Brief Cognitive

TIP 34: Brief Interventions and Brief Therapies for Substance Abuse Module 7: Brief Cognitive- Behavioral Therapy TIP 34 Reference Chapter 4: Brief Cognitive-Behavioral Therapy (pp. 68-86)

TIP 34 Book Module 7

Training Emphasis 1. Key Concepts of Brief Cognitive-Behavioral Therapy

2. Models Used for Brief Cognitive-Behavioral Therapy

Trainer Notes 3. Research on Brief Cognitive-Behavioral Therapy

4. Types of Settings and Clients Appropriate for Brief Cognitive- Behavioral Therapy

5. Applications of Brief Cognitive-Behavioral Therapy in Substance Abuse Treatment

6. Duration of Brief Cognitive-Behavioral Therapy

7. Evaluation of Effectiveness of Brief Cognitive-Behavioral Therapy

8. Strategies Used for Brief Cognitive-Behavioral Therapy

9. Participant Strategy Integration

Learning Objectives 1. Participants will be able to identify three key concepts about brief cognitive- behavioral therapy.

2. Participants will be able to identify three models used for brief cognitive- behavioral therapy.

3. Participants will be able to identify three research findings about brief cognitive-behavioral therapy.

4. Participants will be able to identify three settings or clients appropriate for using brief cognitive-behavioral therapy.

5. Participants will be able to identify three applications of brief cognitive- behavioral therapy with substance abusers.

179 Brief Cognitive-Behaviorial Therapy TIP 34: Brief Interventions and Brief Therapies for Substance Abuse

6. Participants will identify one new brief cognitive-behavioral therapy strategy to integrate into their practice.

7. Participants will identify at least one quality assurance and improvement procedure for the new brief cognitive-behavioral therapy strategy. Agenda 1. Welcome (2 Minutes) 2. Brief Cognitive Therapy Summary Grid Overview and Discussion (20 Minutes) 3. Strategy Identification Exercise (10 Minutes) 4. Strategy Integration Mind-Map Exercise (10 Minutes) 5. Assignments and Closing (3 Minutes)

Training Equipment and Supplies 1. White board and erasable markers – OR – newsprint pad, markers, and easel 2. LCD projector – OR – overhead transparency projector 3. PowerPoint slide CD – OR – overhead transparencies 4. Moveable seating 5. Nametags (optional, reusable or disposable) 6. Attendance record 7. Pens and colored pencils or crayons 8. Continuing education certificates (optional)

Definition of Terms

Functional Analysis: A process used in behavioral and cognitive– behavioral therapy that probes the situations surrounding the client’s substance abuse. A functional analysis examines the relationships among stimuli that trigger use and the consequences that follow. This can provide important clues regarding the meaning of the substance use behavior to the client, as well as possible motivators and barriers to change. In these forms of therapy, this is a first step in providing the client with tools to manage or avoid situations that trigger substance use. Functional analysis yields a roadmap of a client’s interpersonal, intrapersonal, and environmental catalysts and reactions to substance use, thereby identifying likely precursors to substance use.

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TIP 34: Brief Interventions and Brief Therapies for Substance Abuse

Attribution(s): An individual’s explanation of why an event occurred. Some researchers believe that individuals develop attributional styles (i.e., particular ways of explaining events in their lives that can play a role in the development of emotional problems and dysfunctional behaviors) stable/unstable, and global/specific. For instance, clinically depressed persons tend to blame themselves for adverse life events (internal), believe that the causes of negative situations will last indefinitely (stable), and overgeneralize the causes of discrete occurrences (global). Healthier individuals, on the other hand, view negative events as due to external forces (fate, luck, environment), as having isolated meaning (limited only to specific events), and as being transient or changeable (lasting only a short time).

Effect Expectancies: A set of cognitive expectancies that the client develops concerning anticipated effects on hi s/her feelings and behaviors as drinking/drug use are reinforced by the positive affects of the substance being taken. These represent the expectation he/she holds that certain effects will predictably result from drinking or using specific drugs.

Participant Materials (One for Each Participant)

Participant Materials 1. Module 7 Handouts a. Module 7 Packet Cover b. Brief Cognitive-Behavioral Therapy Summary Grid c. Strategy Identification Exercise

d. Strategy Integration Mind-Map Exercise 2. Homework: Handouts for next TIP 34 Training Module

Module 7 – Section 1

Welcome & Introduction Time: 2 Minutes Time Clock Trainer Notes This section can be didactic or involve low group interaction. Trainer and participant introductions are not necessary as these were done in Module 1. Trainer Notes Trainer Script Welcome & Topic Introduction Welcome to the TIP 34 training on brief interventions and brief therapies.

Our topic for this training is “Brief-Cognitive Behavioral Therapy.”

The goal of all brief therapies is to provide clients with tools to change thoughts, attitudes, and/or behaviors.

Brief cognitive-behavioral therapy (CBT) represents the integration of principles derived from both behavioral and cognitive theories, and has been described as cognitive social learning or cognitive–behavioral theory.

CBT attributes a greater role to the interaction of individual variables - such as beliefs, values, perceptions, expectations, and attributions-in the development of substance abuse disorders.

We will explore the theories and models of Brief Cognitive-Behavioral Therapy through the Summary Grid in your handout packet.

We will also use the Strategy Identification Exercise and the Strategy Integration Mind-Map to identify a new brief therapy strategy that you want to integrate into your personal practice. Module 7 - Section 2

Brief Cognitive-Behavioral Therapy Summary Grid Time: 20 Minutes

Time Clock Trainer Notes This section is a combination of didactic presentation and large group discussion. It can involve low to high group interaction.

The trainer should not read each item from the Summary Grid. Summarizing each section of the grid, as well as adding additional information available in the trainer script or through personal clinical experience, will make the

Trainer Notes

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training more interesting.

Integrating group discussions with each section will enhance the effectiveness of the training. Group discussions allow participants to learn from one another as well as from the trainer.

The trainer always facilitates the group discussion and interaction. The trainer’s role is to provide expertise and guidance, and not to prescribe the use of any one model for brief interventions. The trainer maintains focus of discussions on the topic, and is also the leader and timekeeper for the group.

The focus topic of the discussions is the feasibility of using these approaches within the guidelines and services of the agency.

