LeaderLeader’’ss GuideGuide CognitiveCognitive BehaviouralBehavioural && RelapseRelapse PreventionPrevention StrategiesStrategies
Treatnet Training Volume B, Module 3: Updated 18 September 2007 1 TrainingTraining goalsgoals
1. IncreaseIncrease knowledgeknowledge ofof cognitivecognitive behaviouralbehavioural therapytherapy (CBT)(CBT) andand relapserelapse preventionprevention (RP)(RP) strategiesstrategies andand resources.resources.
2. IncreaseIncrease skillsskills usingusing CBTCBT andand RPRP strategiesstrategies andand resources.resources.
3. IncreaseIncrease applicationapplication ofof CBTCBT andand RPRP strategiesstrategies forfor substancesubstance abuseabuse treatmenttreatment
2 ModuleModule 3:3: WorkshopsWorkshops
WorkshopWorkshop 1:1: BasicBasic ConceptsConcepts ofof CBTCBT andand RPRP WorkshopWorkshop 2:2: CognitiveCognitive BehaviouralBehavioural StrategiesStrategies WorkshopWorkshop 3:3: MethodsMethods forfor UsingUsing CognitiveCognitive BehaviouralBehavioural StrategiesStrategies
3 WorkshopWorkshop 1:1: BasicBasic ConceptsConcepts ofof CBTCBT andand RPRP
4 PrePre--assessmentassessment 10 Min.
PleasePlease respondrespond toto thethe prepre--assessmentassessment questionsquestions inin youryour workbook.workbook.
(Your(Your responsesresponses areare strictlystrictly confidential.)confidential.)
5 IcebreakerIcebreaker
IfIf youyou hadhad toto movemove toto anan uninhabiteduninhabited island,island, whatwhat 33 thingsthings wouldwould youyou taketake withwith youyou andand why?why? (food(food andand waterwater areare provided)provided)
6 TrainingTraining objectivesobjectives
At the end of this workshop, you will: 1. Understand that substance use is a learned behaviour that 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 know about the 5 Ws of a client’s drug use
7 WhatWhat areare CognitiveCognitive BehaviouralBehavioural TherapyTherapy (CBT)(CBT) andand RelapseRelapse PreventionPrevention (RP)?(RP)?
8 WhatWhat isis CBTCBT andand howhow isis itit usedused inin addictionaddiction treatment?treatment?
¾ CBTCBT isis aa formform ofof ““talktalk therapytherapy”” thatthat isis usedused toto teach,teach, encourage,encourage, andand supportsupport individualsindividuals aboutabout howhow toto reducereduce // stopstop theirtheir harmfulharmful drugdrug use.use.
¾ CBTCBT providesprovides skillsskills thatthat areare valuablevaluable inin assistingassisting peoplepeople inin gaininggaining initialinitial abstinenceabstinence fromfrom drugsdrugs (or(or inin reducingreducing theirtheir drugdrug use).use).
¾ CBTCBT alsoalso providesprovides skillsskills toto helphelp peoplepeople sustainsustain abstinenceabstinence (relapse(relapse prevention)prevention)
