Cognitive Behaviour Therapy in Cognitive Behaviour Therapy in Addictions Addictions
& CBT Interventions& CBT Interventions
MSc: 29MSc: 29thth January 2014 January 2014
Dr Tim [email protected]
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