The trainer can initiate discussion with open questions:

■ Does anyone in the group have expertise in using brief cognitive- behavioral therapy approaches?

■ What types of brief cognitive-behavioral therapy strategies are within the established guidelines for our agency?

■ What types of brief cognitive-behavioral therapy strategies are currently used in our agency?

■ What other types of brief cognitive-behavioral therapy could be used in our agency?

■ What resources for brief cognitive-behavioral therapy exist outside of our agency?

Tip 34 Book TIP 34 Reference Chapter 7: Brief Cognitive Behavioral Therapy (pp. 68-86)

Participant Workbook ■ Brief Cognitive-Behavioral Therapy Summary Grid Participant Workbook Trainer Script Key Concepts Brief cognitive-behavioral therapy (CBT) tries to change what the client both does and thinks through a mediation process. A primary goal of CBT is to help the individual find a better lifestyle balance, increasing involvement in pleasant and rewarding activities, while reducing the level and sources of stress.

One of the strengths of CBT is the ability to individually tailor coping skills training to the needs of the client.

CBT postulates that cognitive factors mediate all interactions between the client, the demands of the situation, and the coping strategies used by the client.

The therapist focuses on current problems and places a greater emphasis on using behavioral coping strategies, especially early in therapy.

The key ingredients that distinguish CBT from some other therapies and that must be included in a CBT treatment include the following:

1. A functional analysis of substance abuse.

2. An examination of the cognitive processes related to substance abuse.

3. The identification and debriefing of past and future high-risk situations.

4. Individualized coping skills training for managing cravings, managing thoughts about substance abuse, problem solving, planning for emergencies, decision- making, and refusal skills.

5. Practice of skills within sessions.

6. The encouragement and review of the implementation of skills outside the therapy session.

CBT establishes attainable and contracted goals, and seeks to obtain quick results for the most pressing problems. It relies on a variety of empirically based techniques to increase the client’s ability to handle his/her own problems.

In CBT, substance abuse is viewed as a learned behavior having functional utility for the individual. The individual uses substances as a means of trying to deal with problems and the emotional reactions they create.

The substance abuse treatment goal of CBT is to help the client develop and employ effective coping skills to meet the demands of high-risk situations without resorting to the use of substances.

Brief Cognitive-Behavioral Therapy Models

A broader range of cognitions is included in cognitive–behavioral theory than had been involved in earlier versions of cognitive theory. These include attributions, appraisals, self-efficacy expectancies, and substance-related effect expectancies.

The models included in TIP 34 are: 1. Attributions 2. Abstinence Violation Effect (AVE) 3. Cognitive Appraisal

4. Coping Behaviors

5. Self-Efficacy Expectancies

6. Substance-Related Effect Expectancies

7. High Risk Situations

8. Relapse Prevention

9. Functional Analysis

10. Coping Skills Training

Attributions Attributions are an individual’s explanation of why an event occurred.

There are three basic attributional dimensions:

1. Internal/External: Attributing events and their causes to self (internal) or to others (external).

2. Stable/Unstable: Believing that the event will continue to affect the future (stable), or that it can be changed or stopped (unstable).

3. Global/Specific: Believing that one bad circumstance affects all areas of one’s life (global) or just one (specific).

A negative attributional process generally involves internal, stable, and global dimensions. Common attributional styles in clinically depressed clients include:

1. Blame self for adverse life events (internal)

2. Believe that the causes of negative situations will last indefinitely (stable)

3. Overgeneralize the causes of discrete occurrences (global)

Healthier individuals, on the other hand, commonly view negative events as:

1. Due to fate, luck, or environmental forces (external)

2. Being transient or changeable (unstable)

3. Having isolated meaning (specific)

The nature of substance abusers’ attributional styles is thought to have considerable bearing on their perception of their substance abuse problem and their approach to recovery.

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Common attributional styles of substance abusers include: 1. Belief that substance abuse is caused by personal weakness (internal attribution). 2. Belief that other people encourage substance use (external attribution). 3. Belief that failure to maintain abstinence shows that s/he is a weak person who can never succeed at anything (global attribution). 4. Belief that substance use does not represent a general weakness but is instead due to the specific circumstances of the moment (specific attribution). 5. Belief that the cause of a slip is something that cannot change (stable attribution). 6. Belief that the next time a slip occurs, s/he will exert better coping responses (unstable attribution).

The internal, global, and stable attribution for substance abuse is likely to lead to feeling of depression, hopelessness and relapse. The external, specific, unstable attribution is likely to lead to greater efforts to cope with high-risk situations in the future. An Abstinence Violation Effect (AVE) occurs when a negative attributional process after a slip (the first use of a substance after a period of abstinence) leads to continued use and full relapse.

1. AVE involves the attribution of the cause of an initial slip to internal, stable, and global factors.

2. This attributional style tends to be associated with a form of “learned helplessness.”

3. It increases the likelihood that the initial lapse will develop into a full relapse.

Cognitive Appraisal Cognitive Appraisal is an individual’s appraisal of stressful situations and his/her ability to cope with the demands of these situations. This appraisal subsequently influences his/her use or abuse of substances. Primary appraisal: 1. The individual’s perception of a situation 2. The estimation of the potential level of stress, personal challenge, or threat involved with the situation

Secondary appraisal:

1. The individual’s evaluation of his/her ability to meet the challenges and demands specific to the situation 2. Influenced by the extent, nature, and availability of the individual’s coping skills The extent that the individual believes that s/he has the necessary behavioral, cognitive, or emotional coping skills to meet the challenges of the situation, will determine how s/he will appraise the situation as more or less threatening or stressful.

Cognitive appraisals may play a more prominent role than attributions in mediating emotional responses to potentially threatening situations.

Coping Behaviors

CBT posits that substance users are deficient in their ability to cope with interpersonal, social, emotional, and personal problems.

In the absence of more appropriate behavioral, cognitive, and emotional coping skills, the individual uses substances in response to problematic situations as an attempt to cope.

