METCBT Skills Training

1
MET/CBT Skills Training

• Enhance Engagement, Build Competency
• Promote Retention

Nancy L. Hamilton, MPA, CAP, CCJAP Operation PAR,
Inc. nhamilton_at_operpar.org
2
(No Transcript)
3
Theoretical Basis of MET/CBT

• Rogers empathic listening and reflection therapy
• Prochaska DiClementes The Stages of Change
  Model
• Millers Motivational Interviewing
• Miller Rollnicks Motivational Enhanced
  Treatment (MET) approach from Project Match
• Montis Cognitive Behavioral Therapy (CBT) from
  Project Match
• Stephens, R. S., Babor, T. F., Kadden, R.,
  Miller, M., MET/CBT Approach from the (adult)
  Marijuana Treatment Project

4
Normal Adolescent (12-17) Young Adult (18-25)
Development

• Biological changes in the body, brain, and
  hormonal systems that continue into mid-to-late
  20s
• Shift from concrete to abstract thinking
• Improvements in the ability to link causes and
  consequences (particularly strings of events over
  time)
• Separation from a family-based identity and the
  development of peer- and individual-based
  identities
• Increased focus on how one is perceived by peers
• Increasing rates of sensation seeking/experimentin
  g
• Development of impulse control and coping skills
• Concerns about avoiding interpersonal emotional
  or physical violence
• Realizing that they are not invincible to
  environmental risks (which are often less
  proximate or likely)

5
Conceptual Challenges to Address

• Most adolescents do not recognize their substance
  use as a problem and are being mandated to
  treatment (and are angry about it)
• Co-occurring problems (mental, trauma, legal) are
  the norm and often predate substance use
• Treatment has to take into account the multiple
  systems (peers, family, school, welfare, criminal
  justice) involved in their lives
• Adolescents have less control of their lives and
  recovery environment than adults
• Need to be creative in dealing with family and
  peer relationships because they are still central
  to the adolescents self-identity and are not
  easily changed

6
Family, Peer Groups, Community

• Families often play a pivotal role, but vary in
  their ability and willingness to help
• Peer groups are very powerful but can have both
  negative and positive effects
• One or two very disruptive people can destroy a
  group and actually lead to worse outcomes
• Need to minimize confrontational approaches
  unless you have the time and control necessary to
  do them well and safely
• Less availability of aftercare, 12-step groups
  and peer based recovery support

7
Adapting Treatment Manuals/Materials

• Examples need to be reflect the substances,
  situations, and triggers relevant to adolescents
• Motivational strategies and consequences have to
  be reflect things of concern to adolescents
• Concepts need to be expressed in concrete (vs.
  abstract) terms to match developmental stage
• Curricula need to take into account individual
  differences in severity, co-occurring problems,
  and development which often change during the
  course of treatment
• Need for treatment facilities that are physically
  durable and to have access to recreational
  facilities

8
Review - Goals of CBT

• Restructure thoughts, perceptions beliefs

9
Assumptions of CBT

• Substance use is a learned behavior in which use
  becomes triggered by environmental stimuli,
  thoughts and feelings and is maintained by
  reinforcing effects.
• Individuals who wish to stop or reduce substance
  use need skills to cope with these triggers, as
  an alternative to drug and alcohol use.
• Effective learning of these new coping skills
  requires repetition and practice with feedback.

10
Philosopher Epictetus Slave born in Greek
Speaking Roman province of Phyrgia (c. 50-136AD)

• The thing that upsets people is not what happens
  but what they think it means

Attribution Theory
11
Review - CBT Background

• Psychotherapeutic approach
• Promotes positive change in individuals
• Helps alleviate emotional distress
• Addresses a myriad of psycho/social/behavioral
  issues
• Addresses irrational thinking, misconceptions,
  dysfunctional thoughts, faulty learning
• Collaborative relationship between helper
  client very active therapy
• Structured Focused more present centered
  forward looking
• Not Positive Thinking goal is accurate
  rational thinking

12
Review - CBT Background

• CBT the extended form of Behavioral Therapy
• Derives from theories on learning
• Behavior includes overt Covert
• Behavior (except for primitive ones) is learned
  can be unlearned
• Learning theorists Ivan Pavlov, John Watson,
  B.F. Skinner
• Social Leaning theorist Albert Bandura
  Modeling vicarious learning
• Related to self-efficacy

13
Review - Some CBT Techniques

• Challenging irrational beliefs
• Relaxation education training
• Self monitoring
• Cognitive rehearsal
• Thought stopping
• Communication skills training
• Assertiveness skills training
• Social skills training
• Bibliotherapy
• Homework assignments

