1. Cognitive Behaviour Therapy (CBT) Gerhard Ohrband - ULIM University, Moldova 15th lecture CBT in treating addiction and substance abuse

2. Course Structure 1. Introduction: What is CBT? What are differences and similarities with other therapy schools? 2. Diagnostics in CBT 3. Classification of Psychological Disorders (ICD- 10, DSM-IV), Clinical Psychology (Etiology, prevalence, comorbidity and symptoms) 4. Etiological concepts in CBT: learning theories (classical and operant conditioning, vicarious learning, Mowrer’s Two-factor theory) 5. Systematic desensitization: in-vivo exposure and imaginatory 6. Aversion training: overt and covert

3. Course Structure 7. Response prevention: treating obsessive-compulsive disorder (OCD) 8. Social skills training: anger management, assertiveness training 9. Rational-emotive Therapy (RET) 10. Beck’s Cognitive Therapy for depression 11. Marital and Sex Therapy 12. Trauma Therapy: Expressive writing, work with affirmations, visualizations; working with victims of crimes, accidents and other difficult life-events 13. Relaxation techniques: yoga, meditation, Alexander technique, Feldenkrais 14. CBT at school: helping children with autism, hyperactivity, social phobia, social adjustment problems, learning difficulties and antisocial behaviour. 15. CBT in treating addiction and substance abuse

4. Content Health psychology Smoking and health risks Smoking cessation

5. Health Psychology Definition: Health psychology is the branch of psychology that applies psychological principles to the understanding of health and illness Factors influencing health can be External (in the form of stressors, health promotion, advertising of health-impairing products) or Internal (in the form of thoughts, beliefs, decision making and coping responses) Relatively new branch of psychology Slight overlap with clinical psychology Many theories and explanations derive from social and cognitive psychology

6. Health and Clinical Psychology Similarities: Both study stress and how people cope with it Differences: Health psychology tends to concern itself with bodily illness whereas clinical psychology is primarily concerned with mental illness

7. Whitehead’s (1995) factors contributing to health Age, sex and hereditary factors Individual lifestyle factors Social and community influences Living and working conditions General socio-economic, cultural and environmental conditions

8. Cigarette Smoking In the UK, the annual mortality rate that is attributable to smoking is 120,000, accounting for £ 400 million in hospital costs and 500 million lost working days (Health Education Authority, 1991). According to the Imperial Cancer Research Fund, the death rate is equivalent of a jumbo jet crashing every day of the year and killing all the passengers. Worldwide, smoking causes 3 million deaths a year, and this is estimated to increase to 10 million by 2020 (Peto, 1994).

9. Who smokes? The largest reduction in smoking has been found in the most well-off families (Marsh and McKay, 1994). Studies of specific cultural groups have associated a failure to quit with low income (Nevid et al., 1996). Smoking and its health-related problems more prevalent in lower socio-economic groups than in higher ones (Droomers et al., 2002).

10. Study: Droomers et al., 2002 Data on smoking and socio-economic status from the Dutch GLOBE study of 27,000 individuals recruited from southeastern Netherlands in 1991 GLOBE: Dutch acronym for Health and Living Conditions of the Population of Eindhoven and its Surroundings Examined the relationship between educational level and the intention to quit in 1,354 initial Dutch smokers Smoking information was obtained in 1991 and then 6,5 years later Results: participants at the lower end of the education spectrum were significantly more likely to continue smoking than were their better-educated counterparts.

11. Associated problems of smoking Higher intake of fatty food (Shah et al., 1993) Lower fruit and vegetable intake Higher alcohol intake (Morabia and Wynder, 1990) Less physical activity French et al., 1996: Current smokers have been found to consume more alcohol, meat, eggs and chips more frequently than former or non-smokers, although sweet consumption in those who have stopped smoking is higher.

12. Other health risks Increased risks of Cancer Bronchitis Emphysema Strokes Ulcers Non-smokers who are exposed to air contaminated with cigarette smoke (second-hand smoke) also face increased risks of CHD and cancer. As a result: smoking banned in many public places such as public transport, restaurants, cinemas, offices, hospitals, schools and so on.

13. A ‘stigmatised’ habit People’s negative views of smoking have led to the behaviour being labelled a ‘stigmatised’ habit (Furnham et al., 2002). When people are asked to prioritise whou should receive healthcare, for example, smokers are normally given the lowest priority. Studies show that smoking appears to be a ‘stigmatised’ habit which can cloud perceptions of smokers and their treatment for illnesses unrelated to their habit (Furnham and Briggs, 1993; Furnham et al., 2000)

14. Factors which promote the initiation and maintenance of smoking What causes people, especially adolescents, to begin smoking? Lynskey et al., 1998: both imitation and peer pressure For example, adolescent who have favourable impressions of a smoker are likely to imitate that person’s actions. Cigarette manufacturers use this knowledge to advertise their products: they portray smoking as a glamorous, mature, independent, and sometimes rebellious behaviour.

15. Selected studies Biglan et al., 1995: longitudinal study of 634 14- 17-year-olds and their smoking behaviour The best predictor of smoking was peers’ smoking six months earlier Parental smoking also predicted smoking Chassin et al, 1996: Longitudinal study of 4,035 participants (with roughly equal numbers of men and women) Increase in the initiation of smoking from adolescence to childhood Slight decrease in the participants’ initiation in their mid-twenties No initiation in adulthood

16. Rose et al, 1996: likelihood of attempting to quit Likelihood of attempting to quit Perceiving smoking as Dangerous (both personally and generally) Attaining some college education Being femaleBeing married Occupying several social roles

17. Rose et al, 1996: likelihood of successfully quitting likelihood of successfully quitting Smoking less than one packet a day Perceiving oneself as being less likely to be smoking in a year education Having fewer smoking friends Being employed Not living with children

18. A bio-psycho-social model of psychological disorders Biological factors Psychological factors Social Factors Increased vulnerability Non-adaptive behaviour Chronic psychological disorder Stressful life-events reinforcement

19. Stopping smoking Measures put in place to facilitate it: Tobacco advertising bans Sales restrictions Price increases Educational strategies Discussion: What do you think works best?