“Coping” refers to what an individual does or thinks in a relapse crisis situation so as to handle the risk for renewed substance use. The absence of coping skills causes problems to be viewed as threatening, stressful, and potentially unsolvable, and the individual uses substances as a means of coping. Coping responses can occur within the affective, behavioral, and cognitive domains. Dimensions of coping behaviors: 1. Emotion focused 2. Problem focused 3. Avoidant 4. General 5. Craving focused 6. Anticipatory 7. In the moment 8. Restorative

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Coping strategies generally operate in a sequential manner: 1. Initially, when clients are attempting to initiate and stabilize abstinence from substances, they appear to rely more heavily on the behavioral strategies. 2. As the period of abstinence increases, there appears to be a transition from predominantly behavioral strategies toward a greater reliance on cognitive methods of coping. The number of coping attempts and the type of coping will influence both relapse and the return to abstinence. Attempting to cope with a relapse crisis led to higher rates of abstinence than not trying to cope, and the greater the number of coping strategies employed, the less likely the person was to use. Similarly, the greater the number of coping strategies used by an individual following a relapse, the greater the likelihood of returning to abstinence. There appears to be a considerable degree of situational specificity in the coping process. That is, different types of substance-related situations seem to require different types of coping responses. General coping strategies are not equally effective across high-risk situations.

Developing a variety of coping skills for several possible situations in which the client may use substances may also be necessary. Self-Efficacy Expectancies Self-efficacy expectancies refer to an individual’s beliefs about his/her ability to successfully execute an appropriate coping response to a given situation. These expectations are determined in part by the individual’s repertoire of coping skills and an appraisal of his/her relative effectiveness.

They influence the individual’s behavior through cognitive, motivational, and emotional systems. Expectations of personal efficacy determine:

1. Whether coping behavior will be initiated.

2. The amount of effort that will be expended in attempting to cope.

3. How long a coping attempt will continue in the face of obstacles and aversive experiences.

Perceptions of low self-efficacy can cause negative or distorted thoughts and beliefs about self and situations, reduced motivation to cope, depression, relapse, and a sense of helplessness.

Although self-efficacy is related to the availability of coping skills and would be expected to increase as the client learns new skills, this does not always occur spontaneously. Helping the client change the passivity and sense of helplessness that often accompany low self-efficacy is frequently necessary.

Substance-Related Effect Expectancies Substance use is reinforced by the positive effects of the substance on both feelings and behavior. Thus, the individual will likely develop cognitive expectancies about these anticipated effects. Substance-related effect expectancies represent the individual’s expectation that certain effects will predictably result from the use of certain substances. Expectancies are based on observations of others’ substance use to cope with difficult situations, and personal experiences of the positive effects of substances.

Anticipated positive effects of substances serve as an incentive or motivation to use such substances. Negative expectancies are thought to act as a disincentive and reduce drinking or drug use. For example, positive effect expectancies for alcohol include: 1. Being a global elixir 2. Having positive effects on mood, social and interpersonal behavior, sexual behavior, assertiveness, and tension reduction Positive effect expectancies for marijuana include: 1. Relaxation and tension reduction 2. Social and sexual facilitation 3. Perceptual and cognitive enhancement. Positive effect expectancies for cocaine include:

1. Global positive effects 2. Generalized arousal; euphoria 3. Enhanced abilities 4. Relaxation and tension reduction

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Negative effect expectancies for alcohol include: 1. Cognitive and behavioral impairment 2. Risk and aggression 3. Negative self-perception Negative effect expectancies for cocaine include: 1. Global negative effects 2. Anxiety 3. Depression 4. Paranoia

High-Risk Situations Situations (e.g., the people, places, feelings, activities) are high–risk when they become conditioned cues that elicit a strong craving or desire to use a drug. The use of substances is reinforced through operant learning to the extent that it allows the individual to avoid or escape problem situations or emotional reactions. These settings appear to represent situations in which substance use in general will be more likely to occur. While there appears to be considerable overlap in high-risk situations across substances, there are also a number of substance-specific patterns. Dr. Alan Marlatt and colleagues have categorized a number of situations in which substances are abused. While the original taxonomy of these situations focused on settings in which relapse occurred following a period of abstinence from a substance, they also appear to represent situations in which substance use in general will be more likely to occur.

The broadest categories include interpersonal and intrapersonal environmental high-risk situations. These situations include many emotional, interpersonal, and environmental settings in which people commonly abuse substances and where they are likely to relapse. Intrapersonal environmental high-risk situations involve factors that are internal or reactions to non-personal environmental events. They include: 1. Coping with negative emotional states

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2. Coping with negative physical/physiological states 3. Enhancement of positive emotional states

4. Testing personal control

5. Giving in to temptations or urges

Interpersonal high-risk situations involve a current or recent interaction with someone else. They include:

1. Coping with interpersonal conflict

2. Social pressure to drink or use drugs

3. Enhancement of positive emotional states

CBT Model of the Relapse Process The cognitive–behavioral approach attempts to integrate all of these theoretical details into a meaningful model of substance abuse disorders. CBT assumes that over the course of time, substance abusers develop effect expectancies, and believe that substances have positive benefits that are more immediate and prominent than their negative consequences. They come to rely on substances as a means of trying to cope with these high-risk situations. The sense of self-efficacy decreases to the extent that the individual is lacking in the coping skills necessary to deal with the demands of high-risk substance abuse or relapse situations. As personal efficacy decreases, the anticipated positive effects of substance use increase and become more important. Under such conditions, the individual is likely to use. When confronted by similar situations in the future, the likelihood of using continues to be quite high, unless new coping skills have been learned.

Attributional processes and emotional responses also play a role in an individual’s decision to use. If an individual does not have the necessary restorative coping skills to deal with the impact of a negative attributional style, it is more likely that an initial slip will grow into a full relapse. However, if an individual chooses and makes use of an appropriate coping response, and then experiences a sense of self-mastery and an ability to cope with the high-risk situation, the likelihood of relapse increases.

Substance use is less likely to occur and be less pronounced for individuals who are more firmly committed to the goal of abstinence or moderation and for individuals who have maintained such goals longer.