14
Review - Other CBT concepts Cognitive
modification

• Automatic Thoughts involuntary effortlessly
  could be neutral, harmful or good CBT helps
  one to recognize them
• Maladaptive Schemas (shared themes) basic
  assumptions, attitudes or beliefs influence
  thinking indirectly but powerfully (The world
  is a hostile place)
• Irrational Ideas Life should be fair
  magical thinking If you love me you will meet
  all my needs make me happy

15
(No Transcript)
16
Review - Belief Systems

• Precursors
• Messages
• Personalization
• Choice of behavior
• Internal external feedback loop
• Confirm or Conflicts with Beliefs
• New choice of action - behavior

17
Think Feel - Act
18
Tips for Using CBT in Clinical Work with
Adolescents

• Individualize with adolescents concerns avoid
  a cookbook feeling
• Monitor for boasting about antisocial behaviors,
  or excluding some participants
• Try to make it lively interesting

19
MET - Key Concepts

• Ambivalence expected
• Change may mean a gain but losses are
  inevitable
• Reflective Listening, Responding to feelings
  non-judgmental
• Open ended questions promote further discussion

20
MET Key Concepts

• Techniques, Interventions MET information
  gained from assessment clinical interview used
  thru out TX experience
• Motivation beliefs are internal rather than
  external (imposed by others)
• Both client helper behaviors count
• FIVE STATEGIES Express empathy Develop
  Discrepancy Avoid argumentation Roll with
  resistance Support Self-efficacy

21
Assumptions of MET

• Therapist style is a powerful determinant of
  client motivation and change
• Change is more likely when the motivation comes
  from adolescent, rather than being imposed by the
  therapist, family, school, or court
• Need to show respect for the client and
  demonstrate understanding (vs. confrontation)
• Ambivalence about change is normal
• Change involves a process

22
(No Transcript)
23
The Stages of Change Model
Permanent Exit?
Relapse?
Pre-contemplation
Maintenance

Contemplation
MET
Action
Determination
CBT
24
Five Strategies of MET

• 1. Express Empathy
• 2. Develop Discrepancy
• 3. Avoid Argumentation
• 4. Roll with Resistance
• 5. Support Self-Efficacy

25
1. Express Empathy

• Conveyed Non-verbally
• eye contact
• body position
• facial expression
• Conveyed Verbally
• through reflections

26
Reflective Listening

• Open vs. Closed Ended questions
• How often did you xxx vs. Tell me about when
  you xxx...
• How many of your friends use drugs? vs. How
  have your friends reacted to your going into
  treatment?
• Have you had problems with xxx..? vs. Tell me
  about the problem you mentioned with xxx?
• Demonstrating understanding of what the client is
  communicating
• It sounds like you . . .
• So you . . .
• It seems to you that . . .
• It sounds like youre feeling . . .
• Avoid labeling, lecturing, preaching, shaming,
  ridiculing, warning, arguing, or threatening

27
2. Develop Discrepancy

• Discrepancy is thought to be the engine that
  drives change
• Help the client describe the discrepancy between
  how their life is when abusing substances and how
  it was/could be without
• Often need help seeing the pattern of similar
  situations and drawing the link to consequences

28
Facilitating the Risk/Reward Analysis

• Normalize ambivalence to encourage contemplation
• Help tip the decisional balance scales by
• Eliciting pros and cons of use and change
• Emphasizing client choice and responsibility
• Elicit self-motivational statements, and
  summarize them

29
3. Avoid Argumentation

• Resistance is a cue to modify your approach
• Treat ambivalence (mixed feelings) as normal
• Use double-sided reflections

30
Strategies for Gentle Encouragement

• Establish rapport and build trust
• Raise doubts by
• Eliciting the clients perceptions of the problem
• Providing feedback
• Facilitating feedback of a significant other
• Avoid premature prescriptive advice
• Express concern, back off if necessary and keep
  the door open

31
ROLLING WITH RESISTANCE

• Dont get rattled when the client says something
  against change
• Best response is empathy, plus slightly hopeful
  comment
• May need to use small steps (such as relapse
  sampling instead of lifetime commitment)

32
5. Support Self-Efficacy

• Reinforce any willingness
• to hear information
• to acknowledge the problem
• to take steps toward change
• Make the connection between previous successful
  change and potential to change the current problem

33
(No Transcript)
34
1st MET Session Rapport Building
Listen!!

