Cognitive Behaviour Therapy in Cognitive Behaviour Therapy in Addictions Addictions

& CBT Interventions& CBT Interventions

MSc: 29MSc: 29thth January 2014 January 2014

Dr Tim Meynentim.meynen@slam.nhs.uk

TodayTodayCognitive Behaviour Therapy in Addictions Cognitive Behaviour Therapy in Addictions • What is Cognitive Therapy?• Rationale For CT in Substance Misuse• Brief Overview of Evidence Base• Main CT models for addiction

CBT InterventionsCBT Interventions

1. Overview of main CT interventions

2. Case examples and group exercises practicing some interventions

3. Questions?

Group DiscussionGroup Discussion

Knowledge and skillsKnowledge and skills

What do you already What do you already know about CT & know about CT &

Substance Misuse? Substance Misuse?

What would you like to know?What would you like to know?

What is CBT?

• It is a model of psychological therapy that proposes that how we feel, how we think and how we behave are all interrelated, and changes to thoughts and behaviour will influence feelings.

• It’s not the event but the interpretation of the event that’s important

Principles of Cognitive Therapy

(Judith Beck, 1995)

1. Based on an ever-evolving cognitive formulation of the patient & problems

2.  Requires a sound therapeutic alliance

3.  Emphasis on collaboration and active participation

4.  Goal orientated and problem focused

5.  Initial emphasis on present and maintaining factors

6.  Aims to be educative & to teach the patient to be their own therapist

7.  Time limited

8.  Sessions are structured

9.  Focus on identifying, evaluating and responding to dysfunctional thoughts and beliefs

10.  Use of a variety of techniques to change thinking, mood and behaviour.

Brief Overview of Evidence BaseBrief Overview of Evidence Base

• Meta analyses: Irvin et al., 99; Miller et al. 95 Miller and Willbourne 2002

•  Maude-Griffin et al. (98) CT better than other approaches • Can work well in combination with medications: naltrexone

(Anton et al. 99, 2001) and disulfiram (CarolI et al. 2000 & 98)

• Delayed emergence of effects (Baker et al. 2001; Caroll et al. 94)

• Positive effects on long term follow up (Epstein et al., 2003; Carroll et al. 94 & 2000)

• Mental health bonuses (Maude Griffin et al. 98)• Adolescents (Deas and Thomas, 2001: Review) CT and FT

most promising results

But, not all positive

•Crits-Cristoph et al. (99) No signif difference. But was outcome influenced by experience, gender and culture of drug counsellors as well as the number of sessions?

•and Project Match - no signif gains •and Morgernstern & Longabaugh (2000): mechanisms of action?

So some considerations 

Can be very useful, sometimes with additional benefits

 

But

•the need to attend to the therapeutic alliance

•working with ambivalence

•adaptations to materials

•toleration and working with absences

•dealing with crisis

•dealing with relapse and self efficacy

NICE 115 (Alcohol) Key Priorities NICE 115 (Alcohol) Key Priorities for Implementationfor Implementation

• Identification in all settings

• Specialist assessment if appropriate

• Psychological interventions (CBT, BT, SN or Environment Based Therapies)

• CBT common mental illness (anxiety disorders and depression) if continue 3-4 weeks post abstinence

NICE 51 (Drugs) Key Priorities NICE 51 (Drugs) Key Priorities for Implementationfor Implementation

• Brief interventions (structured feedback advice / motivational enhancement)

• Facilitated self-help• Contingency Management (CM)

- targeting drug use

- targeting physical health compliance • Behavioural couples therapy• CBT for common mental illness (anxiety disorders

and depression)

Group DiscussionGroup DiscussionElements of a ModelElements of a Model

What do you think are the key

elements of a cognitive model of

substance misuse?

Some Key

Themes

High Risk Situations

Substance Specific Beliefs

MotivationCravings

Substance Related Activity

Emotional Regulation

Attentional Biases

1. Motivation1. Motivation

• People change in many different ways and for many reasons

• Fluctuates over time• Ambivalence : dilemma of change (Miller and

Rollnick, 1991)• Often faced with negative reaction of others

and confrontational approach• Need to understand client’s perceptions and

functions of use not impose own view• A guiding communication style is ideally

suited to working with ambivalence

2. High Risk Situations2. High Risk Situations

•  Defined as situations in which client encounters substance-related antecedents, cues or triggers leading to use.

• Internal (eg beliefs and emotions) • External situations (physical surrounding,

paraphernalia/people etc/times) • Client’s perception of how they can deal with

these events?

3. Substance Related 3. Substance Related ActivitiesActivities

• Problematic substance use can involve many hours obtaining, taking the drug & recovering from intoxication.

