Cognitive Behavioural & Relapse Prevention Strategies

Cognitive Behavioural & Relapse Prevention Strategies
Introduce yourself and the propose of your presentation. Explain the propose of the series of trainings sponsored by the United Nations Office on Drugs and Crime: “The capacity building program mission is to transfer technology and knowledge on substance abuse intervention to service providers in the participating local areas. Service providers include managers, physicians and psychiatrists, counsellors, psychologists, social workers, peer educators, outreach workers and other professionals working in the substance abuse field”. Thank your audience for their interest in this series of training modules before starting your presentation. Treatnet Training Volume B: Module 3 – Updated 25 January 2007

Icebreaker If you had to move to an uninhabited island, what 3 things would you take with you and why? (food and water are provided) This activity is optional, although recommended. Icebreakers are meant to create interaction in the audience. You may want to change the icebreaker by another one that might be more appropriate for the propose of your training. Ask your audience the question in the slide. They need to mention 3 things that they would take to un inhabited island, considering that food and water are provided.

Training goals Increase knowledge of cognitive behavioural therapy (CBT) and relapse prevention (RP) strategies and resources. Increase skills using CBT and RP strategies and resources. Increase application of CBT and RP strategies for substance abuse treatment Read the training goals to your audience. Explain that it is very important for this module not only to gather new knowledge but also to practice the new skills and be able to apply these skills to everyday work with clients that have substance abuse problems. Explain to your audience your training plan and follow-up plan. Stress that after this training you will be available to answer questions and provide feedback and advice regarding their demonstrations of the new techniques and skills.

Workshop 1: Basic concepts of CBT and RP
One of the most important ingredients of psychosocial treatment for substance use disorders is teaching people how to stop or reduce their substance use and how to avoid relapsing and returning to dangerous levels of use. One set of techniques that have been shown to be highly effective for this purpose are those that have been those based on principles of cognitive behavioural therapy (CBT).

Please respond to the pre-assessment questions in your workbook.
(Your responses are strictly confidential.) 10 minutes Explain to your audience that they will need to complete the 5 questions pre-assessment for this workshop. They have 10 minutes to complete these questions. Explain that each workshop will be preceded by the same activity. The pre-training and post-training tests may create tension among audience members. To reduce such tension, explain to your audience that both tests are confidential and that the audience members do not need to provide any personal information. Explain that the pre-training tests are conducted so as to ensure that the training is appropriate for your particular audience. The post-training tests are conducted only to measure the effectiveness of the training and provide opportunities for improvement.

Training objectives At the end of this workshop, you will be able to:
1. Understand that substance use is a learned behaviour and it can be modified according to principles of conditioning and learning 2. Understand key principles of classical and operant conditioning and modelling 3. Understand how these principles apply to the treatments delivered in cognitive behavioural therapy and relapse prevention training 4. Understand the basic approaches used in cognitive behavioural therapy and how they apply to reducing drug use and preventing relapse 5. Understand how to conduct a functional analysis and learn about the 5 Ws of a client’s drug use Read the training objectives to your audience. Explain to the audience that these objectives should be achieved as a team. Encourage them to ask you questions as needed.

What are Cognitive Behavioural Therapy (CBT) and Relapse Prevention (RP)?
Introduce yourself and the purpose of your presentation. Explain the purpose of the series of trainings sponsored by the United Nations Office on Drugs and Crime: “The capacity building program mission is to transfer technology and knowledge on substance abuse intervention to service providers in the participating local areas. Service providers include managers, physicians and psychiatrists, counsellors, psychologists, social workers, peer educators, outreach workers and other professionals working in the substance abuse field”. Thank your audience for their interest in this series of training modules before starting your presentation.

What is CBT and how is it used in addiction treatment?
CBT is a form of “talk therapy” that is used to teach, encourage, and support individuals about how to reduce / stop their harmful drug use. CBT provides skills that are valuable in assisting people in gaining initial abstinence from drugs (or in reducing their drug use). CBT also provides skills to help people sustain abstinence (relapse prevention) The cognitive-behavioural paradigm works under assumption that substance abuse is a learned maladaptative behaviour rather than caused by an underlying pathology. Under this assumption, therapy on substance abuse takes the form of an educational-learning process where the therapist becomes a coach and the client has a learning active role through the entire process. The individual with a substance abuse problem may re-learn alternative behaviours to substance abuse while the therapist teaches, coaches and reinforces his/her positive behaviour. Very simply put, CBT attempts to help patients recognize, avoid, and cope. That is, RECOGNIZE the situations in which they are most likely to use cocaine, AVOID these situations when appropriate, and COPE more effectively with a range of problems and problematic behaviors associated with substance abuse.

What is relapse prevention (RP)?
Broadly conceived, RP is a cognitive-behavioural treatment (CBT) with a focus on the maintenance stage of addictive behaviour change that has two main goals: To prevent the occurrence of initial lapses after a commitment to change has been made and To prevent any lapse that does occur from escalating into a full-blow relapse.” Because of the common elements of RP and CBT, we will refer to all of the material in this training module as CBT Relapse Prevention (RP) is a generic term that refers to a wide range of therapeutic techniques to prevent lapse and relapse of addictive behaviors. The term ‘relapse’ was initially employed in the medical context to refer to those people who are re-experiencing a disease stage. Currently, this term is being used for a variety of behaviors to include substance abuse (Marlatt & Donovan; 2005). Relapse is being considered the common denominator for people in treatment for psychological problems of any type (Polivy & Herman, 2002). Behavioral changes (smoking cessation, exercising habits, etc.) tend to relapse to previous behavioral repertoires over time (Polivy & Herman, 2002). It has been demonstrated that few individuals are able to completely succeed in substance abuse abstinence in the long-term on the first attempt (Add & Ritter, 2000). Sobriety and relapse are both part of an interactive complex process in the treatment context. Relapse prevention skills can be improved over time in a lapse/relapse learning curve in which increasing practice of coping skills will decrease the probability of relapse. The main goal of RP is maintaining sobriety over time and preventing the occurrence of lapses and their escalation into a full relapse episode. It is difficult to determine whether a lapse may end up in relapse. It ultimately depends on how the client responds to high-risk situations. Relapse prevention is a cognitive-behavioral treatment that includes a large educational component (Marlatt & Donovan, 2005). Relapse Prevention aims to increase the client awareness of high-risk situations and increase coping skills, self-efficacy and control of internal and external variables that may make him/her more prompted to lapse/relapse. In other words, Relapse Prevention (RP) combines cognitive and behavioral techniques such as thought-stopping, coping skills, alternative activities,

