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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)
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
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.
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
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.
Beliefs (groups of thoughts, internal dialogue, reflexive, seldom based on reality, 'sacrosanct')
Distraction, Disputation, Distancing
Learn to change the thoughts ('Pessrum') and change the feelings
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
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”
View of the self
Interpretation of current experience (world/ others)
View of the future
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
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
“Cocaine use makes me competent and witty”
“Smoking hash brings out my creativity”
“When I drink I socialise much better”
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......
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
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)
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)
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
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
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)
B) Skills Training (e.g)- develop strategies and interventions
Generalisable in nature
Repetition (“practice makes permanent”)
Practice ‘Mastering Skills’ in situ
General Treatment Techniques: “What is in the Tool Box?”
Self Monitoring/ Diaries/ Logs/ Mood monitoring
Graded Task Assignment/ Activity Scheduling/ Behavioural
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
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
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)
“Stages of Treatment”
1) Starting treatment/ Engagement
NIDA manual on CBT recommend MI strategies (Miller et al, 1992) to assess risk and elicit change:
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
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
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
4) Life after Drugs
Development of healthy behaviours/ more balanced lifestyle
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
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)
Personality issues
Gender identity
Conduct Disorder
CBT regarded as effective for both addiction and co- morbid conditions (Waldron and Kaminer 2004)
7) Employment of skills to effectively manage (ad hoc) crises
relationship break- ups
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 )
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