• It can also be highly social, especially where a group provides identity and more acceptance of substance use behaviour (e.g. especially where clients have lost other more positive social networks like family and work colleagues) 

4. Substance Specific Beliefs4. Substance Specific Beliefs

• Assumptions that problematic substance use is initiated and maintained by the individuals beliefs about substances (Beck et al. 1993)

• They describe why the client uses drugs • Describe why they find it difficult to control or stop• Generally accepted as true, often without proper

evaluation (e.g ‘’The only way to stop a craving is to use drugs’’)

• Often paint a favourable and unrealistic picture of use

• Trigger cravings

Substance Substance Related Related

CognitionsCognitions

Imagery

Self

Coping & self-efficacy

Negative outcome

expectancies (Control Beliefs)

Permission Giving

Pharmacology and methods of use

Craving and

withdrawal (relief)

Positive Outcome Expectancy

(Anticipatory Beliefs)

5. Cravings5. Cravings• Subjective desire to experience the effects or

consequences of substance use• Continuum of experience• Not experienced by everyone (Drummond, 2001)•  Possible link to beliefs, response to withdrawal and

abstinence. Definite impact on self-efficacy• Beck et al. (1993): 4 types. response to withdrawal

symptoms/response to lack of pleasure/conditioned response to drug cues/response to hedonic desires)

• Extent of craving may be linked to how much client ruminates on thoughts about using

Cognitive Model of Addiction

Beck, Wright, Newman & Liese (1993)

Early life experiences

Development of schemas, basic beliefs, conditional beliefs

Exposure to and experimentation with addictive behaviour

Development of drug related beliefs

Continued useDevelopmental

modelbased on Beck et al (1993)

Activating stimuli (High Risk Situation)

(internal & external cues)

Anxiety, Low Mood, interpersonal conflict,

other usersUrges

& Cravings

Sweating

Basic Drug Beliefs activated

(anticipatory and relief orientated)

Drinking relaxes me

I’ll really be uptight if I don’t use

Automatic ThoughtsDrink smoke

Relax

Go ahead

Facilitating beliefs

(permission)

I’ll quit soon just one will not hurt me

Focus on instrumental

strategies (action)

Call my dealer

There’s some beer in the fridge

Continued use or relapse

Maintenance model Beck et al (1993)

Lethargic

Tearful

Agitated / Irritable

Can’t sleep

Padesky & Mooney’s (1990) Padesky & Mooney’s (1990) Five-Part Generic Cognitive ModelFive-Part Generic Cognitive Model

Situation / TriggersSitting at home

Staring at the TV again

Behaviour

Thought /Beliefs

Mood

Physicalreactions

I’m useless / my life is rubbish

I can’t stand feeling like this…I need to get out of it

I need to forget…..

Ruminating

Use Alcohol

Depressed / low

 So CT in Substance Misuse is carried out in several ways:

1. Examine and understand the sequence of events leading to drug use

2. Explore basic beliefs about the value of drugs to their lives.

3. Evaluate and consider the ways in which their belief system maintains stress and distress.

4. Modify thinking to obtain a more realistic view of the problems and therefore reduce distress caused by faulty thinking.

5. Training to build up a system of controls to apply when confronted with strong craving and urges.

6. Structure the lifestyle so that other sources of pleasure are made available.

Behaviour

Thought /Beliefs

Mood

Physicalreactions

Interventions around Drug Related Beliefs

•Work with control beliefs

•Facilitate belief change (relief orientated/permission/craving)

•Test out with behavioural experiments

•Elicit Change Talk

Activity Scheduling

Problem Solving

Craving Management

Flash cards

Physical Activity

Attention Training

Situation / TriggersIdentification and management of HRs and substance related activity

Activity Scheduling

Case Formulation link to CBT InterventionsCase Formulation link to CBT Interventions

ExerciseExercise

• Read the case of Jane

• What are the main factors and why?

• What interventions might you want to try?

Why?

 Cognitive Techniques

Advantages and Disadvantages

Identifying and Modifying Drug-Related Beliefs

Downward Arrow Technique

Reattribution of responsibility

Daily thought record

Imagery

 

 Behavioural Techniques

Activity monitoring and scheduling

Behavioural Experiments

Graded Task assignment

Problem Solving

Stimulus control

Why BA ?

Co MorbidityCo Morbidity• High prevalence of anxiety and depression

• Behavioural Anti-depressant (trigger for SM)

• High and Low intensity Interventions

Clinical UtilityClinical Utility•Breaking Avoidance/increasing positives

•Brief structured intervention

• Action Orientated

• Problem solving and SMART

• Recovery Mapping

Recovery ModelRecovery Model• Individualised

• Ownership / Responsibility (HW)

• Identify Shift (Kearney &O’Sullivan, 2003)

• Developing opportunity for personal development

• Not just clinical recovery but also social inclusion

• On-going

• Hope

National National Guidance and Guidance and Evidence BaseEvidence Base

NICE 115 (2011): Alcohol: CBT and behavioural therapies recommended specifically on alcohol-related cognitions, behaviour, problems and social networks.