CBT Core Elements

CBT incorporates three core elements: 1. Functional analysis 2. Coping skills training 3. Relapse prevention

Functional analysis is a detailed analysis that helps to determine the treatment process, identify individualized specific interventions, and develop a treatment plan for the client. The functional analysis evaluates: 1. The number and type of high-risk situations

2. The temptation to use in these situations 3. Self-efficacy expectancies 4. The frequency and effectiveness of coping skills 5. Substance-related affect expectancies Without a thorough assessment, CBT treatment cannot proceed and is likely to fail. Questionnaires, interviews, and role-playing measures are available to assist the therapist in the assessment and functional analysis. TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1999c) contains a review of assessment tools that can be used in developing a functional analysis. Teaching coping skills is the core of CBT. CBT views substance abusers as being deficient in their ability to cope with interpersonal, social, emotional, and personal problems. It assumes that substance abusers are deficient in coping skills, choose not to use those they have, or are inhibited from doing so. Deficits in coping skills among substance abusers may be the result of a number of possible factors: 1. They may have never developed these skills, possibly because the early onset of substance use impaired the development of age- sensitive skills.

2. Previously developed coping skills may have been compromised by an increased reliance on substances use as a primary means of coping.

3. Some clients continue to use skills that are appropriate at an earlier age but are no longer appropriate or effective.

4. Others have appropriate coping skills available to them but are inhibited from using them. Relapse prevention stresses the development of a more balanced and healthier lifestyle. Relapse prevention approaches rely heavily on functional analysis, identification of high-risk situations, and coping skills training. Relapse prevention approaches deal directly with the cognitions involved in the relapse process and help the individual gain more positive self-efficacy expectancies. The therapist practicing CBT will also challenge the attributional process and emotional aftermath of a relapse. If a slip occurs, the therapist should try to bring the more negative attributions for relapse (internal, stable, and generalized) to the client’s attention. Clients can be helped to see the relapse as caused by a lack of appropriate coping skills for the particular situation (i.e., external), alterable with training or practice (i.e., unstable), and not implying that everything the person does is wrong (i.e., specific). Including family members in the planning process is important because they are often better able than the client to see the warning signs of an impending relapse.

Research

CBT has substantial research evidence in support of its effectiveness. Research with individuals dependent on alcohol, marijuana, opiates, and other illicit drugs, provides empirical support for the negative attributional style hypothesized to mediate the AVE.

Research on coping behavior has generally supported the basic tenet of CBT: 1. Clients are deficient in their coping skills. 2. These deficiencies contribute to their continued substance abuse. 3. Clients whose deficits are not remedied are at a greater risk of relapse than those who increase their coping through treatment. Research findings on the use of coping skills training with alcohol- and cocaine- dependent clients indicate that this strategy has strong empirical support

1. The number of coping attempts and the type of coping will influence both relapse and the return to abstinence. 2. Attempting to cope with a relapse crisis leads to higher rates of abstinence than not trying to cope. 3. The greater the number of coping strategies employed, the less likely the person is to use. 4. The greater the number of coping strategies used by an individual following a relapse, the greater the likelihood of returning to abstinence.

5. If one coping response was performed, the probability of abstinence was 40%; the probability rose to 80% if two coping attempts were made. Research generally supports the hypothesis that those with lower levels of self-efficacy are more likely to abuse substances. Research has consistently shown that people who expect positive effects from substances are more likely to abuse them. Men and women react with significantly different expectancies concerning substances. Males are more affected by positive expectancies, whereas females have more balanced expectancies about the positive and negative effects. Studies evaluating the efficacy of relapse prevention interventions indicate that the support for relapse prevention is less clear. Relapse prevention was found to be superior to no treatment, but the results have not been as consistent when it is compared to various control conditions or to other types of treatment. Although relapse prevention does not necessarily reduce the rate of relapse, clients treated in relapse prevention appear to have less severe relapses. Skills training approaches have been evaluated more than many other approaches to substance abuse disorders. Research findings on the use of coping skills training with clients dependent on alcohol and cocaine indicate that this strategy has strong empirical support. Types of Settings and Clients

Brief cognitive-behavioral therapy can be used with clients before, during, and after substance abuse treatment in individual, group, and family settings.

Brief cognitive-behavioral therapies are applicable in a wide range of substance abuse settings: 1. Outpatient 2. Inpatient 3. Individual therapy 4. Group settings 5. As part of an intensive phase of treatment 6. As part of less intensive aftercare or continuing care 7. Compatible with self-help groups 8. Compatible with pharmacotherapy Outpatient CBT is generally not appropriate for the following types of clients: 1. Those who have psychotic or bipolar disorders and are not stabilized on medication 2. Those who have no stable living arrangements 3. Those who are not medically stable (as assessed by a pretreatment physical examination) 4. Those who have concurrent substance dependence disorders, with the possible exception of alcohol or marijuana dependence Applications in Substance Abuse Treatment

CBT provides the basis for a more inclusive and comprehensive approach to treating substance abuse disorders. CBT uses learning processes to help individuals reduce their drug use. It helps clients recognize high-risk situations in which they are likely to use, find ways of avoiding those situations, and cope more effectively with situations, feelings, and behaviors related to their substance abuse.

Skills training approaches have been evaluated more than many other approaches to substance abuse disorders. Research findings on the use of coping skills training with clients dependent on alcohol and cocaine indicate that this strategy has strong empirical support. The number of coping attempts and the type of coping will influence both relapse and the return to abstinence. Individuals who are aware of and concerned about the negative consequences associated with substance abuse are less likely to use.

Duration of T h e r a p y

Two advantages of CBT are that it is relatively brief in duration and quite flexible in implementation.

CBT typically has been offered in 12-16 sessions, usually over 12 weeks. However, not all clients will respond in that amount of time. In such cases, an initial trial CBT can serve as preparatory to a more intensive treatment experience. A 12-session CBT program for cocaine addicts suggested that this length of treatment is sufficient to achieve and stabilize abstinence from cocaine.

Evaluation of Effectiveness

Evaluations can be done simply and efficiently, without requiring Excessive staff time and energy, or integrated into routine client contacts. Effectiveness evaluations can be conducted in person, by phone, through the Internet, or by mail. The effectiveness of brief therapy can be evaluated by: 1. Client participation 2. Treatment admissions 3. Discharge against medical advice rates 4. Client satisfaction surveys 5. Follow-up phone calls 6. Counselor-rating questions added to the clinical chart

Module 7 – Section 3

Strategy Identification Exercise Time: 10 Minutes

Trainer Notes ■ Turn off all noisy audio/visual equipment during small Time Clock group discussions. ■ Be aware of any external and internal distractions from the small group discussions. Trainer Notes

The trainer prepares participants for the strategy integration process. The purpose of this process is to encourage participants to develop new therapeutic skills for working with their clients.

