cbt for concurrent disorders - news · pdf filecbt for concurrent disorders shari a. mckee,...
TRANSCRIPT
CBT for Concurrent Disorders
Shari A. McKee, Ph.D., C.Psych.
Sarah Durant, B.A., ACMay 26, 2014
Georgianwood Program for Concurrent Disorders
Waypoint Centre for Mental Health Care
Georgianwood
3-month residential program
Fully integrated mental illness and addiction
treatment
2 streams:
Skills Stream: for clients with major mental illness
CBT Stream: for clients with concurrent anxiety
disorders or depression
Offer CBT, skills training, Seeking Safety, self-help
groups, anger management, psychoeducation,
family education, vocational counseling, etc.
Integrated Treatment for
Concurrent Disorders
Concurrent disorders =mental illness + substance use
Integrated treatment = substance abuse treatment
+
mental illness treatment
- At the same time
- By the same team
Why do CBT with CDs?
CBT targets thoughts & behaviours to improve
mood and is an empirically supported treatment
Is a best-practice recommendation for working with
clients with concurrent disorders (Mueser, Noordsy, Drake & Fox,
2003)
CBT is manualized - can find a CBT manual for
almost any problem (e.g., psychosis, substance use,
depression)
However, few specific manuals for CBT for CDs
CBT is Empirically Supported as
a Treatment for:
OCD
PTSD
Depression
Substance abuse
Eating disorders
Personality disorders
Schizophrenia
Chronic painetcJ. Beck, 1995
Long-term Effects of Cognitive Therapy,
Medications, and Placebo
Patient responders that completed CT were significantly less likely to relapse than responders that terminated medications.
The CT group was no more likely to relapse than the patients continuing on medications.
0
20
40
60
80
100
0 6 12 18 24
CT
Meds.
Plac.
Hollon et al., 2005
Archives of General Psychiatry
Months following acute
treatment
% Surv
ival
Goals of CBT
1. To provide symptom relief
2. To facilitate remission of the mental health
symptoms
3. To help resolve the most pressing problems
4. To give tools to help avoid relapse
Georgianwoods CBT Group
2 co-therapists (ideally)
60-minute session once a week
60-minute homework group once a week
Each session is recorded & rated for fidelity
Group has included clients with bipolar disorder, depression, schizophrenia, anxiety disorders, & schizoaffective disorder all with concurrent substance use disorders
Georgianwoods Pre & Post
Depression & Anxiety Scores (n=153)
Depression:
BDI pre score average = 29 (severe)
BDI post score average = 11 (minimal)
Anxiety:
BAI pre score average = 23 (moderate)
BAI post score average = 9 (mild)
Measuring Outcomes
Want to measure outcomes for many reasons:
To know whether patients are benefitting
To know whether therapists are effective at getting
information across
To justify ongoing administrative support for the group
To continually improve the quality of the group
Example of Outcomes to Measure
Understanding of the content (multiple choice quiz)
Symptoms (anxiety, depression, psychosis screeners)
Attendance
Engagement in the group (rating form for therapists)
Pre-post skills test
PRN use etc
Manuals
Mind over Mood manualGreenberger & Padesky (1995)
Intended as self-help guide very user friendly
Can buy on Amazon, Chapters, etc
We subsidize cost of manual ($10)
We created a 12-session facilitators guide
Great for mood and anxiety symptoms
Hazelden CBT for CDs Manual McGovern, Drake, Merrens, Mueser & Brunette, 2008; 2014
Available through the Hazelden website
Cost: $120 plus shipping
15-session manual with handouts & fact sheets
Was created specifically for patients with CDs
Authors are some of the big names in the field
of CDs (Drake, Mueser, McGovern etc)
Rating Mood
Clients come a few minutes early to group to fill out mood ratings
Can use anxiety & depression screeners from Mind over Mood
Group leaders should examine clients responses to items #10, 11 & 12 of the depression screener (suicide-related)
Or can use emotion thermometers if clients struggle with reading/comprehension
Emotion Thermometers