Foundation of CBT-social learning theory
Cognitive behavioural therapy (CBT) Provides critical concepts of addiction and how to not use drugs Emphasises the development of new skills Involves the mastery of skills through practise Under the cognitive-behavioural paradigm thoughts, feelings and behaviours are separate areas of human behaviour and cognitive processing that become associated through learning. For instance, alcohol use is a behaviour that might be linked to thoughts, feelings and even other behaviours by personal experience and observation. When these associations become stronger over time, they may act as triggers without any substances necessarily being present at the time. For instance, thinking that a cigarette will help me to relax may become a trigger itself. Even behaviours may become triggers for drug use.

Why is CBT useful? (1) CBT is a short-term, comparatively brief approach well-suited to the resource capabilities of most clinical programs. CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support. CBT is structured, goal-oriented, and focused on the immediate problems faced by substance abusers entering treatment who are struggling to control their use. Cognitive-behavioural therapy employs learning principles within a highly structured intervention with clearly-defined goals that focuses on the individual’s current problems. The learning principles are based on classical conditioning and operant conditioning that might occur through observation and direct experience.

Why is CBT useful? (2) CBT is a flexible, individualized approach that can be adapted to a wide range of clients as well as a variety of settings (inpatient, outpatient) and formats (group, individual). CBT is compatible with a range of other treatments the client may receive, such as pharmacotherapy.

Important concepts in CBT (1)
In the early stages of CBT treatment, strategies stress behavioural change. Strategies include: planning time to engage in non-drug related behaviour avoiding or leaving a drug-use situation. In Cognitive Behavioural Therapy the emphasis is not in being strong, but in teaching clients to be wise and making good decisions.

CBT attempts to help clients: Follow a planned schedule of low-risk activities Recognise drug use (high-risk) situations, Avoid these situations Cope more effectively with a range of problems and problematic behaviours associated with using.

As CBT treatment continues into later phases of recovery, more emphasis is given to the “cognitive” part of CBT. This includes: Teaching clients knowledge about addiction Teaching clients about conditioning, triggers, and craving Teaching clients cognitive skills (“thought stopping” and “urge surfing”) Focusing on relapse prevention

Foundations of CBT The learning and conditioning principles involved in CBT are: Classical conditioning Operant conditioning Modelling

Classical conditioning: Addiction
Repeated pairings of particular events, states, or cues with substance use produce craving for that substance Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, affect states Eventually, exposure to cues alone elicit drug or alcohol cravings or urges that are often followed by substance abuse Pavlov demonstrated that over time repeated stimulus (a bell ringing) paired with another (the presentation of food) could elicit a reliable response (dog salivation. The same can be said of the addict. Certain stimuli or cues- Pavlov’s bell can be equated to triggers such as money, boredom, anxiety and over time can result in (dog salivation which can be equated to craving the drug and the presentation of food with using. Classical conditioning is a learning process that has three main components: A Conditioned stimulus (CS), unconditioned stimulus (UCS) and a conditioned response (CR).

Classical conditioning: Concepts
Conditioned Stimulus (CS) does not produce a physiological response, but once we have strongly associated it with an Unconditioned Stimulus (UCS) (e.g., food) it ends up producing the same physiological response (i.e., salivation). Conditioned stimulus (CS) are those stimuli that for their nature do not produce a physiological response in our bodies (i.e. a menu) but that once we strongly associated them with an Unconditioned Stimulus (UCS) (i.e. food) using repeated exposures, they end up producing the same physiological response (i.e. salivation) in absence of the UCS (i.e. food). =

CLASSICAL CONDITIONING
Activity 1: Individual work (1) CLASSICAL CONDITIONING During Conditioning UCS paired with neutral stimulus Conditional Response (CR) (Craving) Ask your audience to take some time and fill the gaps in the graphic for the use of alcohol, for example, alcohol-using friends, bars, etc. They can name some examples from their professional experience working with substance users.

Activity 1: Individual work (2)
CLASSICAL CONDITIONING During Conditioning UCS paired with neutral stimulus Conditional Response (CR) (Craving) Repeat the same exercise discussing a stimulus associated with opioids, for example, the use of paraphernalia. You may also do this exercise discussing other drugs most commonly used in the target community such as cocaine, marijuana, tobacco, etc.

Classical conditioning: Application to CBT techniques (1)
Understand and identify “triggers” (conditioned cues) Understand how and why “drug craving” occurs Clinicians should then work with clients to develop a comprehensive list of their own triggers. Some clients become overwhelmed when asked to identify cues (one person reported that even breathing was associated with cocaine use for him). Again, it may be most helpful to concentrate on identifying the craving and cues that have been most problematic in recent weeks. This list should be started during the session; the practice exercise for this session should include self-monitoring of craving, so patients can begin to identify new, more subtle cues as they arise. (Adapted from Carroll, 2002)

Classical conditioning: Application to CBT techniques (2)
Learn strategies to avoid exposure to triggers Cope with craving to reduce/eliminate conditioned craving over time

Operant conditioning: Addiction (1)
Drug use is a behaviour that is reinforced by the positive reinforcement that occurs from the pharmacologic properties of the drug. Drug use can also be seen as behaviour that is reinforced by its consequences. Drugs may be used because it changes the way a person feels (powerful, energetic, euphoric, stimulated, less depressed), the way they think (I can do anything, I can only get through this if I am high), or behaves (less inhibited, more confident)

Operant conditioning: Addiction (2)
Once a person is addicted, drug use is reinforced by the negative reinforcement of removing or avoiding painful withdrawal symptoms. Drug use can also be seen as behaviour that is reinforced by its consequences. Drugs may be used because it changes the way a person feels (powerful, energetic, euphoric, stimulated, less depressed), the way they think (I can do anything, I can only get through this if I am high), or behaves (less inhibited, more confident)

Operant conditions (1) Positive reinforcement strengthens a particular behaviour (e.g., pleasurable effects from the pharmacology of the drug; peer acceptance) Positive reinforcement occurs when a particular behaviour increases its occurrence by the consequence of experiencing or observing a positive condition. For example, if I eat when hungry, the consequence will be to feel satisfied, therefore I will probably repeat this behaviour again in the future.