The trainer invites participants to think about a particular client that would likely benefit from a brief cognitive behavioral therapy.

The participants review the handout for the Strategy Identification Exercise. This handout presents lists of strategies of the module topic, usually organized according to the basic conceptual models presented in the Summary Grid.

The trainer directs the participant to place a check (√) next to strategies s/he has used successfully in his/her practice, and to place a star (*) next to new strategies s/he wants to include in his/her clinical practice.

While the participants work on completing the Strategy Identification Exercise, the trainer is available to respond to questions and moves about the room to help participants.

The trainer facilitates a whole-group discussion about this exercise, asking participants to share which strategies they have successfully used with agency clients. Participants can later use staff members with successful experiences to help them integrate a new strategy into their own practice. Participant Workbook ■ Brief Cognitive-Behavioral Therapy Strategy Identification Exercise

Participant Workbook Trainer Script Strategy Identification Exercise The purpose of this training is to integrate new skills for brief therapy into our professional practice. You will begin this process by identifying one new strategy that you believe will be helpful for one of your current clients.

Please review the handout for Strategy Identification Exercise for Brief Cognitive-Behavioral Therapy. These strategies are based on the CBT models discussed earlier: 1. Behavioral Coping Strategies 2. Cognitive Coping Strategies 3. Active Coping Strategies 4. Avoidant Coping Strategies 5. Self-Efficacy Expectancies

6. Substance-Related Effect Expectancies 7. Intrapersonal–Environmental High-Risk Situations 8. Interpersonal High-Risk Situations 9. Relapse Prevention 10. Coping Skills Training 11. Intrapersonal Coping Skills 12. Interpersonal Coping Skills 13. Standardized Format for Coping Skills Training 14. Functional Analysis The handout directs you to place a check (√) next to strategies that you have used successfully in your practice, and to place a star (*) next to new strategies that you would like to include in your clinical practice. After completing this portion of the exercise, you select one new strategy (from the strategies with a star) to use with a current client.

This exercise gives us an opportunity to share successful experiences we have had with these brief therapy strategies. Please pay close attention to the expertise of our staff that is revealed in this exercise. You may want to recruit them to help you with your new strategy.

Who would like to share your successful brief therapy experiences Group Exercise with us?

Brie f C ogn i t iv e - B e h a vi o r i a l T h e r a p y 198 TIP 34: Brief Interventions and Brief Therapies for Substance Abuse Module 7 - Section 4 Strategy Identification Mind-Map Exercise Time: 10 Minutes

Trainer Notes ■ Turn off all noisy audio/visual equipment during small group discussions. Time Clock ■ Be aware of any external and internal distractions from the small group discussions. Participants work individually to complete this exercise.

While the participants are working on the Strategy Integration Mind- Map, the trainer is available to respond to questions and moves about the room to Trainer Notes help participants. The use of colored pencils or crayons with this exercise helps to enhance an atmosphere of creativity for brainstorming. Brainstorming is for developing ideas, not for evaluating them. The trainer encourages participants to help one another with a nonjudgmental attitude. When most of the participants have completed the mind-map, the trainer may invite volunteers to share their strategy and plan with the rest of the group. Maintaining the group rule regarding respect is very important in this discussion so as not to discourage a participant from executing his/her plan.

Participant Workbook ■ Strategy Integration Mind-Map

Trainer Script ■ Strategy Integration Mind-Map Exercise Introduction Participant Workbook You will develop a plan of action for utilizing your new strategy and evaluating its effectiveness. The Strategy Integration Mind-Map Exercise is used for this purpose. This is in your handout packet. The purpose of the Strategy Integration Mind-Map is to develop a plan about how you will integrate the selected new brief behavioral therapy skill into your clinical practice. You should select the ideas that are the best and most appropriate for

your client. Do not put the name of your client on this form. However, you may want to include this strategy in your client’s treatment plan.

Mind-Mapping Directions This exercise is a mind-map. Mind-mapping allows you to conceptualize the integration of a new strategy on one page, and in a manner that is more easily remembered than other forms of writing, such as outlines or lists. It uses brainstorming to encourage the generation of new ideas, and allows you to organize your thinking by fitting ideas together into a conceptual “map.” You can write or draw your ideas. You can have fun and be creative while you develop your ideas. The use of colors can help to separate different parts of your map. By personalizing the map with symbols and designs, you can develop a strategy that will be more easily remembered and used with your client. All ideas on the mind-map are related to the theme in the center. The ideas are connected to the central theme or to one another with lines or arrows to indicate their relationship. Key ideas for the strategy mind- map are suggested on the border of the exercise form. Write your selected new strategy in the center of the mind-map, and then – using pens, colored pencils, or crayons – place related ideas in boxes, circles, lists, or drawings that radiate from the center.

Group Exercise Would anyone volunteer to briefly share your strategy and mind-map with the rest of the group?

TIP 34: Brief Interventions and Brief Therapies for Substance Abuse Module 7 - Section 5 Assignments and Closing Time: 3 Minutes

Trainer Notes The trainer gives a brief preview of the next training topic. The trainer distributes the handout packet for the next training Time Clock session, and encourages the participants to read the Summary Grid and Strategy Identification Exercise before the training. The trainer discusses date, time, and place of the next training session. The trainer gives TIP 34 reading references for this training. Trainer Notes Participant Workbook ■ Handout Packet for Next TIP 34 Training

Participant Workbook Trainer Script

Reading and Homework Thank you for participating in this TIP 34 Training Program. Our next training module will explore [Training Topic].

Please read the Summary Grid and complete the Strategy Identification Exercise before the training. The TIP 34 references for this training are [relevant TIP 34 pages or chapter]. This training module is scheduled for [date, time, and place].

Participant Workbook

Module 7: Brief Cognitive-Behavioral Therapy

TIP 34: Brief Interventions and Brief Therapies for Substance Abuse Brief Cognitive Behavioral Therapy Summary Grid

Key Concepts ■ Brief cognitive-behavioral therapy (CBT) represents the integration of principles derived from both behavioral and cognitive theories, and has been described as cognitive social learning or cognitive – behavioral theory.