NICE 51 (2007): Drug Misuse: CBT recommended when co-existing presence of mental health problem

DH: Drug misuse and dependence (2007)

Basic key work skills (Building recovery capital/coping strategies/relapse prevention)

•Activate clients to increase the potential for rewarding experiences & engagement in their world without the use of substances

•And at same time work on processes that inhibit activation such as escape and avoidance behaviours including substance use

Framework of interventionFramework of intervention• Explain the rationale and description of BA

• Assessment and development of idiosyncratic formulation (inc. typical examples/ activity diary)

• Developing SMART Goals and valued direction

• Identifying routine, pleasurable and necessary activities (Richards, 2010)

• Planning and implementation (Hierarchy/ Activity log/worry and rumination)

• Reviewing progress (incl. measurement of outcome)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

What

Where

When

Who

What

Where

When

Who

What

Where

When

Who

Evening

Afternoon

Morning

What values are important to you? (e.g. being a good father)

What are your goals?

Hobbies

Emotions/Moods

Work

Reading. Technical manuals software

Visiting buildings and exhibitions (design/creative inspiration)

Bike riding

Photography

Learning about new design software

Visiting museums

Using the internet

Voluntary job (manual? outdoors)

Jobcentre plus: explore potential for own business

Self-employment

CV:Jobcentre plus

Reduce alcohol use (1 can per day)

Reduce cannabis use (by half)

Eat regularly (Bkfast/lunch and dinner)

Exercise (at least 3 times per week)

Increase friendship group

Explore voluntary work

Email old friends in Australia

Improve living conditions to be able to socialise

Feel less depressed (drink less alcohol)

Improve energy levels (more exercise). Walking and possibly swimming

Increase wellbeing (develop more interests)

Being creative. Using my mind productively. Caring and supporting others. Sharing

Social Relationships

Health and Physical

Education

1. First, list the activities you want to do this week

2. Then, set your goals for these activities

3. Finally, decide what days you want to do each activity, and tick the ‘set’ box for that day. Then tick off the ‘done’ box as you complete your activities

throughout the week!

Activity

Weekly goal for this activity Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Number of days

How long for

Wash and shower (routine)

3 30m Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Eat breakfast (routine)

7 30m Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Walk in park (afternoon & early evening) (pleasure)

7 30m Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Tidy Room (routine)

2 15m Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Dentist (necessary)

1 Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Cook curry (pleasure)

1 60m Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

Set Done

•Disruptions to lifestyle routines (e.g. sleep & eating)•Consequences of SM (e.g. hangovers, cravings)•Presence of many high risk situations•Lack of resources (e.g. money)•Reduced availability of social network•Forgotten talents•Lack of educational/vocational attainment•Stigma and negative judgement

Substance Substance Related Related

CognitionsCognitions

Imagery

Self

Coping & self-efficacy

Negative outcome expectancies

(Control Beliefs)

Permission Giving

Cravings

Positive Outcome Expectancy

Substance Substance Related Related

CognitionsCognitions

Knocks me out and helps me sleep

Helps me socialise

I need it to cope with the pain / thoughts /

memories

Makes me more paranoidReduces motivation

Makes me argumentative I’ll have just one…..Everyone else is drinking/having a joint so….

I need it to stop me craving

Calms my nervesForget troubles

Cognitive biases filter information in the environment in a distorted way, which can reinforce drug and alcohol-related beliefs.

Role:

•exaggerate and select only the positive reasons for taking drugs

•give the client permission to use

•minimise any attempts by the client to control their using pattern

•Thinking in an ‘all or nothing way’‘If I don’t have a drink, I will never get any sleep’

•Paying attention only to the negative side of things‘I’ve probably damaged my health too much by now, what’s the point’

•Generalising from specific situation to all situations ‘I really mucked up that presentation (without valium) I’m going to be rubbish every time’

•Over exaggerating how bad things are‘I’ve always smoked cannabis, I’ll never be able to reduce it’

•Mind reading others ‘Everyone thinks I’m boring because I want to cut down’

•Predicting the future‘Nobody will talk to me unless I join in with having a drink’

Review last episode• What was going through your mind before you had a

binge on alcohol?• Why did (the situation) make you drink?

Define meaning• What do you mean by this…..? (e.g. that you can’t

cope without having a drink)• What would it look like? (e.g. not coping) and how

does drinking help here?• What is the worst thing that could happen if you do not

drink?• What would be so bad about that?

