Cognitive Behavioral Therapy and Mindfulness

in Addiction Treatment

Tony Pacione, LCSW, CSADC

Objectives

On our Slate for today… Why CBT/Mindfulness for addictions? Role of automatic thoughts Identifying and changing thought patterns Self management of mood, and craving states Understand and Define Mindfulness Meditation (Dr.

Angres) For HRC… Implement CBT and Mindfulness Disclaimers…

In Early Recovery, Cover Your…

A

S

S

ccountability

tructure

upport

Pacione and Buino, 2009

Accountability…

… for WHAT you are responsible in recovery

Understanding your thoughts

Identifying thinking patterns

Willingness to change ineffective thinking

Structure…

… HOW you achieve your goals in recovery

Thought log

Challenging thoughts

‘Acting as if’ strategies

Meditation/mindfulness techniques

Support …

…WHO will support your efforts

Treatment Counselors

Sponsor

Therapist

Psychiatrist

Self-help

Family/friends

Cognition

How thoughts are:

– Formed

– Maintained

– Discontinued

– Intensity of thoughts

Cognitive Schema: A Beck, 1993

Automatic Thoughts

(Mental) Reactions to situations

– Real

– Imaginary/perceived

– Anticipatory

Association among feelings, mood, and beliefs, behaviors

Cognitive Schema

Conditional Beliefs

More general than automatic thoughts

– Boolean logic: “If… than; and/or”

Assumptions

Roles/expectations

Attitudes/values

Cognitive Schema

More general than conditional beliefs Strongly held beliefs, underlying assumptions

about who we are and our world Develop early in life and are often reinforced as

we age Can become a ‘filter’ for interpreting life

experiences (“self-fulfilling prophecies”) Can be identified and changed!

Core Beliefs(Self Efficacy)

Cognitive Schema: Core Beliefs

Two ‘varieties’ of defective core beliefs - Beck 1993

1. Un-lovable unworthy; irrelevant; needy; self-centered

2. Incompetent defective; helpless; failure; screw-up

The Complete Cognitive Schema

Relevant Childhood and Developmental data:

Core Beliefs:

Conditional assumptions (if/then):

Compensatory Strategy:

Situation:

Automatic Thoughts:

Emotions:

Behavior:

Cognitive Restructuring

1. Observe thoughts

2. Identify thinking patterns

3. Identify cognitive distortions

4. Challenge cognitive distortions

5. Construct alternative thoughts/beliefs

6. Complete cognitive schema

7. Behavioral Experiments (“act as if”)

8. Validate (#1)

(DPW3 = GTH)

Thought Record (Steps 1-2) 42 y/o female alcoholic

Situation/Event Automatic Thought Related FeelingRating Mood and Desire/Craving (1-10)

I fought with my husband overmissing our son's basketball gameto attend an AA meeting.

“He is not supportingmy recovery."

Anger FrustrationMisunderstood 6

My husband invites me to his holiday work party; I remember last year’s party whenI had leave because I was sointoxicated.

“I am an embarrassment to my husband and a bad wife.

GuiltDepression 8

My sister is hosting the holidaydinner this year and asks me tomake a run to the liquor store to buythe supplies for the event.

“She is insensitive andPutting me in a badposition for a relapse.”

AngerHurt 6

I tell me boss I’ve beenstruggling with my recovery and hereally wants to help me get sober.

“I am a bad employee for letting my drinking affectmy work.”

FrustrationGuilt 8

I’m celebrating my son’s birthday, and realize I’ve missed many of hisachievements and milestones because of my drinking

“I am a bad mother forletting him down for solong.”

GuiltDepression 10

Common Cognitive Distortions (Step 3)

Dichotomous thinking

Overgeneralization

Mental filters

Jumping to conclusions

‘Catastrophizing’

Emotional reasoning

Personalization

Burns, D. 1999

Thought Record- Cognitive Distortions (Steps 3) 42 y/o female alcoholic

Overgeneralization and catastrophizing

Emotional reasoning and dichotomous thinking

Catastrophizing

Emotional reasoning and dichotomous thinking

Emotional reasoning and dichotomous thinking

“He is not supporting my recovery.”

“I am an embarrassment to my husband and a bad wife.”

“She is insensitive and putting me in a bad position for a relapse.”

“I am a bad employee for letting my drinking affect my work.”

“I am a bad mother for letting him down for so long.”

Challenging Automatic Thoughts(Steps 4-5) Using I.C.E. to cool off ‘Hot’ thoughts

I – Identify/rate the thought

C – Challenge the thought

E – Evaluate/re-rate the truthfulness of the thought

A. Pacione, 2003

I.C.E.(Steps 4-5)

I didn’t attend a single one of his basketball games last season, when all the other mothers were there.

I realized I had a problem and sought treatment; If I am sober I can be there for him from now on.

He did poorly in math class because I wasn’t there to help him with his homework.

I have made sure he always had a roof over his head and food on his plate.

I couldn’t chaperone his class field trip because I didn’t want anyone to see me with the shakes.

