Transcript Cognitive Behavioral Treatments & Practicum Course

Cognitive Behavioral
Therapies & Practicum
Course #39457
Current Professionals Track
Substance Abuse Studies Training Program
UNM Continuing Education
Behavior Therapy
Behavior therapy is a method of
counseling that focuses on
modifying the patient’s learned
behavior that are negatively
affecting his or here life.
Cognitive Therapy
Cognitive therapy holds that the principal
determinant of emotions, motive and
behavior is an individual’s thinking, which
is a conscious process.
Change perception, alter emotions =
changes in lifestyle.
Classical Conditioning
A model where a particular
response to a stimuli can be
elicited overtime by association
with a related stimulus.
Unconditioned stimulus
(UCS)
A component of classical
conditioning: an event that
produces an unconditional
response when present.
Unconditioned Response
(UCR)
A natural reaction to an
unconditioned stimulus
Conditioned Response
A response that is identical to an
unconditioned response, yet it is
elicited by the conditioned
stimulus, not the unconditioned
stimulus.
Operant Conditioning
This model is based on the theory
that where behavior is reinforced
and learned based on the
consequences of the behavior.
Reinforcement
Something that is added to a
situation that increased the
likelihood of that even or behavior
of occurring again.
Negative Reinforcement
Something that is taken away or
removed from the situation that
increase the likelihood of the
behavior occurring again.
Modeling
A principle where a behavior is
learned by observing the
consequences of someone else’s
experience.
Shaping
The procedure of rewarding
successive approximations to
the desired response.
Coping Skills Training
Interpersonal
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.
Introduction to
Assertiveness
Passive
Aggressive
Passive-aggressive
Assertive
See handout #1
Receiving Criticism about
Drinking
Type of Criticism
1. Constructive
2. Destructive
See handout # 2
Refusal Skills
• Learned in the CRA Class
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
Other Coping Skills
• Communications skills
• Nonverbal communications
• Listening skills
• Refusal skills
• Resolving Relationship problems
• See Monti et al., (2002)Treating
Alcohol Dependence, Guilford Press.
Coping Skills Training
Intrapersonal
• 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
Managing urges to drink/use
• See handout #4
• Positive Thinking worksheet &
• Urge control information sheet
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 ******
Urge Control
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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.)
Urge Control - Steps
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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?
Managing negative thinking
• Triggers (event, person, place)
• Thoughts (I can’t do this)
• Feelings (Scared, depressed, angry)
• How do you change each one of the
above?
• See handout #5
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?
Planning for emergencies
• See handouts # 6 for exercise
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.
Contingent
• Dependent on something conditional
• Something that may or may not
happen.
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).
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
Voucher Results
• 75% of the clients who received
the vouchers completed 24weeks of abstinence compared to
only 40% in the non-voucher
group.
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
Implementing a Voucher
Program
• Frequent Urine Monitoring
• Provide Feedback
• Minimizing delay in Voucher exchange
• Frequent and regular voucher
spending
• Voucher Redemption
• Abstinence Reinforcement Summary
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?
Behavioral Contracting
• This is a means of scheduling
reinforcements (verbal, behaviors,
events) between two or more
people.
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.
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
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.
Behavioral Contracting
• The therapist should eventually
let the clients take the lead on
making agreements.
• Use positive wording making out
contracts.
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.
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.
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.
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
Aversion Therapy
• Aversion therapy has mixed results.
• Some treatment centers won’t release
their results.
• Treatment (inpatient) usually lasts for
5, 30 minutes sessions with 2 booster
sessions after discharge.
Aversion Therapy
• There have been other drugs used
including a curare like drug that
actually caused total paralysis,
including breathing.
• Who’s next? Would you try it?
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.
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.
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).
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.
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.
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.
Why use BSCT?
• Those who refuse a goal of
abstinence.
• Attracts a broader range of drinkers.
• In may cases moderation leads to
abstinence.
Description
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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
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 we’ve discussed in this class.
• Don’t play the client from Hell. This is a
learning experience.
• Debrief with group
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.
Recovery Maintenance Strategies:
Marlatt and Gordon RP Model
• Effective coping in high risk situations leads to
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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*
Recovery Maintenance Strategies:
Marlatt 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
Marlatt and Gordon RP Model
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High Risk Situation
Ineffective Coping
Response
More Relapse Risk
Increased SelfEfficacy
Decreased SelfEfficacy
Increased AVE
Less
Lapse/Relapse Risk
Positive Outcome
Expectancy
Effective Coping
Response
More
Lapse Risk
Recovery Maintenance Strategies:
Marlatt and Gordon RP Model
Characteristics of a “high risk” situation
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Unpleasant emotions
Physical discomfort
Pleasant emotions
Testing personal control
Urges and temptations
Social problems at work
Social tension
Positive social situations
Outcome Expectancy* or
What 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
Expectancy Effects
Told they
Received
Alcohol
Told they
Received no
Alcohol
Received
Alcohol
Received No
Alcohol
YES
YES
NO
NO
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 >0.06, experience negative mood
effects
Recovery Maintenance Strategies:
Marlatt and Gordon RP Model
Abstinence Violation Effect (AVE):
an individual’s cognitive and affective
response to a lapse.*
(Disease model focuses on physiology-driven loss of control)
Recovery Maintenance Strategies:
Marlatt 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
Recovery Maintenance Strategies:
Marlatt 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
Recovery Maintenance Strategies:
Marlatt 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
Recovery Maintenance Strategies:
Self-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)
Recovery Maintenance Strategies:
Self-Efficacy
• Analysis of client’s high-risk situations (Inventory of
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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)
Recovery Maintenance Strategies:
Self-Efficacy
Effective Homework Assignments*
– Challenging tasks
– Moderate effort
– Little external aid
– Pattern of improvement
– Increase in personal control
– Success directly relevant to recovery
Recovery Maintenance Strategies:
Functional Analysis
• Emphasis upon lapse/relapse as learning opportunity
• Reasons for becoming sober/clean may not be the same
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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
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
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.
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.
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
Cultural Issues
• Respect for Culture
• Give Dignity to all
• Never think you know the culture