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

Behavior Therapy Behavior therapy is a method of counseling that focuses on modifying the patient’s learned behavior that are negatively affecting his or here life.

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

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

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

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

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

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

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

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

Modeling A principle where a behavior is learned by observing the consequences of someone else’s experience.

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

Coping Skills Training Interpersonal 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.

Introduction to Assertiveness PassiveAggressivePassive-aggressiveAssertive See handout #1

Receiving Criticism about Drinking Type of Criticism 1.Constructive 2.Destructive See handout # 2

Refusal Skills Learned in the CRA Class Learned in the CRA Class

Developing Social Support Network There are many stresses associated with problem drinking and drug use. (relationships, illness, job loss, etc.) 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. Often, people who stop using still have friends who drink and use drugs. Many people feel that drinking and using helps them to socialize. Many people feel that drinking and using helps them to socialize. See handout #3 See handout #3

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

Coping Skills Training Intrapersonal Managing urges to drink/use Managing urges to drink/use Problem solving (CRA) Problem solving (CRA) Increasing pleasant activities (CRA) Increasing pleasant activities (CRA) Anger Management (CRA- FA) Anger Management (CRA- FA) Managing negative thinking Managing negative thinking Seemingly irrelevant decisions Seemingly irrelevant decisions Planning for emergencies Planning for emergencies

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

Urge Control Urges and Cravings are normal Urges and Cravings are normal They happen more in the early part of tx. They happen more in the early part of tx. They have triggers, physical, environmental and psychological. They have triggers, physical, environmental and psychological. Urges are time Limited ****** Urges are time Limited ******

Urge Control Teach client to recognize triggers. Teach client to recognize triggers. 1. Exposure to cue 2. Watching others drinking or using 3. Contact with people, places, activities. 4. Elicit emotional states (anger, stress, etc) 5. Examine physical feelings (shakes, etc.)

Urge Control - Steps Avoid identified urges Avoid identified urges Find competing behaviors Find competing behaviors Talk to a friend Talk to a friend Surf it (discuss urge surfing) Surf it (discuss urge surfing) Challenge and change the thought Challenge and change the thought Review positive things since stopped using Review positive things since stopped using Wait 15 minutes before you act Wait 15 minutes before you act Use self talk. What is the worst that can happen? Use self talk. What is the worst that can happen?

Managing negative thinking Triggers (event, person, place) Triggers (event, person, place) Thoughts (I can’t do this) Thoughts (I can’t do this) Feelings (Scared, depressed, angry) Feelings (Scared, depressed, angry) How do you change each one of the above? How do you change each one of the above? See handout #5 See handout #5

Seemingly irrelevant decisions Many events are seemingly unrelated to a relapse but lead to one, Right? Many events are seemingly unrelated to a relapse but lead to one, Right? What is a behavioral chain of events? What is a behavioral chain of events? Can we change the outcome and where do we intervene? Can we change the outcome and where do we intervene?

Planning for emergencies See handouts # 6 for exercise See handouts # 6 for exercise

Contingency Management The theoretical foundation of CM was derived from principles of operant conditioning. 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. Behaviors are controlled by its consequences, and is amenable to change by altering its consequences.

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

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). Patients are offered some attractive options, including tangible goods and services, immediately contingent on demonstrating objective evidence (i.e., drug-free urine samples).

Voucher Program For every clean Urine, client gets monetary rewards 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. 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. For every 3 consecutive drug-free urines the client received a $10.00 bonus. In 12 weeks the client could earn up to $ In 12 weeks the client could earn up to $

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

Implementing a Voucher Program Describe the program to patients Describe the program to patients Target Abstinence Target Abstinence –One drug at a time works best Set up a reinforcement schedule Set up a reinforcement schedule –Escalating pay –Reset the pay for non-compliance

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

Give examples of CM Being on Probation? Being on Probation? Ultimatum from spouse? Ultimatum from spouse? Boss says next time you come in late your fired? Boss says next time you come in late your fired? Condition of Probation is not going to bars? Condition of Probation is not going to bars? How else can you use CM in your practice? How else can you use CM in your practice?

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

Behavioral Contracting Involve all relevant parties. Involve all relevant parties. Write contracts, do not leave it to memory. Write contracts, do not leave it to memory. Have all parties sign the contract, which in effect is a review process. 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. Be sure contracts are understood by asking each party to describe what they have agreed to.