■ CBT tries to change what the client both does and thinks, and is mediational in nature.

■ A primary goal of CBT is to help the individual find a better lifestyle balance, increasing involvement in pleasant and rewarding activities while reducing the level and sources of stress.

■ One of the strengths of CBT is the ability to individually tailor the skills training to the needs of the client.

■ CBT postulates that cognitive factors mediate all interactions between the client, the demands of the situation, and the coping strategies used by the client.

■ The therapist focuses on current problems, and places a greater emphasis on learning and practicing a variety of coping skills, especially early in therapy.

■ The key ingredients that distinguish CBT from other some other therapies and that must be included in a CBT treatment include the following: 1. A functional analysis of substance abuse. 2. An examination of the cognitive processes related to substance abuse. 3. The identification and debriefing of past and future high-risk situations. 4. Individualized coping skills training for managing cravings, managing thoughts about substance abuse, problem solving, planning for emergencies, decision-making, and refusal skills. 5. Skills are practiced within sessions. 6. The use of skills outside the therapy session is encouraged and reviewed in the therapy session.

■ CBT establishes attainable and contracted goals, and seeks to obtain quick results for the most pressing problems. It relies on a variety of empirically based techniques to increase the client’s ability to handle his/her own problems. ■ Substance abuse is viewed as a learned behavior having functional utility for the individual. ■ The substance abuse treatment goal of CBT is to help the client develop and employ effective coping skills to meet the demands of high-risk situations without resorting to the use of substances.

203 Brief Cognitive-Behavioral Therapy

Models ■ A broader range of cognitions is included in cognitive–behavioral theory than had been involved in earlier versions of cognitive theory. These include attributions, appraisals, self-efficacy expectancies, and substance-related effect expectancies. ■ Attributions: 1. This refers to an individual’s explanation of why an event occurred. 2. Substance abusers’ attributional styles are thought to have considerable bearing on their perception of their substance abuse problems and their approaches to recovery. 3. Basic attributional dimensions: (1) internal/external, (2) stable/unstable, (3) global/specific. 4. Internal/External: Attributing events and their causes to self (internal) or to others (external). 5. Stable/Unstable: Believing that the event will continue to affect the future (stable), or that it can be changed or stopped (unstable). 6. Global/Specific: Believing that one bad circumstance affects all areas of one’s life (global) or just one (specific). 7. A negative attributional process generally involves internal, stable, and global dimensions, and is likely to lead to feelings of depression, hopelessness and relapse. 8. A healthier attributional process generally involves external, unstable, and specific dimensions, and is likely to lead to greater efforts to cope with high-risk situations in the future, abstinence and/or moderate use. ■ Abstinence Violation Effect (AVE): 1. AVE is a negative attributional process that can occur after a slip and that may lead to full relapse. 2. The cause of an initial slip is attributed to internal, stable, and global factors. 3. This attributional style tends to be associated with a form of “learned helplessness”. ■ Cognitive Appraisal: 1. This refers to an individual’s appraisal of stressful situations and his/her ability to cope with the demands of these situations.

2. Primary appraisal: the individual’s perception of a situation and an estimation of the potential level of stress, personal challenge, or threat involved with the situation. 3. Secondary appraisal: the individual’s evaluation of his/her ability to meet the challenges and demands specific to the situation. 4. The extent that the individual believes that s/he has the necessary behavioral, cognitive, or emotional coping skills to meet the challenges of the situation, s/he will appraise the situation as less or more threatening/stressful.

Brief Cognitive Behavioral Therapy 204

5. Cognitive appraisals may play a more prominent role than attributions in mediating emotional responses to potentially threatening situations.

■ Coping Behaviors: 1. “Coping” refers to what an individual does or thinks in a relapse crisis situation in order to handle the risk for renewed substance use. 2. The absence of coping skills causes problems to be viewed as threatening, stressful, and potentially unsolvable, and the individual uses substances as a means of coping. 3. Coping responses can occur within the affective, behavioral, and cognitive domains. 4. Dimensions of coping behaviors include: (1) emotion focused, (2) problem focused, (3) avoidant, (4) general, (5) craving focused, (6) anticipatory, (7) in the moment, and (8) restorative. 5. The number of coping attempts and the type of coping will influence both relapse and the return to abstinence. 6. A considerable degree of situational specificity exists in the coping process.

■ Self-Efficacy Expectancies: 1. This refers to an individual’s beliefs about his/her ability to successfully execute an appropriate response in order to cope with a given situation. 2. They are determined by the individual’s repertoire of coping skills and the appraisal of their relative effectiveness. 3. They influence the individual’s behavior through cognitive, motivational, and emotional systems. 4. Expectations of personal efficacy determine whether coping behavior will be initiated, the amount of effort that will be expended in attempting to cope, and how long a coping attempt will continue in the face of obstacles and aversive experiences. 5. Low levels of self-efficacy are related to substance use and an increased likelihood of relapse.

■ Substance-Related Effect Expectancies: 1. This represents the individual’s expectation that certain effects will predictably result from the use of certain substances. 2. Expectancies are based on observations of others’ substance abuse to cope with difficult situations, and personal experiences of the positive effects of substance use.

3. Substance use is reinforced by the positive effects of the substances on both feelings and behavior. 4. Anticipated positive effects of substances serve as an incentive or motivation to use such substances. 5. Negative expectancies are thought to act as a disincentive and reduce drinking or drug use.

■ High-Risk Situations: 1. Situations (e.g., the people, places, feelings, activities) are high–risk when they become conditioned cues that elicit a strong craving or desire to use a drug. 2. These settings represent situations in which substance use will be more likely to occur. 3. While there appears to be considerable overlap in high-risk situations across substances, there are also a number of substance-specific patterns. 4. Intrapersonal–Environmental High-Risk Situations (i.e., factors that are either internal to the individual or reactions to non-personal environmental events): Coping with negative emotional states; Coping with negative physical/physiological states; Enhancement of positive emotional states; Testing personal control; Giving in to temptations or urges. 5. Interpersonal High-Risk Situations (i.e., involving a present or recent interaction with someone else): Coping with interpersonal conflict; Social pressure to drink or use; Enhancement of positive emotional states.