Operant conditions (2) Punishment is the negative condition that decreases the occurrence of a particular behaviour (e.g., If you sell drugs, you will go to jail. If you take too large a dose of drugs, you can overdose.) Punishment refers to the negative condition that decreases the occurrence of a particular behaviour. For example, if we put our hand in a hot stove the consequence will be that we will burn our hands (pain – a negative consequence) therefore we will probably avoid repeating this behaviour again

Operant conditions (3) Negative reinforcement occurs when a particular behaviour gets stronger by avoiding or stopping a negative condition (e.g., If you are having unpleasant withdrawal symptoms, you can reduce them by taking drugs.). Negative reinforcement occurs when a particular behaviour increases its occurrence by avoiding or stopping a negative consequence. For example, a rat in a cage receives a mild electrical shock on its feet (negative consequence), the rat discovers that pressing a bar stops the shocks; as a consequence the behaviour of pressing the bar is strengthened.

Operant conditioning: Application to CBT techniques
Functional Analysis – identify high-risk situations and determine reinforcers Examine long- and short-term consequences of drug use to reinforce resolve to be abstinent Schedule time and receive praise Develop meaningful alternative reinforcers to drug use

Modelling: Definition
Modelling: To imitate someone or to follow the example of someone. In behavioural psychology terms, modelling is a process in which one person observes the behaviour of another person and subsequently copies the behaviour. Under a Cognitive Behavioural Approach, substance abuse is a learnt behaviour that was developed through complex interplays from modelling, classical conditioning, or operant conditioning. The same principles are applicable to help the client stop substance use (adapted from Carroll, 2002, p ) Employ CBT principles to teach your client to initiate abstinence or reduction of substance use such as Modelling, Operant Conditioning and Classical Conditioning. Modelling – This technique will help your client to learn new behaviours and coping skills through observing other people acting. If you employ techniques such as role-playing, observing videos or good models acting in an adaptative way, your client will learn by observation the same behaviour. Either in individual or group settings, your conduct (or the model’s conduct) will be observed by the client/s and then copied. For instance, the client will learn to respond in new way by watching you applying useful techniques to high-risk situations (i.e. refusing drugs from a friend).

Basis of Substance Use Disorders: Modelling
When applied to drug addiction, modelling is a major factor in the initiation of drug use. For example, young children experiment with cigarettes almost entirely because they are modelling adult behaviour. During adolescence, modelling is often the major element in how peer drug use can promote initiation into drug experimentation. MODELLING: For example, children learn language by listening to and copying their parents. SPORT; the adult can learn to ski by watching good and well talented skiers. The same may be true for many substance abusers, by seeing their parents use alcohol, individuals may learn to cope with problems by drinking. Teenagers often begin smoking after watching their friends use cigarettes. So too may some drug abusers begin to use after watching their friends or family members use drugs or alcohol.

Modelling: Application to CBT techniques
Client learns new behaviours through role-plays Drug refusal skills Watching clinician model new strategies Practising those strategies Observe how I say NO! Just as CBT assumes that substance use is learned behaviour and that some individuals learn to use through modelling, operant conditioning or classical conditioning, the same learning concepts can be applied to help patients to stop using. For example, modelling is used to help clients to learn new behaviours such as refusing drug offers; how to break off from a drug associate, by watching the clinician, clients participate in role plays during the treatment. Thus the patient learns to respond in new unfamiliar ways by watching the therapist model those behaviours and practice those strategies within the context of the therapy hour. NO thanks, I do not smoke

CBT techniques for addiction treatment: Functional Analysis / the 5 Ws

The first step in CBT: How does drug use fit into your life?
One of the first tasks in conducting any type of CBT treatment is to learn the details of a client’s drug use. It is not enough to know that they use drugs or a particular type of drug. It is critical to know how the drug use is connected with other aspects of a client’s life. Those details are critical to creating a useful treatment plan.

The 5 Ws (functional analysis)
The 5 Ws of your drug use (also called a functional analysis) When? Where? Why? With / from whom? What happened? Following the cognitive-behavioural model previously presented, it is essential in relapse prevention to identify situations and risk factors that maintain the use of drugs over time. These drug maintaining factors are divided in external and internal variables (McCrady, 2001) that make more likely the use of drugs. The therapist may interview the client to identify external and internal antecedents (A) and consequents (C) of the drug use behaviour (B) in what is called a Functional Analysis or ABC Analysis The maintaining factors are as follows: External antecedents or circumstances surrounding the use of drugs: place or places where the use of drugs usually happened, the day and time in which usually occurs, direct or indirect peer pressure (individuals that use drugs with the client), paraphernalia, the drug itself (it sight or smell) and events that happen before and after using substances (I.e. having marital problems, etc.). Internal antecedents that might be categorized in three cognitive-behavioural levels: Physiological sensations and feelings: whether the client is aware of them or not such as withdrawal symptoms, cravings, emotions (rage, sadness, feeling lonely), etc. Cognitions such as thoughts, ideas, positive expectations of the drug effect, planning, etc. Behaviours or client conduct repertoires such as copings skills. c. Consequences – may include consequences at the individual level such as decreased withdrawal symptoms or cravings, desired drug effects, decrease in negative emotions; or external consequences at a social level such as increase socialization, etc.

The 5 Ws People addicted to drugs do not use them at random. It is important to know: The time periods when the client uses drugs The places where the client uses and buys drugs The external cues and internal emotional states that can trigger drug craving (why) The people with whom the client uses drugs or the people from whom she or he buys drugs The effects the client receives from the drugs ─ the psychological and physical benefits (what happened) You will need to use the form entitled “Functional Analysis.”