Issues that can Interfere with CBT
Post-acute withdrawal
Medications (sedating)
Symptoms of mental illness (e.g., poor
concentration, apathy)
Cognitive impairment or illiteracy
Chaotic lifestyle distracted by life problems
Ongoing substance abuse
Tips for Doing Groups with People
with Serious Mental Illness
Use lots of visuals write on the board, handouts
Focus on a few key skills
Use strategic repetition
Have a clear structure to the group
Maintain group so that only one person is talking at
a time
Keep it short (one hour max) or else have breaks
Modifying CBT for CDs
Can adapt standard CBT skills to help clients
overcome problems related to both mental illness
and addiction
Always prompt clients for examples from both
areas:
E.g., if client focused on anxiety, ask for issues related
to substance use such as urges or cravings and relate
them back to the anxiety
20 Session Outline for
Hazelden CBT for CDs Manual
Session 1 Intro to the group
Session 2 Breathing retraining
Session 3 & 4 Primary symptoms of CDs
Session 5 & 6 Associated symptoms of CDs
Session 7 & 8 First 3 steps of CR
Session 9-13 Five steps of CR
Session 14-15 Wrap up
Intro to CBT for CDs Group
Introduces clients to main skills
Give an overview of CBT - structure
Instill hope and normalize their problems
Discuss goals
Create crisis plans if necessary
Hope & Goals
Want to instill hope
Discuss the effectiveness of CBT how it is an
empirically supported intervention for CDs
Normalize discuss the prevalence of co-morbid
disorders such as depression & substance abuse
Discuss their goals for therapy what do they
hope to get out of CBT? (make sure goals are
reasonable)
The Cognitive Model
Peoples feelings & actions are affected by how
they think about a situation:
Situation Thoughts Mood
Discuss Homework
Is typically part of CBT
Years of negative thinking is not likely to be
changed in just 45 minutes a week
Homework should build on the skill taught that
week but not be overwhelming
If not done, try to process what got in the way.
Need to be flexible.
Breathing Retraining
Gives clients an immediate skill they can start using
to cope with anxiety
Can discuss use of substances as a maladaptive way
of coping with anxiety
Breathing affects the way we feel & breathing
retraining can reduce physical tension & anxiety
Breathing Retraining contd
Often people mistakenly think that taking a
deep breath is helpful to calm down
What happens when you take deep, gulping
breaths?
May start to hyperventilate which increases
anxiety (fight or flight)
Overbreathing decrease the amount of CO2 in
the blood which means less blood to brain,
heart & extremities
Breathing Retraining contd
Overbreathing leads to symptoms of anxiety
Want to conserve CO2 through breathing
retraining
Best to breathe in through the nose
The exhalation is what aids relaxation
Want to exhale slowly
Can be helpful to use a relaxation cue word
such as Calm or Relax
Breathing Retraining Steps
1. Take normal breath in (by nose)
2. Exhale slowly
3. On exhaling, say C-a-a-a-a-a-a-a-a-a-l-m
4. Count to 4, and then take in the next breath
5. Practice this several times a day 10-15 breaths
at each practice
Exercise: Breathing Retraining
Lets try it as a group!
Primary Symptoms of CDs
This section includes psychoeducation for clients
about mental illness symptoms & links to
substance use
Go slowly & encourage active participation
Ask clients to describe their experiences with their
symptoms & how each symptom does or doesnt
apply to them
Primary Symptoms contd
If you make the education more personally
meaningful, it will be more memorable
Very important to continually link the symptoms to
substance use
Want to explain how substance use works how it
helps the client, hurts the client, & the sequence of
events that led to substance use
Fact Sheets
The manual comes with Fact Sheets about 10
common psychiatric diagnoses:
Schizophrenia, schizoaffective disorder, bipolar disorder,
major depression, dysthymia, PTSD, GAD, OCD, social
phobia, panic disorder
Should review charts prior to gr