Behavioral Contracting Role-Play the contact. Role-Play the contact. Clarify each parties responses. Clarify each parties responses. There must be a benefit for each party. There must be a benefit for each party. No value judgments. No value judgments. What is the pay-off or the desirable long term goal of the contract? What is the pay-off or the desirable long term goal of the contract? There should be some reinforcer sampling There should be some reinforcer sampling

Behavioral Contracting There should be flexibility, if one party refuses an agreement suggest alternatives. There should be flexibility, if one party refuses an agreement suggest alternatives. Always teach how to compromise. Always teach how to compromise. Small agreements will lead to larger agreements. Small agreements will lead to larger agreements. You can build in sanctions for failure to follow through. You can build in sanctions for failure to follow through.

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

Behavioral Contracting Guide Select one or two behaviors that you want to work on first. Select one or two behaviors that you want to work on first. Describe those behaviors so that they may be observed or measured. Describe those behaviors so that they may be observed or measured. Identify rewards that will help provide motivation to succeed. Identify rewards that will help provide motivation to succeed. Monitor or make sure someone monitors the contract and rewards success. Monitor or make sure someone monitors the contract and rewards success.

Behavioral Contracting Write the contract so everyone understands it fully. Write the contract so everyone understands it fully. Troubleshoot if needed. Troubleshoot if needed. Rewrite the contract whether there is improvement or not. Rewrite the contract whether there is improvement or not. Continue to monitor the contract over time. Continue to monitor the contract over time. Select new behaviors to work on. Select new behaviors to work on.

Aversion Therapy Aversion therapy attempts to interrupt the drinking behavior by creating a aversion or distaste for alcohol. 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. Alcohol is repeatedly paired with an US which is extremely unpleasant. That unpleasantness then generalized and becomes associated with alcohol.

Aversion Therapy Alcohol is paired with drugs, electrical shock, imagery, smell or other very unpleasant stimulus. 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. Began in 1935 with injections of emetine, which cause nausea and vomiting. Drank alcohol – injection = sick, sick, sick Drank alcohol – injection = sick, sick, sick

Aversion Therapy Aversion therapy has mixed results. Aversion therapy has mixed results. Some treatment centers won’t release their results. Some treatment centers won’t release their results. Treatment (inpatient) usually lasts for 5, 30 minutes sessions with 2 booster sessions after discharge. Treatment (inpatient) usually lasts for 5, 30 minutes sessions with 2 booster sessions after discharge.

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

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. 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.

Cue Exposure CE is derived from learning and social learning theory models. 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 can include sight, smells, places, people and emotional feelings (anger, stress, depressed, happy etc.). Cues may play a role in resumption of using. Cues may play a role in resumption of using.

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). 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).

Cue Exposure First, repeated exposure to a cue should result in habituation, (decreasing the strength of the cue). 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. Second, practice using coping skill in the presence of cues should make it easier to use them in a real situation.

Cue Exposure Urge Control is part of 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. Use “Daily record of Urges” to help clients identify urges and how strong an urge becomes.

Behavioral Self-Control Training BSCT can be used for moderation or a goal of abstinence. 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. Most likely to work for clients who are at the beginning of treatment, and are experiencing less severe problems.

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

Description Setting limits. Setting limits. Self-monitoring of drinking behaviors Self-monitoring of drinking behaviors Changing the rate of drinking. Changing the rate of drinking. Practice refusal skills Practice refusal skills Setting up a reward system for achievement of goals. Setting up a reward system for achievement of goals. Learning which triggers result in overdrinking Learning which triggers result in overdrinking Learning new coping skills to resist drinking Learning new coping skills to resist drinking

Practice Exercise Develop a Treatment Plan, just pick one or two areas to work on, (one or two goals) 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 we’ve discussed in this class. Then develop a strategy to accomplish these treatment goals using one of the strategies we’ve discussed in this class. Don’t play the client from Hell. This is a learning experience. Don’t play the client from Hell. This is a learning experience. Debrief with group Debrief with group

Recovery Maintenance Strategies: Marlatt and Gordon (1980) Cognitive-Behavioral Model Distinguished lapse from relapse.* Distinguished lapse from relapse.* Creation of a Relapse Prevention (RP) model based on Cognitive-Behavioral principles. Creation of a Relapse Prevention (RP) model based on Cognitive-Behavioral principles.