Questions therapists can use to learn the 5 Ws
What was going on before you used? How were you feeling before you used? How / where did you obtain and use drugs? With whom did you use drugs? What happened after you used? Where were you when you began to think about using? Assessing high-risk situations The cognitive-behavioral approach assumes that substance abuse can be better treated if clinicians focus on current maintaining factors. The model theories that external antecedents of drug use that have been previously conditioned through repeated pairing have an important role in determining subsequent drug use. Cognitions, physiological responses and emotions mediate the relationship between the external antecedents and the behavior of using substances and even play a role in determining subsequent use of drugs. In addition to this, the consequences of the use of drugs might be physiological, psychological or interpersonal in their origin (McCrady, 2001).

Conducting a functional analysis
Review the Functional Analysis form. You will need to use the form entitled “Functional Analysis.”

Functional Analysis or High-Risk Situations Record
Antecedent Situation Thoughts Feelings and sensations Behavior Consequences Where was I? Who was with me? What was happening? What was I thinking? How was I feeling? What signals did I get from my body? What did I do? What did I use? How much did I use? What paraphernalia did I use? What did other people around me do at the time? What happened after? How did I feel right after? How did other people react to my behavior? Any other consequences?

Activity 3: Role-play of a functional analysis
Script 1 Conduct a role-play of a functional analysis: Review 5 Ws with client Provide analysis of how this information will guide treatment planning Ask your audience to get their Functional Analysis form. They will have to write some notes on them. Ask your audience to take notes on their Functional Analysis Form Ask your audience for feedback and what they would make differently. 20 minutes

Questions? Comments?

Workshop 2: Cognitive Behavioural Strategies

Identify a minimum of 4 cognitive behavioural techniques Understand how to identify triggers and high- and low-risk situations Understand craving and techniques to cope with craving Present and practise drug refusal skills Understand the abstinence violation syndrome and how to explain it to clients Understand how to promote non-drug-related behavioural alternatives Read the training goals to your audience. Explain that it is very important for this module not only to gather new knowledge but also to practice the new skills and being able to apply these skills to their everyday work with clients that have substance abuse problems. Explain your audience your training plan and follow up plan with them. Stress that after this training you will be available to answer questions and provide feedback and advice of their practicing of the new techniques and forms.

CBT techniques for addiction treatment: Functional Analysis & Triggers and Craving

“Triggers” (conditioned cues)
One of the most important purposes of the 5 Ws exercise is to learn about the people, places, things, times, and emotional states that have become associated with drug use for your client. These are referred to as “triggers” (conditioned cues). Therapists should then work with patients to develop a comprehensive list of their own triggers. Some patients become overwhelmed when asked to identify cues (one patient reported that even breathing was associated with cocaine use for him). Again, it may be most helpful to concentrate on identifying the craving and cues that have been most problematic in recent weeks. This list should be started during the session; the practice exercise for this session should include self-monitoring of craving, so patients can begin to identify new, more subtle cues as they arise. (Adapted from Carroll, 2002)

“Triggers” for drug use
A “trigger” is a “thing” or an event or a time period that has been associated with drug use in the past Triggers can include people, places, things, time periods, emotional states Triggers can stimulate thoughts of drug use and craving for drugs Keep in mind that the general strategy of “recognize, avoid, and cope” is particularly applicable to craving. After identifying the patients’ most problematic cues, therapists should explore the degree to which some of these can be avoided. This may include breaking ties or reducing contact with individuals who use or supply cocaine, getting rid of paraphernalia, staying out of bars or other places where cocaine was used, or no longer carrying money, as in the following example: “You’ve said that having money in your pocket is the toughest trigger for you right now. Let’s spend some time thinking through ways that you might not have to be exposed to money as much. What do you think would work? Is there an amount of money you can carry with you that feels safe? You talked about giving your check to your mother earlier; do you think this would work? You’ve said that she’s very angry about your cocaine use in the past; do you think she’d agree to do this? How would you negotiate her keeping your money for you? How could you arrange with her to get money you needed for living expenses? How long would this arrangement go on?” Therapists should spend considerable time exploring the relationship between alcohol and cocaine with patients who use them together to such an extent that alcohol becomes a powerful cocaine cue. Specific strategies to reduce, or preferably, stop alcohol use should be explored. (Adapted from Carroll, 2002)

External triggers People: drug dealers, drug-using friends
Places: bars, parties, drug user’s house, parts of town where drugs are used Things: drugs, drug paraphernalia, money, alcohol, movies with drug use Time periods: paydays, holidays, periods of idle time, after work, periods of stress

Internal triggers Anxiety Anger Frustration Sexual arousal Excitement
Boredom Fatigue Happiness

Triggers & Cravings Trigger Thought Craving Use
Explain to your audience how a trigger can initiate some thoughts about using drugs what leads the client to have cravings and finally to use the substance.

Activity 3: Role-playing
Using the Internal and External Trigger Worksheets, conduct a role-play of how they are used to identify triggers. 15 minutes

CBT techniques for addiction treatment: High- & low-risk situations

High- and low-risk situations (1)
Situations that involve triggers and have been highly associated with drug use are referred to as high-risk situations. Other places, people, and situations that have never been associated with drug use are referred to as low-risk situations.

High- and low-risk situations (2)
An important CBT concept is to teach clients to decrease their time in high-risk situations and increase their time in low-risk situations.

Using the “high-risk vs. low-risk” continuum (see Triggers charts), use information from the functional analysis (5Ws) and the trigger analysis to construct a high-risk vs. low-risk exercise. Role-play the construction of a high- vs. low-risk analysis. 15 minutes

CBT techniques for addiction treatment: Strategies to cope with craving

Understanding craving
Craving (definition) To have an intense desire for To need urgently; require Many people describe craving as similar to a hunger for food or thirst for water. It is a combination of thoughts and feelings. There is a powerful physiological component to craving that makes it a very powerful event and very difficult to resist. Common triggers include being around people with whom one used cocaine, having money or getting paid, drinking alcohol, social situations, and certain affective states, such as anxiety, depression, or joy. Triggers for cocaine craving also are highly idiosyncratic, thus identification of cues should take place in an ongoing way throughout treatment. To explain the ideas of conditioned cues, therapists might paraphrase Pavlov’s classical conditioning paradigm by equating food to cocaine, the animal’s salivation to cocaine craving, and the bell as the trigger. Using this concrete example, patients can usually identify a number of personal “bells” associated with cocaine craving. The example of Pavlov’s experiments is often enough to demystify the experience of craving and help patients identify and tolerate conditioned craving when it occurs. (Adapted from Carroll, 2002)

Craving: Different for different people
Cravings or urges are experienced in a variety of ways by different clients. For some, the experience is primarily somatic. For example, “I just get a feeling in my stomach” or “My heart races” or “I start smelling it.” For others, craving is experienced more cognitively. For example, “I need it now” or “I can’t get it out of my head” or “It calls me.”