■ CBT Model of the Relapse Process: 1. CBT assumes that over the course of time, substance abusers develop effect expectancies, and believe that substances have positive benefits that are more immediate and prominent than their negative consequences. 2. They come to rely on substances as a means of trying to cope with high-risk situations. 3. The sense of self-efficacy decreases to the extent that the individual is lacking in the coping skills necessary to deal with the demands of high-risk substance abuse or relapse situations. 4. As personal efficacy decreases, the anticipated positive effects of substance use increase and become more important. Under such conditions, the individual is likely to use. 5. When confronted by similar situations in the future, the likelihood of using continues to be quite high, unless new coping skills have been learned. 6. If an individual does not have the necessary restorative coping skills to deal with the impact of a negative attributional style, it is more likely that an initial slip will grow into a full relapse. 7. Substance use is less likely to occur and be less pronounced for individuals who are more firmly committed to the goal of abstinence or moderation and for individuals who have maintained such goals longer.

■ CBT incorporates three core elements: 1. Functional analysis 2. Coping skills training 3. Relapse prevention

Research

■ CBT has substantial research evidence in support of its effectiveness. ■ Research Outcomes Related to Attributions and AVE provide empirical support for the attributional style hypothesized to mediate the AVE. ■ Research Outcomes Related to Coping Behaviors: 1. Research on coping behavior has generally supported the basic tenet of CBT: (1) that clients are deficient in their coping skills, (2) that these deficiencies contribute to their continued substance abuse, and (3) that clients whose deficits are not remedied are at a greater risk of relapse than those who increase their coping through treatment. 2. The number of coping attempts and the type of coping will influence both relapse and the return to abstinence. 3. Attempting to cope with a relapse crisis leads to higher rates of abstinence than not trying to cope. 4. The greater the number of coping strategies employed, the less likely the person is to use. 5. The greater the number of coping strategies used by an individual following a relapse, the greater the likelihood of returning to abstinence. 6. If one coping response was performed, the probability of abstinence was 40%; the probability rose to 80% if two coping attempts were made. 7. Exclusive use of active coping strategies was associated with maintaining abstinence in contrast to exclusive reliance on avoidant strategies. 8. There appears to be a considerable degree of situational specificity in the coping process. Different types of substance-related situations seem to require different types of coping responses. 9. Treatment should not only rectify deficiencies in coping abilities, but focus on skills to deal with both general stress and substance-related temptation.

■ Research Outcomes Related to Self-Efficacy Expectancies generally support the hypothesis that those with lower levels of self-efficacy are more likely to abuse substances.

■ Research Outcomes Related to Substance-Related Effect Expectancies: 1. Research has consistently shown that people who expect positive effects from substances are more likely to abuse them. 2. Positive effect expectancies are associated with a greater likelihood of relapse, poorer outcomes, and lower self-efficacy.

3. Negative effect expectancies are related to decreased relapse and less consumption.

4. Men and women react with significantly different expectancies concerning substances: males are more affected by positive expectancies, whereas females have more balanced expectancies about the positive and negative effects.

■ Research Outcomes Related to High-Risk Situations: 1. Positive social experiences and negative emotional states were important risk factors for patients dependent on alcohol or cocaine. 2. Positive emotional and situational factors were most important for those using marijuana. 3. Negative physical states and interpersonal conflict were the most important risk factors for individuals dependent on sedatives and tranquilizers or heroin/opiates.

■ Research Outcomes Related to Relapse Prevention: 1. Studies evaluating the efficacy of relapse prevention interventions indicate that the support for relapse prevention is less clear. 2. Relapse prevention was found to be superior to no treatment, but the results have not been as consistent when it is compared to various control conditions or to other types of treatment. 3. Although relapse prevention does not necessarily reduce the rate of relapse, clients treated in relapse prevention appear to have less severe relapses.

■ Research Outcomes Related to Coping Skills Training: 1. Skills training approaches have been evaluated more than many other approaches to substance abuse disorders.

2. Research findings on the use of coping skills training with clients dependent on alcohol and cocaine indicate that this strategy has strong empirical support.

Types of Settings and Clients

■ CBT is applicable in a wide range of substance abuse treatment settings: 1. Outpatient 2. Inpatient 3. Individual therapy 4. Group settings 5. As part of an intensive phase of treatment 6. As part of less intensive aftercare or continuing care 7. Compatible with self-help groups 8. Compatible with pharmacotherapy

Brief Cognitive Behavioral Therapy 208 TIP 34: Brief Interventions and Brief Therapies for Substance Abuse

■ Types of clients for whom outpatient CBT is generally not appropriate: 1. Those who have psychotic or bipolar disorders and are not stabilized on medication 2. Those who have no stable living arrangements 3. Those who are not medically stable (as assessed by a pretreatment physical examination) 4. Those who have concurrent substance dependence disorders, with the possible exception of alcohol or marijuana dependence Applications in Substance Abuse Treatment

■ CBT has substantial research evidence in support of its effectiveness.

■ CBT provides the basis for a more inclusive and comprehensive approach to treating substance abuse disorders. ■ CBT uses learning processes to help individuals reduce their drug use. It helps clients recognize high- risk situations in which they are likely to use, find ways of avoiding those situations, and cope more effectively with situations, feelings, and behaviors related to their substance abuse. ■ Skills training approaches have been evaluated more than many other approaches to substance abuse disorders. Research findings on the use of coping skills training with clients dependent on alcohol and cocaine indicate that this strategy has strong empirical support. ■ The number of coping attempts and the type of coping will influence both relapse and the return to abstinence. ■ Individuals who are aware of and concerned about the negative consequences associated with substance abuse are less likely to use.

Duration of B r i e f Therapy

■ Two advantages of CBT are that it is relatively brief in duration and quite flexible in implementation.

■ CBT typically has been offered in 12 - 16 sessions, usually over 12 weeks. ■ However, not all clients will respond in that amount of time. In such cases, an initial trial CBT can serve as preparatory to a more intensive treatment experience.

Evaluation of Effectiveness

■ Evaluations can be done simply and efficiently, without requiring excessive staff time and energy, or integrated into routine client contacts. ■ Effectiveness evaluations can be conducted in person, by phone, through the Internet, or by mail.

