
ated 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
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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
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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)
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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 Ref
rame 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
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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) Understan
d 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
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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 Emphas
is 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
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4) Life after Drugs Development of healthy
behaviours/ more balanced lifestyle Meditatio
n Nutrition Exercise Spiritual
practices Guard against transfer of
Addictive Behaviours Development of healthy
positive relationships Co- dependency Enabli
ng 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
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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 (gt60
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)
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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