Coping with craving Many clients believe that once they begin to crave drugs, it is inevitable that they will use. In their experience, they always “give in” to the craving as soon as it begins and use drugs. In CBT, it is important to give clients tools to resist craving

Triggers & cravings Trigger Thought Craving Use

Strategies to cope with craving
Coping with Craving: Engage in non-drug-related activity Talk about craving “Surf” the craving Thought stopping Self-talk Contact a drug-free friend or counsellor Pray The variety of strategies for coping with craving include the following. Distraction Talking about craving Going with the craving Recalling the negative consequences of cocaine abuse Using self-talk Therapists may wish to point out that these strategies may not stop craving completely. However, with practice, they will reduce the frequency and intensity of craving and make it less disturbing and frustrating when it occurs (Adapted from Carroll, 2002)

Use the “Trigger-Thought-Craving-Use” sheet to educate clients about craving and discuss methods for coping with craving. Role-play a discussion of techniques to cope with craving. 15 minutes

How to say “No”: Drug refusal skills
One of the most common relapse situations is when a client is offered drugs by a friend or a dealer. Many find that they don’t know how to say “No.” Frequently, their ineffective manner of dealing with this situation can result in use of drugs. A major issue for many substance abusers is reducing availability of the drug and effectively refusing offers of the drug. Clients who remain ambivalent about reducing their drug use often have particular difficulty when offered the drug directly. For instance, many cocaine users’ social networks have so narrowed that they associate with few people who do not use cocaine, and cutting off contact may mean social isolation. Also, many individuals have become involved in distribution, and extricating themselves from the distribution network is difficult. Many clients lack the basic assertiveness skills to effectively refuse offers of the drug or prevent future offers. Thus, this session includes sections on reducing availability, refusal skills, and a review of general assertiveness skills. Clinicians should carefully direct questions to ferret out covert indicators of ambivalence and resistance to change and the social forces working against change. Failure of patients to take initial steps toward removing triggers and avoiding the drug may reveal a number of clinically significant issues. (Adapted from Carroll, 2002)

CBT techniques for addiction treatment: Drug refusal skills—How to say “No”

Drug refusal skills: Key elements
Improving refusal skills/assertiveness: There are several basic principles in effective refusal of drugs: Respond rapidly (not hemming and hawing, not hesitating) Have good eye contact Respond with a clear and firm “No” that does not leave the door open to future offers of drugs Make the conversation brief Leave the situation Clinicians should review the patients’ suppliers and explore strategies for reducing contact with them. In some cases, a clear and assertive refusal, followed by a statement that the patient has decided to stop and a request that cocaine no longer be offered, can be surprisingly effective. In other cases, patients can arrange to avoid any contact with particular users or suppliers. When patients are in a close, intimate relationship with someone who uses and supplies cocaine, the problem is more difficult. For example, it may not be easy for a woman to abstain when her partner supplies cocaine or continues to use, and she may not be ready to break off the relationship. Furthermore, sometimes only limited change in a patient’s stance toward such a relationship can be effectively undertaken in 12 weeks of treatment. Rather than seeing this as either-or (“I can either stop cocaine use or get out of the relationship”), therapists should explore the extent to which exposure to cocaine can be renegotiated and limits set. “I hear you say that you feel like you want to stay with Bob for now, but he’s not willing to stop using cocaine. Being there is pretty risky for you, but maybe we can think of some ways to reduce the risk. Have you thought about asking him not to bring cocaine into the house or use it in the house? You’ve said you know there’s a lot of risk to you while he continues to do that, both in terms of your stay ing abstinent as well as having drugs around your kids.” There are several basic principles in effective refusal of cocaine and other substances. Respond rapidly (not hemming and hawing, not hesitating). Have good eye contact. Respond with a clear and firm “no” that does not leave the door open to future offers of cocaine. Many patients feel uncomfortable or guilty about saying no and think they need to make excuses for not using, which allows for the possibility of future refusals. Inform patients that “no” can be followed by changing the subject, suggesting alternative activities, and clearly requesting that the individual not offer cocaine again in the future. (“Listen, I’ve decided to stop and I’d like you not to ask me to use with you anymore. If you can’t do that, I think you should stop coming over to my house.”) (Adapted from Carroll, 2002)

Drug refusal skills: Teaching methods
After reviewing the basic refusal skills, clients should practise them through role-playing, and problems in assertive refusals should be identified and discussed. Pick an actual situation that occurred recently for the clients. Ask clients to provide some background on the target person. After reviewing the basic refusal skills, patients should practice them through role-playing, and problems in assertive refusals should be identified and discussed. Since this is the first session that includes a formal role-play, it is important for therapists to set it up in a way that helps patients feel comfortable. Pick a concrete situation that occurred recently for the patients. Ask patients to provide some background on the target person. For the first role-play, have patients play the target individual, so they can convey a clear picture of the style of the person who offers cocaine and the therapist can model effective refusal skills. Then reverse the roles for subsequent role-plays. Role-plays should be thoroughly discussed afterward. Therapists should praise any effective behaviors shown by patients and also offer clear, constructive criticism: “That was good; how did it feel to you? I noticed that you looked me right in the eye and spoke right up; that was great. I also noticed that you left the door open to future offers by saying you had stopped cocaine ‘for a while.’ Let’s try it again, but this time, try to do it in a way that makes it clear you don’t want Joe to ever offer you drugs again.” Quite often, the role-plays will reveal deficits in understanding and feeling comfortable with assertive responding. For such individuals, therapists should devote another session to reviewing and practicing assertive responding. An excellent guide to this topic is given in Monti et al. (1989). Key areas to review include defining assertiveness, reviewing the differences between response styles (passive, aggressive, passive- aggressive, and assertive), body language and nonverbal cues, and anticipating negative consequences. (Adapted from Carroll, 2002)

Role-play: Drug-offer situation
Role-play a situation where a drug user friend (or dealer) makes an offer to give or get drugs. Role-play an ineffective response and role-play an effective use of how to say “No.”