I’ve always made sure to tell him he is loved and that he is an extraordinary person.

Identify and rate the thought: “I’ve missed so many of my son’s achievements because of drinking. I I am a bad mother.” truthfulness rating = 90% (of the time)

EVIDENCE FOR EVIDENCE AGAINST

Challenge the thought:

I.C.E. cont.(Step 4-5)

Evaluate/re-rate the thought: Post challenge truthfulness rating = 30%

Revise the thought: “I’ve let him down in the past, but I am doing everything I can now to stay sober; I can be more present for my son.”

Practice Time!

ICE your colleague

Cognitive Grid(Step 6)

Relevant Childhood and Developmental Data: Absent mother; alcoholic father

Core Belief: “I’m un-lovable.” Conditional assumptions (if/then): “If I am

a good mother I will feel loved by my son; then I am lovable!”

Compensatory strategy: “Make sure I am always available for him, whatever he needs.”

Cognitive Grid continued

Situation: Missed a lot of my son’s achievements while drinking.

Automatic Thoughts: “I am a bad mother.” “My son doesn’t love me”

Emotions: “Depression and guilt”

Behavior(s): Increased potential for isolation, self-sabotage, and relapse

Challenging Core Beliefs(‘acting as if’ - Step 7) Amended Core Belief: “If I remain sober,

I’ll be a better mother. I can be loved for who I am.”

How to ‘act as if’ you’re a good mother:– Attend my son’s basketball games when I

can

– Offer to help him with his homework

– Tell him I love him and praise his good work

– Set limits and rules for him to follow

Practice Time!

Create a Cognitive Grid

Mindfulness = Becoming More Aware More Often

“A powerful influence taking us away from being ‘fully present’ in each moment is our automatic tendency to judge our experience as being not quite right in some way—that it is not what should be happening, not good enough, or not what we expected or wanted. These judgments can lead to sequences of thoughts about blame, what needs to be changed or how things could or should be different. Often, these thoughts will take us, quite automatically down some fairly well-worn paths in our minds. In this way, we may lose awareness of the moment, and also the freedom to choose what if any, action needs to be taken.”

Segal, et al. 2002

Mindfulness in recovery

Thoughts Judgments Actions Consequences

Becoming more aware more often of– Thinking patters

– Situations that activate your core belief

– Urges and craving to use

CBT + Mindfulness CBT = modifying

– perception – beliefs and thoughts– judgment

Mindfulness =– being more aware more often– less interested in thought content– focus on arising and ceasing of thought

(DPW3= GTH)

Principles of Mindfulness

1. Non-judging

2. Patience

3. Fresh Mind

4. Trust

5. Non-striving

6. Acceptance

7. Letting Go

Kabat-Zinn, 1990

1. Non-judging

Become aware of the judging thoughts

Notice how often we label and categorize – assigning value to people and experiences

Pain Vs. Suffering

2. Patience

Be completely open to each moment

Accept each moment in its fullness

Know that life can only unfold in its own time

3. Fresh Mind

See things as if for the first time

Be receptive to new possibilities – prevents getting stuck

Experiment

– Try having a fresh mind with your partner, child, patient, or someone else familiar to you

4. Trust

Develop trust within yourself – Knowing when to seek help

– You can’t have all the answers

Don’t compare yourself to others

The more we trust ourselves, the easier it is trust others and seek help

5. Non-striving

Allowing anything we experience from moment to moment to just be here

Thinking of how you “should” be implies you are not ok right now

– “IF I weren’t so stressed at work, THEN I would be able to stay sober.”

6. Acceptance

We have to accept ourselves and situations as they really are before things can change.

Acceptance does NOT mean:

You have to like everything

That you have to tolerate things as they “have to be”

That you should stop trying or give up

7. Letting Go

Pay attention to inner experience to discover what thoughts and feelings the mind wants to hold on to

Holding on is the opposite of letting go

Example:

Catching monkeys

Practice Time!

De-centering Meditation

CBT and Mindfulness

1. Observe thoughts-Centering meditation/ non-striving

2. Identify thinking patterns- “If your mind has wandered…”

3. Identify cognitive distortions-Non-judging/accepting mind

4. Challenge cognitive distortions-Fresh mind

5. Construct alternative thoughts-Letting go

6. Complete cognitive schema

7. Behavioral Experiments (“act as if”)-Trust/patience

(DPW3 = GTH)

Bibliography Beck, A., Wright, F., Newman, C. Liese, B. (1993).

Cognitive Therapy of Substance Abuse. New York: The Guilford Press, Inc.

Burns, David. (1999). Feeling Good (revised edition). New York: Avon Books.

Kabat-Zinn, John. (1994). Wherever you go there you are: mindfulness meditation in everyday life. New York: Hyperion.

Kabat-Zinn, John. (1990). Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell Publishing.

Project MATCH Research Group. (1993 and 2000). Project MATCH: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 17, 1130-1145.

Segal, ZV, Williams, JM, Teasdal, JD. (2002). Mindfulness-Based Cognitive therapy for Depression: A new approach to preventing relapse. New York: The Gilford Press.