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Cognitive Behavioral Therapies

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Cognitive Behavioral Therapies & Practicum Course #39457 Current Professionals Track Substance Abuse Studies Training Program UNM Continuing Education – PowerPoint PPT presentation

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Title: Cognitive Behavioral Therapies


1
Cognitive Behavioral Therapies Practicum
Course 39457 Current Professionals
Track Substance Abuse Studies Training
Program UNM Continuing Education
2
Behavior Therapy
  • Behavior therapy is a method of counseling that
    focuses on modifying the patients learned
    behavior that are negatively affecting his or
    here life.

3
Cognitive Therapy
  • Cognitive therapy holds that the principal
    determinant of emotions, motive and behavior is
    an individuals thinking, which is a conscious
    process.
  • Change perception, alter emotions changes in
    lifestyle.

4
Classical Conditioning
  • A model where a particular response to a stimuli
    can be elicited overtime by association with a
    related stimulus.

5
Unconditioned stimulus(UCS)
  • A component of classical conditioning an event
    that produces an unconditional response when
    present.

6
Unconditioned Response (UCR)
  • A natural reaction to an unconditioned stimulus

7
Conditioned Response
  • A response that is identical to an unconditioned
    response, yet it is elicited by the conditioned
    stimulus, not the unconditioned stimulus.

8
Operant Conditioning
  • This model is based on the theory that where
    behavior is reinforced and learned based on the
    consequences of the behavior.

9
Reinforcement
  • Something that is added to a situation that
    increased the likelihood of that even or behavior
    of occurring again.

10
Negative Reinforcement
  • Something that is taken away or removed from the
    situation that increase the likelihood of the
    behavior occurring again.

11
Modeling
  • A principle where a behavior is learned by
    observing the consequences of someone elses
    experience.

12
Shaping
  • The procedure of rewarding successive
    approximations to the desired response.

13
Coping Skills TrainingInterpersonal
  • 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.

14
Introduction to Assertiveness
  • Passive
  • Aggressive
  • Passive-aggressive
  • Assertive
  • See handout 1

15
Receiving Criticism about Drinking
  • Type of Criticism
  • Constructive
  • Destructive
  • See handout 2

16
Refusal Skills
  • Learned in the CRA Class

17
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

18
Other Coping Skills
  • Communications skills
  • Nonverbal communications
  • Listening skills
  • Refusal skills
  • Resolving Relationship problems
  • See Monti et al., (2002)Treating Alcohol
    Dependence, Guilford Press.

19
Coping Skills TrainingIntrapersonal
  • 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

20
Managing urges to drink/use
  • See handout 4
  • Positive Thinking worksheet
  • Urge control information sheet

21
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

22
Urge Control
  • 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.)

23
Urge Control - Steps
  • 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?

24
Managing negative thinking
  • Triggers (event, person, place)
  • Thoughts (I cant do this)
  • Feelings (Scared, depressed, angry)
  • How do you change each one of the above?
  • See handout 5

25
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?

26
Planning for emergencies
  • See handouts 6 for exercise

27
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28
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.

29
Contingent
  • Dependent on something conditional
  • Something that may or may not happen.

30
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).

31
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

32
Voucher Results
  • 75 of the clients who received the vouchers
    completed 24-weeks of abstinence compared to
    only 40 in the non-voucher group.

33
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

34
Implementing a Voucher Program
  • Frequent Urine Monitoring
  • Provide Feedback
  • Minimizing delay in Voucher exchange
  • Frequent and regular voucher spending
  • Voucher Redemption
  • Abstinence Reinforcement Summary

35
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?

36
Behavioral Contracting
  • This is a means of scheduling reinforcements
    (verbal, behaviors, events) between two or more
    people.

37
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.

38
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

39
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.

40
Behavioral Contracting
  • The therapist should eventually let the clients
    take the lead on making agreements.
  • Use positive wording making out contracts.

41
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.

42
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.

43
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.

44
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

45
Aversion Therapy
  • Aversion therapy has mixed results.
  • Some treatment centers wont release their
    results.
  • Treatment (inpatient) usually lasts for 5, 30
    minutes sessions with 2 booster sessions after
    discharge.

46
Aversion Therapy
  • There have been other drugs used including a
    curare like drug that actually caused total
    paralysis, including breathing.
  • Whos next? Would you try it?

47
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.

48
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.

49
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).

50
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.

51
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.

52
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.

53
Why use BSCT?
  • Those who refuse a goal of abstinence.
  • Attracts a broader range of drinkers.
  • In may cases moderation leads to abstinence.

54
Description
  • 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

55
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 weve
    discussed in this class.
  • Dont play the client from Hell. This is a
    learning experience.
  • Debrief with group

56
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.

57
Recovery Maintenance StrategiesMarlatt and
Gordon RP Model
  • Effective coping in high risk situations leads to
    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

58
Recovery Maintenance StrategiesMarlatt 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

59
Marlatt and Gordon RP Model
  • .

High Risk Situation
Effective Coping Response
Ineffective Coping Response
More Relapse Risk
Increased Self- Efficacy
Decreased Self- Efficacy
Increased AVE
Less Lapse/Relapse Risk
Positive Outcome Expectancy
More Lapse Risk
60
Recovery Maintenance StrategiesMarlatt and
Gordon RP Model
  • Characteristics of a high risk situation
  • Unpleasant emotions
  • Physical discomfort
  • Pleasant emotions
  • Testing personal control
  • Urges and temptations
  • Social problems at work
  • Social tension
  • Positive social situations

61
Outcome Expectancy orWhat 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

62
Expectancy Effects
Received Alcohol Received No Alcohol
Told they Received Alcohol YES YES
Told they Received no Alcohol NO NO
63
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 gt0.06, experience negative mood effects

64
Recovery Maintenance StrategiesMarlatt and
Gordon RP Model
  • Abstinence Violation Effect (AVE)
  • an individuals cognitive and affective response
    to a lapse.
  • (Disease model focuses on physiology-driven loss
    of control)

65
Recovery Maintenance StrategiesMarlatt 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

66
Recovery Maintenance StrategiesMarlatt 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

67
Recovery Maintenance StrategiesMarlatt 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

68
Recovery Maintenance StrategiesSelf-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)
69
Recovery Maintenance StrategiesSelf-Efficacy
  • Analysis of clients high-risk situations
    (Inventory of 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)

70
Recovery Maintenance StrategiesSelf-Efficacy
  • Effective Homework Assignments
  • Challenging tasks
  • Moderate effort
  • Little external aid
  • Pattern of improvement
  • Increase in personal control
  • Success directly relevant to recovery

71
Recovery Maintenance StrategiesFunctional
Analysis
  • Emphasis upon lapse/relapse as learning
    opportunity
  • Reasons for becoming sober/clean may not be the
    same 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

72
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

73
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.

74
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.

75
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

76
Cultural Issues
  • Respect for Culture
  • Give Dignity to all
  • Never think you know the culture
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