CBT techniques for addiction treatment: Preventing the abstinence violation effect

Abstinence violation syndrome
If a client slips and uses drugs after a period of abstinence, one of two things can happen. He or she could think: “I made a mistake and now I need to work harder at getting sober. Or He or she could think: “This is hopeless, I will never get sober and I might as well keep using.” This thinking represents the abstinence violation syndrome.

Abstinence violation syndrome: What people say
One lapse means a total failure. I’ve blown everything now! I may as well keep using. I am responsible for all bad things. I am hopeless. Once a drunk/junkie, always a drunk/junkie. I’m busted now, I’ll never get back to being straight again. I have no willpower…I’ve lost all control. I’m physically addicted to this stuff. I always will be.

Preventing the abstinence violation syndrome
Clients need to know that if they slip and use drugs/alcohol, it does not mean that they will return to full-time addiction. The therapist can help them “reframe” the drug-use event and prevent a lapse in abstinence from turning into a full return to addiction.

Abstinence violation effect: Examples of “reframing” (1)
I used last night, but I had been sober for 30 days before. So in the past 31 days, I have been sober for 30. That’s better than I have done for 10 years.

Learning to get sober is like riding a bicycle. Mistakes will be made. It is important to get back up and keep trying.

Most people who eventually get sober do have relapses on the way. I am not unique in having suffered a relapse, it’s not the end of the world.

CBT techniques for addiction treatment: Making lifestyle changes

Developing new non-drug-related behaviours: Making lifestyle changes
CBT techniques to stop drug use must be accompanied by instructions and encouragement to begin some new alternative activities. Many clients have poor or non-existent repertoires of drug-free activities. Efforts to “shape and reinforce” attempts to try new behaviours or return to previous non-drug-related behaviour is part of CBT.

Workshop 3: Methods for Using Cognitive Behavioural Strategies

Understand the clinician’s role in CBT Structure a session Conduct a role-play establishing a clinician’s rapport with the client Schedule and construct a 24-hour behavioural plan Read the training goals to your audience. Explain that it is very important for this module not only to gather new knowledge but also to practice the new skills and being able to apply these skills to their everyday work with clients that have substance abuse problems. Explain your audience your training plan and follow up plan with them. Stress that after this training you will be available to answer questions and provide feedback and advice of their practicing of the new techniques and forms.

Role of the clinician in CBT

The clinician’s role To teach and coach the client towards learning new skills for behavioural change and self-control. The role of the therapist is to teach and coach the client towards the learning process of new skills for behavioural change and self-control. The client ultimately should learn to be his or her own coach in the behavioural change process to achieve abstinence or reduction of drug use (Addy & Ritter, 2000)

The role of the clinician in CBT
CBT is a very active form of counselling. A good CBT clinician is a teacher, a coach, a “guide” to recovery, a source of reinforcement and support, and a source of corrective information. Effective CBT requires an empathetic clinician who can truly understand the difficult challenges of addiction recovery. The process revolves primarily around the relationship between the counsellor and the client. It is this relationship that leads to growth and change. The counsellor works ‘with’ the client, and a sense of partnership and collaboration prevails. In essence, the counsellor functions as an ally or guide who helps the client change himself, rather than as an expert who ‘fixes’ all the client’s problems (Ranganathan, Jayaraman & Thirumagal)

The CBT clinician has to strike a balance between: Being a good listener and asking good questions in order to understand the client Teaching new information and skills Providing direction and creating expectations Reinforcing small steps of progress and providing support and hope in cases of relapse

The CBT clinician also has to balance: The need of the client to discuss issues in his or her life that are important. The need of the clinician to teach new material and review homework. The clinician has to be flexible to discuss crises as they arise, but not allow every session to be a “crisis management session.”

The clinician is one of the most important sources of positive reinforcement for the client during treatment. It is essential for the clinician to maintain a nonjudgemental and non-critical stance. Motivational interviewing skills are extremely valuable in the delivery of CBT.

How to conduct a CBT session

CBT sessions CBT can be conducted in individual or group sessions.
Individual sessions allow more detailed analysis and teaching with each client directly. Group sessions allow clients to learn from each other on the successful use of CBT techniques. Treatment Goal The primary goal is to initiate abstinence or reduction in substance use and preventing relapse by addressing potential precipitants of relapse and high-risk factors and teaching the individual coping mechanisms and the necessary skills to effectively exercise control. The secondary goal is to help the client recover from the damage addiction has caused in his life. That is, the patient is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills to continue recovery as a lifelong process.

How to structure a session
The sessions last around 60 minutes. Cognitive Behavioural Therapy applied to Relapse Prevention is highly structured and more didactic than other treatment modalities. There will be a great deal of different activities such as reviewing and practicing exercises, debriefing problems than may have occurred since the last session, skills training, feedback on skills training, in-session practice, and planning for the next week. This active stance must be balanced with adequate time for understanding and engaging with the patient (Carroll, 2001).

How to organise a clinical session with CBT: The 20/20/20 rule
CBT clinical sessions are highly structured, with the clinician assuming an active stance. 60-minute session flow divided into three 20-minute sessions Empathy and acceptance of client needs must be balanced with the responsibility to teach and coach. Avoid being non-directive and passive Avoid being rigid and machine-like The sessions late around 60 minutes

First 20 minutes Set agenda for session
Focus on understanding client’s current concerns (emotional, social, environmental, cognitive, physical) Focus on getting an understanding of client’s level of general functioning Obtain detailed, day-by-day description of substance use since last session. Assess substance abuse, craving, and high-risk situations since last session Review and assess their experience with practise exercise The first 20 minutes of each session: The therapist will focus on getting a clear understanding of patients’ current concerns, level of general functioning, and substance use and craving during the past week. During this section, clients will play a more active role in responding questions or describing their experiences. Therapist will also get information on the experiences in practicing exercises learnt in previous sessions (except for the first session), urine test or breath testing and the client response to medication and compliance, if applicable. (Carroll, 2001).

