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COGNITIVE BEHAVIOR THERAPY FOR SUBSTANCE USE DISORDERS: FROM THEORY TO PRACTICE

Heather G. Fulton, PhD, RPsyc OBJECTIVES

• Describe overall theory of CBT, CBT for SUD specifically, and how this model guides individualized treatment • Identify how a functional analysis can assist in conceptualization and tailoring of interventions within CBT for SUD • Differentiate between different types of coping skills interventions • Refer to list of resources for further information on CBT for SUDs

2 CBT

• Survey question • Familiarity with CBT?

3 4 CBT MODEL

Same Thought: It’s a bear! situation but how we think about it Behavior: Run! Emotion: Fear changes our emotions Thought: It’s a baby deer and behaviors Behavior: Slowly turn around, take Emotion: Curiosity? out camera Excitement? 5 CBT MODEL Thoughts/Cognitions

Behaviors Emotions

6 CBT MODEL Thoughts/Cognitions

Behaviors Emotions

“Hot cross bun” model Physical Padesky model 7 Sensations WHAT ACTUALLY HAPPENS IN CBT? • Techniques and strategies based on presenting problems and client • Common key elements throughout . Collaborative relationship  “coach” . Interventions guided by individualized conceptualization . Present-focused . Identification of client goals . Time-limited, goal-focused sessions . Sessions have a collaborative agenda; are structured . Psychoeducation . Out of session practice* & review *avoid the term “homework”

8 IS CBT EFFECTIVE?

• MANY studies on CBT • “First line” or “best practice” for numerous disorders • Supporting evidence for: o Depression & other mood disorders o PTSD o OCD o disorders (GAD, phobias, etc) o Substance Use o Psychosis o Chronic Pain o Etc…

For Reviews, check out:  Tolin, , D.F. (2010). Is cognitive behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Review, 30, 710-720.  Hoofman et al. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta- analyses. Research, 26(5), 427-440. 9 CBT FOR

Relapse Coping Skills Prevention Training (Marlatt) (Monti, Kadden, Carroll)

*Not reviewing , Motivational Interviewing, Community Approaches, Community Reinforcement and Family Training, other couple, family or child-focused therapies 10 CBT FOR SUD • CBT for SUD found to be effective as monotherapy & in combination with other approaches- including pharmacotherapy o o o o o Polysubstance dependence e.g., Dutra et al., 2008; Magill & Ray, 2009; McHugh et al., 2010; Gates et al., 2016; Ray et al., 2018

11 QUESTIONS SO FAR?

12 CASE EXAMPLE Carl  Male, 30s  Alcohol Use, Cocaine use (intranasal), past history of and cannabis use  Alcohol Use Disorder – mild  Cocaine Use Disorder- severe  Last use of cocaine and alcohol was 30days ago  Comorbid depression, GAD  Goal for treatment: “to get my use under control”  “Probably not use any cocaine”  Would like to drink alcohol socially still

*details changed to protect confidentiality 13 THEORY • Addiction is a learned behavior o (learned associations), (learning through consequences) o Biological, pharmacological, social contexts also play a role

Mitcheson et al., 2010; Hendershot et al., 2011

14 Emotion photo credit: Ohio State University

You feel Learning by You take substances association anxious and feel more calm Learning by Overtime this can become… consequence

You feel like you want to use substances You feel You’re not sure how else to calm down anxious apart from using substances 15 THEORY • Addiction is a learned behavior Classical conditioning (learned associations), operant conditioning o (learning through consequences) o Biological, pharmacological, social contexts also play a role • Addiction emerges and is maintained in an environmental context E.g. availability of substances, learning from peers/parents, social o deprivation (e.g. other rewards), cultural influences

• Addiction is developed and maintained by thought patterns and processes o E.g. outcome expectancies, permission to use, self-efficacy, affective state Mitcheson et al., 2010; Hendershot et al., 2011

16 CBT/RP Model

Marlatt & Gordon, 1985 17 Marlatt & Gordon, 1985 18 (transient over time)

(stable over time)

19 CBT FOR SUBSTANCE USE

Primary tasks of treatment:

(1) Identify antecedents and determinants of substance use: -What specific needs are substances being used to meet ?

(2) Develop skills that provide alternative ways of meeting those needs

20 FUNCTIONAL ANALYSIS

• Builds individualized conceptualization • Fancy word for simple procedure o “slow mo’ replay”

What was happening:  Before  During  After

21 22 CBT FOR SUBSTANCE USE

Primary tasks of treatment:

(1) Identify antecedents and determinants of substance use: -What specific needs are substances being used to meet ?