• Getting to know you Introductions lower
  anxiety demonstrate safety, support
  understanding casual start with less
  threatening information
• Assess depth of resistance
• Discuss expectations of TX
• Ask for clients assessment of issues Provide
  Individualized feedback (PFR) about SA problems,
  etc. allow client to elaborate on items
• Summarize session ask for confirmation

Exercise 1 client 2 helper 3 - observer
35
2nd MET Session Rapport Building

• Review progress, thoughts, reactions since
  Session 1 let the client tell you how they are
  doing (use, etc.)
• Collaborate on TX Goals and Goals for remaining
  in treatment sessions explain why goals are
  important (personal goal sheet)
• Introduce concept of functional analysis client
  centered language include triggers, thoughts
  feelings, behaviors positive negative aspects
  of using
• Prepare for group sessions how long what to
  expect elicit questions

Exercise 1 client 2 helper 3 - observer
36
Communication
37
CBT Session 3 Refusal Skills

• Transition from Individual to group discuss
  confidentiality, personal sharing, redirect to
  include other clients - dont pressure sharing
  but encourage it (REMEMBER adolescent need to
  be COOL)
• Specific goals for each session BUT must be
  interesting, interactive, client centered
  encourage role playing (real life PFR)
  rehearsal follow with processing reinforce
  positive participation
• Non-Verbal Verbal Behaviors are discussed
  rehearsed

Exercise 1 instructor 2 observer 3, 4, 5,
6, 7, 8 -clients
38
CBT Session 4 Enhancing the Social Support
Network Increasing Pleasant Activities

• Improves confidence Provides additional source
  of help Several sources of help
• Review progress thus far review real life
  practice Hows it going in your real world?
• Discuss who might help
• Discuss what types of support would help
• Discuss how would you get the support you need
• Role play asking for help support
• Brainstorm Pleasant Activities

Exercise 1 observer 2 instructor 3, 4, 5,
6, 7, 8 -clients
39
CBT Session 5 Planning for Emergencies
Coping with Relapse

• Addresses High Risk Relapse situations ways to
  cope
• Review progress real life practice so far
• Brainstorm events that could precipitate a
  relapse
• Plan ways to cope thru problem solving (use model
  provided)
• Discussion of guilt shame associated with
  failure
• Use emergencies lapses as learning experiences
• Develop an emergency plan
• Summarize the MET/CBT experience

Exercise 6 observer 5 instructor 1, 2, 3,
4, 6, 7, 8 -clients
40
Summary of Key Concepts
41
(No Transcript)
42
(No Transcript)
43
READINESS TO CHANGE
44
THE DYNAMICS OF CHANGE
45
(No Transcript)
46
Comparison of Models
47
Define the Objective

• IS THE PURPOSE OF THE CONFRONTATION
• For you or for the client?
• To force the client to make a choice?
• To express your feelings to the client?
• To get the client to look at their beliefs,
  attitudes behaviors contemplate better
  choices?

48
Changing the PARADIGM

• Previous treatment reflected little understanding
  of women, adolescents, minorities - based on
  white male alcoholic opiate addicts
• Recent research shows techniques based on the way
  other populations think, behavior respond to
  interventions have increased outcomes
• The way we treat clients is a reflection of our
  own world view belief systems

49
Confrontational Model

• Accepts Addict Label
• Emphasis on Disease
• Limited Choices
• Emphasis on Powerlessness
• Client is helplessness
• Treatment is Superimposed
• Convinces Client of Diagnosis
• Resistance is a Client Trait
• Resistance is Met with Confrontation
• Objective Data is Used to Confront Double Bind
  Client

50
Motivational Model

• De-Emphasis on Labels
• Emphasis on Choices
• Emphasizes Power
• Client is in-control
• Treatment is Negotiated
• Solicits Residents Concerns
• Resistance is seen as Interpersonal
• Resistance is Met with Reflection
• Objective Data is Presented in an Un-imposed
  Manner

51
Remember

• You can have the best soup in the world on your
  shelves
• BUT if no one comes into your store, walks down
  your aisle, looks at the soup or decides to buy
  it
• All you have is a store with a lot of unsold soup

52
Motivationally-Enhanced Cognitive Behavioral
Therapy (MET/CBT) - 5 7 Sessions
53
MET/CBT 5 7 12 Sessions

• 1. Rapport Motivation Building
• 2. Goal Setting Preparing for Group
• 3. Marijuana Refusal Skills
• 4. Enhancing Social Support Network
• 5. Coping with High-Risk Situations Relapses
• 6. Problem Solving
• 7. Awareness of Anger
• 8. Anger Management
• 9. Receiving Criticism
• 10.Coping with Cravings Urges to Use Marijuana
• 11. Managing Negative Moods Depression
• 12. Managing Thoughts about Marijuana

54
I Think therefore I am