Second 20 minutes Introduce and discuss session topic
Relate session topic to current concerns Make sure you are at the same level as client and that the material and concepts are understood Practise skills The second 20 minutes will be devoted to introduction and discussion of a particular skill. Here, therapist or clinicians will have a more active role of teaching and explaining the news skills but always obtaining feedback from clients to assess their degree of understanding or agreement on the relevance of the new skill/s. (Carroll, 2001).

Final 20 minutes Explore client’s understanding of and reaction to the topic Assign practise exercise for next week Review plans for the period ahead and anticipate potential high-risk situations Use scheduling to create behavioural plan for next time period The final 20 minutes reverts to be more patient dominated, as patients and therapists agree on a practice exercise for the next week and anticipate and plan for any difficulties the patients might encounter before the next session (Carroll, 2001). AFTER THIS SLIDE – VIDEO

Challenges for the clinician
Difficulty staying focused if client wants to move clinician to other issues 20/20/20 rule, especially if homework has not been done. The clinician may have to problem-solve why homework has not been done Refraining from conducting psychotherapy Managing the sessions in a flexible manner, so the style does not become mechanistic

Principles of using CBT

Match material to client’s needs
CBT is highly individualised Match the content, examples, and assignments to the specific needs of the client. Pace delivery of material to insure that clients understand concepts and are not bored with excessive discussion Use specific examples provided by client to illustrate concepts Adapt materials to your Client’s needs – CBT is highly individualized. Therapist should carefully match the content, timing, and nature of presentation of the material to the patient. Do not belabour topics or rush through material in an attempt to cover all of it in a few weeks. It depends on the client’s needs. Some clients may need several weeks to truly master a basic skill while others may need only a few sessions. It is more effective to slow down and work at pace that is comfortable and productive for you client than to risk the therapeutic alliance by using a pace that is too aggressive.

Repetition Habits around drug use are deeply ingrained
Learning new approaches to old situations may take several attempts Chronic drug use affects cognitive abilities, and clients’ memories are frequently poor Basic concepts should be repeated in treatment (e.g., client’s “triggers”) Repetition of whole sessions, or parts of sessions, may be needed Use repetition – Learning new skills and effective skill-building requires time and practice. Drug users have very defined routines around acquiring, preparing, using the drug and recovering form it. It is important for the therapist or counsellor to recognize how difficult it is for them to change these patterns especially when they encounter the withdrawal symptoms. In addition to this, clients usually seek help after long periods of chronic use. Drugs may affect their attention, memory and other cognitive skills and make it difficult for them to understand, memorize and use new skills to cope with their drug dependence. Therefore repetition of sessions or part of the sessions may be necessary for patients that do not easily understand the concepts or the rationale of the treatment. Therefore, therapist should feel free to repeat as many times as you need the sessions herein explained (Carroll, 2002). It is important to recognise how uncomfortable it is to learn new habits, so learning new approaches. Moreover most patients come to treatment after a long period of use and chronic use affects cognitive abilities.

Practise Mastering a new skill requires time and practise. The learning process often requires making mistakes, learning from mistakes, and trying again and again. It is critical that clients have the opportunity to try out new approaches. Practise – In cognitive behavioural therapy practicing is a central component since is part of the learning process. Mastering a new skill requires time and practice. The learning process often requires making mistakes and being able to change them and try again over and over until the skills are mastered. In CBT, practice of new skills is a central, essential component of treatment. The degree to which the treatment is skills training over merely skills exposure has to do with the amount of practice. It is critical that patients have the opportunity to try out new skills within the supportive context of treatment. Through firsthand experience, patients can learn what new approaches work or do not work for them, where they have difficulty or problems, and so on. CBT offers many opportunities for practice, both within sessions and outside of them. Each session includes opportunities for patients to rehearse and review ideas, raise concerns, and get feedback from the therapist. Practice exercises are suggested for each session; these are basically homework assignments that provide a structured way of helping patients test unfamiliar behaviours or try familiar behaviours in new situations. However, practice is only useful if the patient sees its value and actually tries the exercise. Compliance with extra-session assignments is a problem for many patients. Several strategies are helpful in encouraging patients to do homework.

Give a clear rationale Clinicians should not expect a client to practise a skill or do a homework assignment without understanding why it might be helpful. Clinicians should constantly stress the importance of clients practising what they learn outside of the counselling session and explain the reasons for it. Explain to training participants that giving a clear rationale of the homework or other assignments is critical. Many people drop out and do not practice their homework because they do not understand the importance of the suggested assignments and practicing them. It is critical that clients know the reasons why you are making a specific recommendation or assignment. Give a Clear Rationale - Therapists should not expect a patient to practice a skill or do a homework assignment without understanding why it might be helpful. Thus, as part of the first session, therapists should stress the importance of extra-session practice.

Activity 7: Script 1 “It will be important for us to talk about and work on new coping skills in our sessions, but it is even more important to put these skills into use in your daily life. It is very important that you give yourself a chance to try new skills outside our sessions so we can identify and discuss any problems you might have putting them into practise. We’ve found, too, that people who try to practise these things tend to do better in treatment. The practise exercises I’ll be giving you at the end of each session will help you try out these skills.”

Communicate clearly in simple terms
Use language that is compatible with the client’s level of understanding and sophistication Check frequently with clients to be sure they understand a concept and that the material feels relevant to them Communicate in simple terms with your client - Similarly, therapist should be careful to use language that is compatible with the patient’s level of understanding and sophistication. Therapist should check frequently with patients to be sure they understand a concept and that the material feels relevant to them. Reading your client’s signs is also important such as lack of eye contact, overly brief responses, failure to come up with examples or homework. These signals may indicate that your client does not understand or that is not well suited to the materials that you presented.