(2) Develop skills that provide alternative ways of meeting those needs

23 Recognize antecendants, determinants Avoid triggers when possibleID Understand needs that substances being used to meet

Practice to  Increase Prevent lapses Improve Coping

Other ways to Challenge myths, meet needs? beliefs

24 Marlatt & Gordon, 1985; Carroll, 1998 COPING SKILLS TRAINING

• Use tracking/ functional analysis o Thoughts, emotions and behaviors before, during, & after craving or use o Positive and negative consequences of use/no use

• Focus on present, current symptoms (thoughts, feelings, behaviors)

• Psychoeducation & address skill deficits o PRACTICE

25 BASIC COPING SKILLS Everyone is different- ‘different tools in toolbox’ Experiment Emotion Regulation  Distraction (esp. )  Talk to someone   urge-surfing  Examine & challenge self-talk, beliefs (outcome expectancy, permission giving, etc.)  Keeping slip/lapse/use in perspective  F#%* it Factor Interpersonal  Refusal Skills  Assertiveness Organizational/problem solving difficulties  Scheduling, agenda  disorganization & time spent using  Remember the negative consequences  “play the tape through”  Remembering values & goals  Increasing pleasurable, meaningful activities including social connection and belonging alternative reinforcers Carroll, 1998; McHugh, Hearon & Otto, 2010; Mitcheson et al., 2010; Allen et al., 2018; Ellingsen et26 al., 2018 BASIC COPING SKILLS CONTINUED… Adjust for cognitive/learning abilities  Rehearsal  Imaginal exposure and/or rehearsal  Behavior experiments  Repetition  Reminders can help

Modified from SUBI Workbook, 2005; Carroll’s work

27 CARL Key coping skills  Identifying high risk situations  Alone  Using alcohol  Feeling guilty, ashamed, hopeless, out of control  Testing thoughts  I’m just going to mess up later anyways, it’s hopeless  I need a break (and cocaine will give it to me)  People will judge me if they knew my history  Doing fun activities that give a sense of mastery and pleasure  Laundry, organizing things  Biking  Referral to couples counselling; meeting with partner about how to help cope  Reviewed successful coping in high risk situations

*details changed to protect confidentiality 28 CARL

• Tapered last sessions (1x/week, 1x/2-3weeks, 1x/month)

• Had not used cocaine for 7months – despite encountering high risk situations (e.g. offers, seeing former dealer) • Decided to avoid alcohol use for now • Ongoing couples therapy • Promoted in job

*details changed to protect confidentiality 29 RESOURCES

https://archives.drugabuse.gov/sites/default/files/cbt.pdf 30 REFERENCES • Allen, A.M., Abdelwahab, N.M., Carlson, S., Bosch, T.A., Eberly, L.E., & Okuyemi, K. (2018). Effect of brief exercise on urges to smoke in men and women smokers. Addictive Behaviors, 77, 34-37.

• Carroll KM. A cognitive-behavioral approach: Treating cocaine addiction (NIH Publication 98- 4308) Rockville, MD: National Institute on Abuse; 1998

• Dutra, L., Stathopoulou, G., Basden, S., Leyro, T.M., Powers, M.B., & Otto, M.W. (2008). A Meta-Analytic Review of Psychosocial Interventions for Substance Use Disorders. The American Journal of , 165(2), 179-187.

• Ellingsen, M.M., Johannesen, S.L., Martinsen, E.W., & Hallgren, M. (2018). Effects of acute exercise on drug craving, self-esteem, mood and in adults with poly-: Feasibility and preliminary findings. Drug and Alcohol Reviews, 37(6), 789-793.

• Gates, P.J., Sabionoi, P., Copeland, J., Le Foll, G., & Gowing, L. (2016). Psychosocial interventions for cannabis use disorders Psychosocial interventions for . Cochrane Database of Systematic Reviews 2016(5), 1-135. DOI: 10.1002/14651858.CD005336.pub4

• Hendershot C. S., Witkiewitz K., George W. H., & Marlatt G. A. (2011). prevention for addictive behaviors. Treatment, Prevention, and Policy, 6(1), 17.

• Hoofman et al. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy Research, 26(5), 427-440.

31 REFERENCES

• Magill, M. & Ray, L.A. (2009). Cognitive-Behavioral Treatment With Adult Alcohol and Illicit Drug Users: A Meta- Analysis of Randomized Controlled Trials. Journal of Studies on Alcohol and , 70(4), 516-527). • Marlatt G.A. & Gordon, J.R. (1985). . New York: Guilford Press. • McHugh, R.K., Hearon, B.A., & Otto, M.W. (2010). Cognitive-Behavioral Therapy for Substance Use Disorders. Psychiatric Clinics of North America, 33(3), 511-525. • Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R., & Wanigaratne, S. (2010). Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: A Practical Treatment Guide. Chichester, UK: John Wiley & Sons. • Padesky, C.A., & Mooney, K.A. (1990). Clinical tip: Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13-14. • Ray, L.A., Bujarski, S., Grodin, E., Hartwell, E., Green, R., Venegas, A., Lim, A.C., Gillis, A., & Miotto, K. (2018). State-of-the-art behavioral and pharmacological treatments for alcohol use disorder. The American Journal of Drug and Alcohol Abuse, 45(2), 124-140. • The Substance Use Brain Injury Project Team. (2005) Client Workbook. Retrieved from: https://www.brainline.org/sites/default/files/SUBIClientWorkbook.pdf  Tolin, D.F. (2010). Is cognitive behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30, 710-720.  Witkiewitz, K., & Marlatt, G. A. (2004). Relapse Prevention for Alcohol and Drug Problems: That Was Zen, This Is Tao. American Psychologist, 59(4), 224-235. 32