■ The effectiveness of brief therapy can be evaluated by: 1. Client participation 2. Treatment admissions 3. Discharge against medical advice rates 4. Client satisfaction surveys 5. Follow-up phone calls 6. Counselor-rating questions added to the clinical chart

Sample Strategy Identification Exercise Brief Cognitive- Behavioral Therapy

■ Place a check (√) next to strategies that you have used successfully in your clinical practice.

■ Place a star (*) next to new strategies that you want to include in your clinical practice.

Behavioral Coping Strategies: ● Basic avoidance of situations that have been previously associated with substance abuse. ● Seek social support when confronted with the temptation to drink or use drugs. ● Anticipate and plan how to deal with upcoming situations (Anticipatory: “What can I do if...”). ● Cope with difficult, in-the-moment, substance-related situations (“What can I do now...”). ● Cope with a relapse situation (Restorative: “What can I do now that I’ve...”). These play a role in determining whether an initial use of drugs will escalate into a full relapse.

Cognitive Coping Strategies: ● Examine the client’s cognitive processes related to substance abuse ● Identify negative thinking ● Identify negative consequences that have resulted from substance abuse, and instill a desire to experience these no more.

● Identify positive thinking ● Identify all the benefits that are accrued by being clean and sober and instill a desire to experience these more

Active Coping Strategies: ● Engage in alternative activities that are incompatible with substance use. ● Use problem solving ● Seek support from others ● Think of the consequences of using ● Use positive/negative self-talk

Avoidant Coping Strategies: ● Ignore the situation

● Deal with it indirectly, such as by eating

● Rely on willpower

Self-Efficacy Expectancies: ● Help the client change passivity and sense of helplessness. ● The use of performance accomplishments appears to have the greatest impact and lasting influence in increasing self-efficacy. ● Coach the client to do something that s/he previously was unable to do. ● Gradually expose the client to increasingly difficult situations with greater relapse risk, but without using (the rate of the exposure is calculated to be at a level that the client can handle). ● Successful accomplishment of homework tasks reinforces the client’s growing sense of self- efficacy.

Substance-Related Effect Expectancies: ● Challenge social beliefs about the effects of a substance may alter its use ● Challenge the client’s positive expectancies about the effects of substances ● Change the client’s belief in the positive effects of the substance ● Pay attention to the client’s knowledge and experience of the negative effects of the substance ● Help the client acknowledge that other consequences exist that need attention ● Provide information on placebo effects ● Conduct a decisional balance procedure by having the client consider both the positive and negative effects of the substance ● Gain credibility and reduce client resistance by acknowledging the substance’s positive effects, then the client can more easily acknowledge the negative aspects of substance abuse and make those beliefs more prominent

Intrapersonal–Environmental High-Risk Situations: ● Identify and debrief past and future high-risk situations. ● Help the client cope with negative emotional states (e.g., frustration, anger, fear, anxiety, tension, depression, loneliness, sadness, boredom, grief, loss, or guilt). ● Help the client cope with negative physical/physiological states associated with substance abuse (e.g., pain, illness, injury, or fatigue). ● Help the client enhance positive emotional states (e.g., using substances to enhance pleasure, or for celebration) associated with substance abuse

● Help the client test personal control (e.g., using substances to test “willpower,” to see if treatment worked, or to see if one can drink or use in a moderate way)

Interpersonal High-Risk Situations: ● Help the client cope with frustration, anger, or other interpersonal conflict ● Help the client cope with direct and indirect social pressure to drink or use drugs ● Help the client enhance positive emotional states

Relapse Prevention: ● Educate the client about the relapse process ● Prepare the client for the possibility of a relapse ● Help the client to plan ways to avoid relapse ● Help the client stop the relapse process quickly and with minimal harm when it does occur ● Help the client conduct a decisional balance procedure ● Help the client develop concrete emergency plans and use an analogy of fire drills and preparing for emergencies ● Help the client include family members in the planning process ● Coach the client to do something that s/he previously was unable to do ● Challenge the attributional process and emotional aftermath of a relapse ● Bring the negative attributions for relapse (internal, stable, and generalized) to the client’s attention ● Reduce the client’s sense of helplessness and loss of control ● Stress the development of a more balanced and healthier lifestyle

Coping Skills Training: ● Help the client recognize high-risk situations and develop more effective means of coping with them ● Help the client recognize and cope with cravings ● Help the client manage thoughts about substance abuse ● Help the client use substance refusal skills ● Encourage and review the implementation of skills outside of therapy sessions ● Use published manuals to guide skills training

Intrapersonal Coping Skills: ● Help the client use decision making skills ● Help the client use relaxation training and stress management

● Encourage the awareness and management of anger ● Encourage the awareness and management of negative thinking ● Help the client increase pleasant activities ● Help the client cope with persistent problems

Interpersonal Coping Skills: ● Help the client use communication skills ● Help the client cope with anger or depression ● Help the client refuse offers to drink or use drugs ● Help the client start conversations ● Help the client a ppropriate body language ● Help the client give and receive compliments ● Help the client use assertiveness training

● Help the client communicate emotions ● Help the client communicate in intimate relationships ● Help the client give and receive criticism ● Help the client enhance social support networks

Standardized Format for Coping Skills Training: ● Provide an overview of the session, describe the area to be addressed and the rationale for the specific intervention to be used ● Provide skill guidelines for the most important aspects of the CBT approach ● Model the effective coping skill for the particular topic ● Ask the client to participate in a role-playing scenario in which s/he can rehearse the new coping behaviors ● Provide feedback and guidance while the client continues to rehearse the behavior ● Give homework assignments that provide the client with an opportunity to try behaviors in real-life settings ● In the following session, begin with a review of this homework and the client’s reactions to it

Functional Analysis of Substance Abuse: ● Identify the antecedents and consequences of substance abuse behavior ● Assess features in client’s emotions, thoughts, and environment that are highly associated with substance abuse

● Assess the client’s coping abilities, self-efficacy perceptions, substance-related effect expectancies, and attributional processes ● Identify situations that are particularly high-risk for the individual ● Determine the client’s thoughts, feelings, and behaviors during and after high-risk situations ● Gain information about high-risk situations in which a relapse crisis was encountered but averted ● Identify and remediate deficits in coping skills ● Identify the number, range, and effectiveness of the client’s coping skills

● Assess the client’s strengths and adaptive skills ● Anticipate high-risk situations and develop specific methods to avoid or cope with them