20. Study: Willemsen and De Zwart, 1999 Review of studies of the effect of these measures on adolescent smoking Results: In isolation, few of these measuures were effective The measures were most effective in combination Of the isolated measures, price increases was the single most prohibitive factor Setting an age limit had no effect on smoking

21. Smoking Cessation New treatment programmes for cigarette smokers have revolved around nicotine replacement. This replacement is normally undertaken via a nicotine gum or a transdermal patch, a plaster-like patch that allows nicotine to be absorbed through the skin Over several months, the nicotine levels of the patches are reduced, and the individual is weaned from nicotine altogether Mixed success rate A review of the effectiveness of nicotine gums and patches suggests success rates of 11 % and 13 % for each therapy respectively (Law and Tang, 1995)

22. The body’s response to stopping cigarette smoking TimescaleResponse Within 20 minutes of last puffBlood pressure and pulse return to normal levels Within 8 hoursNicotine and carbon monoxide levels in the blood are halved, oxygen levels in the blood return to the normal Within 1 dayCarbon monoxide is eliminated from the body and lungs start to clear out the accumulated tar Within 2 daysThere is no tar left in the body Taste and smell start to return to normal Within 3 daysBreathing becomes easier due to relaxing of bronchial tubes; energy levels increase From 2 weeks to 3 monthsCirculation of the blood improves; walking and running becomes easier From 3 months to 9 monthsCoughing, wheezing and breezing problems improve as lung function is increased by up to 10 % After 5 yearsRisk of heart attack falls to about half that of a smoker After 10 yearsRisk of lung cancer falls to half that of an continuing smoker

23. Prevention programmes Prevention programmes designed by health psychologists and health professionals are generally aimed at combating social factors such as Imitation Peer pressure Influence from advertisement (Evans et al., 1984)

24. Lapse back … Situations in which quitters may lapse are those in which smoking cues and alcohol consumption are present (Schiffman, 1982) When smokers and quitters are tempted to smoke, they are usually 1. Feeling quite negatively and restless 2. Are exposed to smoking cues and 3. Are likely to be eating or drinking in company (Schiffman et al., 1996) Exposing smokers to positive images of smoking hav been shown to predict their willingness or intention to smoke (Dinh et al., 1995) whereas negative images predict successful abstinence from smoking (Gibbons and Eggleston, 1996).

25. The Waterloo Smoking Prevention Project Canadian anti-smoking programme (Flay et al., 1985) Especially effective in reducing the number of young adolescent who experiment with smoking Technique: students were first asked to seek out information about smoking and to think about their beliefs regarding smoking. Next they were taught about the social pressures involved in smoking and were given explicit training in how to resist those pressures – for example, politely turning down a cigarette when one is offered.

26. Technique This training also included role playing such resistance strategies and asking each student to make a commitment whether they would start smoking or not. Results: The students were monitored five times over the next two years to see how many of them had experimented with smoking. By the end of the two-year period, fewer than 8 % of the students who had been involved in the prevention programme were experimenting with smoking In contrast, almost 19 % of the students who had not gone through the programme had experimented with smoking While these results are encouraging, the students were only monitored for two years. Long-term prevention programmes have shown that many participants begin experimenting with smoking later on, hinting that occasional ‘booster’ sessions may be necessary to maintain the effects of the initial training (Murray et al., 1989)

27. Sex differences in smoking cessation Men have a higher smoking cessation rate than do women Discussion: How do you explain these findings?

28. Literature Biglan, A., Duncan, T.E., Ary, D.V. and Smolkowski, K. (1995). Peer and parental influences on adolescent tobacco use. Journal of Behavioural Medicine, 18 (4), 315-330. Droomers, M., Schrijvers, C.T.M. and Mackenbach, J.P. (2002). Why do lower educated people continue smoking? Explanations from the longitudinal GLOBE study. Health Psychology, 21, 263-272. French, S.A., Hennrikus, D.J. and Jeffrey, R.W. (1996). Smoking status, dietary intake, and physical activity in a sample of working adults. Health Psychology, 15 (6), 448-454. Lynskey, M.T., Fergusson, D.M. and Horwood, L.J. (1998). The origins of the correlations between tobacco, alcohol, and cannabis use during adolescence. Journal of Child Psychology and Psychiatry, 39 (7), 995-1005. Niaura, R. and Abrams, D.B. (2002). Smoking cessation: Progress, priorities and prospects. Journal of Consulting and Clinical Psychology, 70 (3), 494-509. Rose, J.S., Chassin, L., Presson, C.C. and Sherman, S.J. (1996). Prosprective predictors of quit attempts and smoking cessation in young adults. Health Psychology, 15 (4), 261-268.

29. Journals British Journal of Health Psychology British Journal of Medical Psychology British Medical Journal Health Psychology International Journal of Behavioural Medicine International Journal of Stress Journal of Abnormal Psychology Journal of Community and Applied Psychology Journal of Health Psychology New England Journal of Medicine Psychology, Health and Medicine Psychosomatic Medicine Social Science and Medicine The Lancet