Drug Related Belief

Evidence For Evidence AgainstAlternative (Control)

Alcohol stops the thinking and helps me sleep

85%

Evaluating Drug-Related BeliefsEvaluating Drug-Related Beliefs

1. Examine the evidence that supports the belief. (What makes you think this is true? Where did you get this idea from?)

2. Examine the evidence that contradicts the belief. (What things have happened to you that don’t fit with this view? Have you always thought this? Is this a belief or fact?)

3. Examine the advantages and disadvantages of thinking this way (e.g. “I deserve a treat”). (How helpful is this belief? How does this belief help you achieve your goal of abstinence?)

Linking a New Control Belief Linking a New Control Belief to to

Behaviour ChangeBehaviour Change

“Now that you have developed this control belief…”“What might you do differently next time?” “How can you take things forward?”“How could we find out if that is true?“

• Draw out an alternative formulation (hot cross bun)

Role of Behavioural Experiments in Role of Behavioural Experiments in Substance MisuseSubstance Misuse

“So how can we test this out ?’’

• To challenge situations where the client exaggerates the benefits of using or catastrophises the consequences of not using

• To test other effective ways of managing difficult mood states without using ‘non-prescribed medication’

• To discover new interests for personal development without relying on their drug for support

• To test the effectiveness of new coping strategies

Balanced view? Situation

Prediction What do you think will

happen ? How would you know ? Rate belief (0-100)

Experiment What did you do to test the prediction?

Outcome What actually happened ?

Was the prediction correct ?

What was learned

(Rate belief 0-100) How likely is what you predicted to happen in the

future? (Rate 0-100)

Going to a party with my best friend

I will need to drink alcohol to get though this evening without feeling overwhelmed

by anxiety(90%)

Go to party without drinking before and use learnt techniques during the

party instead of drinking to manage anxiety.

Went to party without drinking and felt very

nervous. Used techniques and they helped calm me

down. Got involved in conversations and met a very interesting person

who had similar experiences to me. Forgot about worries for a time and still did not take a

drink.

I manage to go to cope with my anxieties before and during the

social event without resorting to drinking. I still get very anxious

but the strategies did help. I also quite enjoyed myself and

felt proud at the end of the evening that I had done this. I can enjoy a social occasion

without a drink (80%) - but I did need my friend's support and I was only there for a short time

ReferencesReferencesBeck, A. T., Wright, F. D., Newman, C. F. & Liese, B. S. (1993). Cognitive Therapy of Substance Abuse. London: Guilford Press.

Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.http://www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf

Drummond, D.C. (2001). Theories of drug craving, ancient and modern. Addiction, 96, 33-46.

Graham, H., Copello, A., Birchwood, M.J., Mueser, K., Orford, J., McGovern, D. Atkinson, E., Maslin, J., Preece, M., Tobin, D. & Georgiou, G. (2004). Cognitive-Behavioural Integrated Treatment (C-BIT): A treatment manual for substance misuse in people with severe mental health problems. Chichester: John Wiley & Sons Ltd.

ReferencesReferencesLejuez, C. W., Hopko, D. R., LePage, J., et al., (2001). A brief behavioral activation treatment for depression. Cognitive and Behavioral Practice, 8, 164-175.

Liese, B.S. and Franz, R.A. (1996). Treating substance use disorders with cognitive therapy: lessons learned and implications for the future. In P.M. Salkovskis (Ed), Frontiers of Cognitive Therapy. London: Guilford Press.

Marlatt, G. A. & Gordon, J. R. (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press.

Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R., Wanigaratne, S. (2010). Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: A Practical Treatment Guide. Chichester: Wiley-Blackwell.

ReferencesReferencesNational Institute for Health and Clinical Excellence. (2007). NICE clinical guideline 51. Drug misuse: psychosocial interventions. London: National Institute for Health and Clinical Excellence.

National Institute for Health and Clinical Excellence. (2011). NICE clinical guideline 115. Alcohol-use disorders: diagnosis, assessment and treatment of harmful drinking and alcohol dependence. London: National Institute for Health and Clinical Excellence.

Padesky, C.A. and Mooney, K.A. (1990). Clinical tip: Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, pp. 13-14 (available from www.padesky.com/clinicalcorner.htm).

Pilling, S., Hesketh, K. & Mitcheson, L. (2009). Psychosocial Interventions in Drug Misuse: A Framework and Toolkit for Implementing NICE-recommended Treatment Interventions. British Psychological Society, Centre for Outcomes, Research and Effectiveness (CORE) Research Department of Clinical, Educational and Health Psychology, University College London. www.nta.nhs.uk.

Other Common Interventions Applied Other Common Interventions Applied to Substance Useto Substance Use

• Cost and Benefits Analysis• Defence Barrister Role Play• Tackling Cognitive Distortions • Pie Charts• Imagery• Cognitive Continuum• Downward Arrow Technique• Problem solving• Craving Management