Recovery Maintenance Strategies: Marlatt and Gordon RP Model Effective coping in high risk situations leads to enhanced self-efficacy* Effective coping in high risk situations leads to enhanced self-efficacy* Enhanced self-efficacy = less relapse* Enhanced self-efficacy = less relapse* Ineffective coping in high risk situations leads to decreased self-efficacy and increase in positive outcome expectancy 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* Low self-efficacy + increased positive outcome expectancies = more relapse*

Recovery Maintenance Strategies: Marlatt 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

Marlatt and Gordon RP Model. High Risk Situation Effective Coping Response Ineffective Coping Response Increased Self- Efficacy Decreased Self- Efficacy Less Lapse/Relapse Risk Positive Outcome ExpectancyMore Lapse Risk Increased AVE More Relapse Risk

Recovery Maintenance Strategies: Marlatt and Gordon RP Model Characteristics of a “high risk” situation Unpleasant emotions Unpleasant emotions Physical discomfort Physical discomfort Pleasant emotions Pleasant emotions Testing personal control Testing personal control Urges and temptations Urges and temptations Social problems at work Social problems at work Social tension Social tension Positive social situations Positive social situations

Outcome Expectancy* or What the IP expects from using Global positive changes Global positive changes Sexual enhancement Sexual enhancement Physical and social pleasure Physical and social pleasure Social assertiveness Social assertiveness Relaxation and tension reduction Relaxation and tension reduction Arousal and power Arousal and power Expectancy plays a major role in the control and prediction of relapse

Expectancy Effects ReceivedAlcohol Received No Alcohol Told they ReceivedAlcoholYESYES Received no Alcohol NONO

Biphasic Effects of Alcohol Description of the usual physical effects of drinking 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 of 0.01 to 0.06, experience positive mood effects (mostly due to expectancy) BAC >0.06, experience negative mood effects BAC >0.06, experience negative mood effects

Recovery Maintenance Strategies: Marlatt and Gordon RP Model Abstinence Violation Effect (AVE): an individual’s cognitive and affective response to a lapse.* (Disease model focuses on physiology-driven loss of control)

Recovery Maintenance Strategies: Marlatt 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

Recovery Maintenance Strategies: Marlatt 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

Recovery Maintenance Strategies: Marlatt 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

Recovery Maintenance Strategies: Self-Efficacy* Enter high risk drinking situation Enter high risk drinking situation Cognitive appraisal Cognitive appraisal Reach judgment (efficacy expectation) about ability to cope Reach judgment (efficacy expectation) about ability to cope Drink/use or not drink/not use Drink/use or not drink/not use (Helen Annis)

Recovery Maintenance Strategies: Self-Efficacy Analysis of client’s high-risk situations (Inventory of Drinking Situations - IDS-100) Analysis of client’s high-risk situations (Inventory of Drinking Situations - IDS-100) Creation of Client Profile Creation of Client Profile –Generalized –Positive –Negative –Mixed Develop hierarchy of risky situations Develop hierarchy of risky situations Identify strengths, resources and coping responses Identify strengths, resources and coping responses Monitor self-efficacy (Situational Confidence Questionnaire - SCQ-39) Monitor self-efficacy (Situational Confidence Questionnaire - SCQ-39)

Recovery Maintenance Strategies: Self-Efficacy Effective Homework Assignments* –Challenging tasks –Moderate effort –Little external aid –Pattern of improvement –Increase in personal control –Success directly relevant to recovery

Recovery Maintenance Strategies: Functional Analysis Emphasis upon lapse/relapse as learning opportunity Emphasis upon lapse/relapse as learning opportunity Reasons for becoming sober/clean may not be the same as the reasons for staying sober/clean* Reasons for becoming sober/clean may not be the same as the reasons for staying sober/clean* Assumes that lapse/relapse makes sense Assumes that lapse/relapse makes sense Examines the before, during and after of lapse/relapse behavior Examines the before, during and after of lapse/relapse behavior Done in a non-judgmental attitude Done in a non-judgmental attitude Want to get the “story” Want to get the “story” Remember to go far enough back in time Remember to go far enough back in time

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

Exercise Develop a relapse plan for your client 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. Role play developing a relapses plan using the relapse strategies discussed, and then discuss with the group your plan.

Cultural Issues Cultural Barriers to treatment Cultural Barriers to treatment Lack of gender specific programming Lack of gender specific programming Cultural structures, beliefs or values that discourage acknowledgment of alcohol or drug related problems or seeking formal treatment. Cultural structures, beliefs or values that discourage acknowledgment of alcohol or drug related problems or seeking formal treatment. Language barriers. Language barriers.

Cultural Issues Lack of culturally specific programming. Lack of culturally specific programming. Lack of effective culturally specific outreach and advertisement. Lack of effective culturally specific outreach and advertisement. Lack of treatment to meet special needs of the culture. Lack of treatment to meet special needs of the culture. Lack of training in cultural issues Lack of training in cultural issues

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