Monitoring Monitoring: to follow-up by obtaining information on the client’s attempts to practise the assignments and checking on task completion. It also entails discussing the clients’ experience with the tasks so that problems can be addressed in session. Monitor Closely Following up on assignments is critical to improving compliance and enhancing the effectiveness of these tasks. Checking on task completion underscores the importance of practicing coping skills outside of sessions. It also provides an opportunity to discuss the patient’s experience with the tasks so that any problems can be addressed in treatment. In general, patients who do homework tend to have therapists who value homework, spend a lot of time talking about homework, and expect their patients to actually do the homework. The early part of each session must include at least 5 minutes for reviewing the practice exercise in detail; it should not be limited to asking patients whether they did it. If patients expect the therapist to ask about the practice exercise, they are more likely to attempt it than are patients whose therapist does not follow through. Similarly, if any other task is discussed during a session (e.g., implementation of a specific plan to avoid a potential high-risk situation), be sure to bring it up in the following session. For example, “Were you able to talk to your brother about not coming over after he gets high?”

Praise approximations
Clinicians should try to shape the client’s behaviour by praising even small attempts at working on assignments, highlighting anything that was helpful or interesting. Praise Approximations Just as most patients do not immediately become fully abstinent on treatment entry, many are not fully compliant with practice exercises. Therapists should try to shape the patients’ behaviour by praising even small attempts at working on assignments, highlighting anything they reveal was helpful or interesting in carrying out the assignment, reiterating the importance of practice, and developing a plan for completion of the next session’s homework assignment.

Example of praising approximations
I did not work on my assignments…sorry. Well Anna, you could not finish your assignments but you came for a second session. That is a great decision, Anna. I am very proud of your decision! That was a great choice! Ask the audience what has changed about the way the client refers to her drinking. Oh, thanks! Yes, you are right. I will do my best to get all assignments done by next week.

Overcoming obstacles to homework assignments
Failure to implement coping skills outside of sessions may have a variety of meanings (e.g., feeling hopeless). By exploring the specific nature of the client’s difficulty, clinicians can help them work through it. Explore Resistance Some patients literally do the practice exercise in the waiting room before a session, while others do not even think about their practice exercises. Failure to implement coping skills outside of sessions may have a variety of meanings: patients feel hopeless and do not think it is worth trying to change behaviour; they expect change to occur through willpower alone, without making specific changes in particular problem areas; the patients’ life is chaotic and crisis ridden, and they are too disorganized to carry out the tasks; and so on. By exploring the specific nature of patients’ difficulty, therapists can help them work through it.

Example of overcoming obstacles
I could not do the assignments…I am very busy and, besides, my children are at home now so I do not have time…. But it was something very easy. I understand, Anna. How can we make the assignments easier to complete next week? Ask the audience what has changed about the way the client refers to her drinking. Well, I think that if I just start by doing one or two days of assignments…no more.

What makes CBT ineffective
Both of the following two extremes of clinician style make CBT ineffective: Non-directive, passive therapeutic approach Overly directive, mechanical approach

Conduct a role-play that exhibits each of these extremes (non-directive and overly directive). Then role-play an effective CBT clinician style. 15 minutes

Creating a Daily Recovery Plan

Develop a plan (1) Establish a plan for completion of the next session’s homework assignment.

Develop a plan (2) Many drug abusers do not plan out their day. They simply do what they “feel like doing.” This lack of a structured plan for their day makes them very vulnerable to encountering high-risk situations and being triggered to use drugs. To counteract this problem, it can be useful for clients to create an hour-to-hour schedule for their time.

Develop a plan (3) Planning out a day in advance with a client allows the CBT clinician to work with the client cooperatively to maximise their time in low-risk, non-trigger situations and decrease their time in high-risk situations. If the client follows the schedule, they typically will not use drugs. If they fail to follow the schedule, they typically will use drugs.

Nothing is more motivating than being
Develop a plan (4) A specific daily schedule: Enhances your client's self-efficacy Provides an opportunity to consider potential obstacles Helps in considering the likely outcomes of each change strategy. Nothing is more motivating than being well prepared! How to strengthen commitment to change? A solid plan for change enhances your client's self-efficacy and provides an opportunity for them to consider potential obstacles and the likely outcomes of each change strategy. Furthermore, nothing is more motivating than being well prepared—no matter what the situation, a well-prepared person is usually eager to get started. A sound plan for change can be negotiated with your client by the following means: Offering a menu of change options Developing a behaviour contract Reducing or eliminating barriers to action Enlisting social support Educating your client about treatment Initiating the plan on a specific date Preparing relatives and friends to move into action (see Module 1) (SAMHSA TIP 35, 1999)

Stay on schedule, stay sober
Encourage the client to stay on the schedule as the road map for staying drug-free. Staying on schedule = Staying sober Ignoring the schedule = Using drugs

Develop a plan: Dealing with resistance to scheduling
Clients might resist scheduling (“I’m not a scheduled person” or “In our culture, we don’t plan our time”). Use modelling to teach the skill Reinforce attempts to follow a schedule, recognizing perfection is not the goal Over time, let the client take over responsibility for the schedule.

Activity 5: Exercise Have pairs of participants sit together and practise the creation of a 24-hour behavioural plan. Help the client construct an hour-by-hour schedule for the upcoming 24 hours and write it down with them. Use the Daily/Hourly Schedule Sheet to create a 24-hour plan that will reduce exposure to high-risk situations and triggers. 15 minutes

Post-assessment Please respond to the post-assessment questions in your workbook. (Your responses are strictly confidential.) 10 minutes Explain to your audience that they will need to complete the 5 post-assessment questions for this workshop. They have 10 minutes to complete these questions. Explain that each module will be followed by the same activity. The pre-training and post-training tests may create tension among audience members. Remind your audience that both tests are confidential and that the audience members do not need to provide any personal information. Explain that these assessments are conducted so as to ensure that the training is appropriate for your particular audience and only to measure the effectiveness of the training and provide opportunities for improvement.

Thank you for your time!

Cognitive Behavioural & Relapse Prevention Strategies

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