COGNITIVE–BEHAVIORAL THERAPYAn Evidence-Based Approach to Relapse Prevention

Philip J. Pellegrino, Psy.D.

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Participants will be able to:2

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

Brief Biology of Drug Use3

Reward/Reinforcement Pathway Neurotransmitter release Keep this in mind when discussing

classical and operant conditioning Brain neuroplasticity

Scientific Principles Behind CBT

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Social Learning Theory Classical Conditioning Operant Conditioning Core Beliefs and Schemas

Social Learning Theory5

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

Classical Conditioning6

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.

Operant Conditioning7

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

Operant Conditioning (cont’d)

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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

Core Beliefs and Schemas9

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

Overview of CBT Model10

CBT Model (cont’d)11

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

Philosophy of CBT 12

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)

Short-Term Brief Therapy13

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

Flexible and Individualized14

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

Collaborative Relationship15

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.”

Collaborative Empiricism16

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….?”

Focus on Present Circumstances

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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!!

Focus on Present Circumstances

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We use the past to inform are current conceptualization of how the individual is behaving or perceiving their world.

Guided Discovery19

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=sG0P

6TlbYOw Examples

Guided Discovery (cont’d)20

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

Homework21

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

Be Your Own Therapist22

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!!

Mood Check/Agenda23

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

A Typical CBT Session24

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)

CBT Treatment Strategies25

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)

Functional Analysis26

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?

Functional Analysis (cont’d)27

Use the FBA to identify triggers and high-risk situations

Allows individual to avoid/change triggers and provide new consequences for positive behaviors

Coping with Cravings28

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.

Coping with Cravings (cont’d)

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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

Assertiveness/Refusal Skills30

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.)

Assertiveness (cont’d)31

Passive, aggressive and assertiveness Using “I” statements Being specific

Seemingly Irrelevant Decisions

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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.

SIDs (cont’d)33

Recognizing Avoiding Coping Provide concrete examples Explore past personal experiences

Positive Reinforcement34

Teaching students how to reward themselves for success

Chips in AA/NA meetings

All Purpose Coping Plan/Relapse Prevention

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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

Relapse Prevention36

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?

Relapse Prevention (cont’d)37

Let’s develop our own relapse prevention plan.

Problem Solving38

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)

Problem Solving (cont’d)39

1. Identify the problem Most important part

2. Generate alternatives (Ways to solve the problem)

Brick exercise Withhold judgments

3. Assess the cost and benefits of alternatives

4. Choose a solution

5. Act on solution

6. Evaluate outcomes and return to step 2

Challenging Negative Thinking

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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

CBT and Recovery41

Smart Recovery CBT-based recovery group http://www.smartrecovery.org/

References42

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.