9 WhatWhat isis relapserelapse preventionprevention (RP)?(RP)?
BroadlyBroadly conceived,conceived, RPRP isis aa cognitivecognitive--behaviouralbehavioural treatmenttreatment (CBT)(CBT) withwith aa focusfocus onon thethe maintenancemaintenance stagestage ofof addictiveaddictive behaviourbehaviour changechange thatthat hashas twotwo mainmain goals:goals: ToTo preventprevent thethe occurrenceoccurrence ofof initialinitial lapseslapses afterafter aa commitmentcommitment toto changechange hashas beenbeen mademade andand ToTo preventprevent anyany lapselapse thatthat doesdoes occuroccur fromfrom escalatingescalating intointo aa fullfull--blowblow relapserelapse BecauseBecause ofof thethe commoncommon elementselements ofof RPRP andand CBT,CBT, wewe willwill referrefer toto allall ofof thethe materimaterialal inin thisthis trainingtraining modulemodule asas CBTCBT
10 FoundationFoundation ofof CBT:CBT: SocialSocial LearningLearning TheoryTheory
CognitiveCognitive behaviouralbehavioural therapytherapy (CBT)(CBT) ¾¾ProvidesProvides criticalcritical conceptsconcepts ofof addictionaddiction andand howhow toto notnot useuse drugsdrugs ¾¾EmphasisesEmphasises thethe developmentdevelopment ofof newnew skillsskills ¾¾InvolvesInvolves thethe masterymastery ofof skillsskills throughthrough practisepractise
11 WhyWhy isis CBTCBT useful?useful? (1)(1)
¾ CBTCBT isis aa counselingcounseling--teachingteaching approachapproach wellwell--suitedsuited toto thethe resourceresource capabilitiescapabilities ofof mostmost clinicalclinical programsprograms
¾ CBTCBT hashas beenbeen extensivelyextensively evaluatedevaluated inin rigorousrigorous clinicalclinical trialstrials andand hashas solidsolid empiricalempirical supportsupport
¾ CBTCBT isis structured,structured, goalgoal--oriented,oriented, andand focusedfocused onon thethe immediateimmediate problemsproblems facedfaced byby substancesubstance abusersabusers enteringentering treatmenttreatment whowho areare strugglingstruggling toto controlcontrol theirtheir useuse
12 WhyWhy isis CBTCBT useful?useful? (2)(2)
¾ CBTCBT isis aa flexible,flexible, individualizedindividualized approachapproach thatthat cancan bebe adaptedadapted toto aa widewide rangerange ofof clientsclients asas wellwell asas aa varietyvariety ofof settingssettings (inpatient,(inpatient, outpatient)outpatient) andand formatsformats (group,(group, individual)individual)
¾ CBTCBT isis compatiblecompatible withwith aa rangerange ofof otherother treatmentstreatments thethe clientclient maymay receive,receive, suchsuch asas pharmacotherapypharmacotherapy
13 ImportantImportant conceptsconcepts inin CBTCBT (1)(1)
InIn thethe earlyearly stagesstages ofof CBTCBT treatment,treatment, strategiesstrategies stressstress behaviouralbehavioural change.change. StrategiesStrategies include:include:
¾ planningplanning timetime toto engageengage inin nonnon--drugdrug relatedrelated behaviourbehaviour
¾ avoidingavoiding oror leavingleaving aa drugdrug--useuse situation.situation.
14 ImportantImportant conceptsconcepts inin CBTCBT (2)(2)
CBTCBT attemptsattempts toto helphelp clients:clients:
Follow a planned schedule of low-risk activities Recognise drug use (high-risk) situations and avoid these situations Cope more effectively with a range of problems and problematic behaviours associated with using
15 ImportantImportant conceptsconcepts inin CBTCBT (3)(3)
AsAs CBTCBT treatmenttreatment continuescontinues intointo laterlater phasesphases ofof recovery,recovery, moremore emphasisemphasis isis givengiven toto thethe ““cognitivecognitive”” partpart ofof CBT.CBT. ThisThis includes: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
16 FoundationsFoundations ofof CBTCBT
TheThe learninglearning andand conditioningconditioning principlesprinciples involvedinvolved inin CBTCBT are:are:
¾ClassicalClassical conditioningconditioning
¾OperantOperant conditioningconditioning
¾ModellingModelling
17 ClassicalClassical conditioning:conditioning: ConceptsConcepts
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).
=
18 ClassicalClassical conditioning:conditioning: AddictionAddiction
¾ RepeatedRepeated pairingspairings ofof particularparticular events,events, emotionalemotional states,states, oror cuescues withwith substancesubstance useuse cancan produceproduce cravingcraving forfor thatthat substancesubstance
¾ OverOver time,time, drugdrug oror alcoholalcohol useuse isis pairedpaired withwith cuescues suchsuch asas money,money, paraphernalia,paraphernalia, particularparticular places,places, people,people, timetime ofof day,day, emotionsemotions
¾ Eventually,Eventually, exposureexposure toto cuescues alonealone producesproduces drugdrug oror alcoholalcohol cravingscravings oror urgesurges thatthat areare oftenoften followedfollowed byby substancesubstance abuseabuse
19 ClassicalClassical conditioning:conditioning: ApplicationApplication toto CBTCBT techniquestechniques (1)(1)
¾ UnderstandUnderstand andand identifyidentify ““triggerstriggers”” (conditioned(conditioned cues)cues) ¾ UnderstandUnderstand howhow andand whywhy ““drugdrug cravingcraving”” occursoccurs
20 ClassicalClassical conditioning:conditioning: ApplicationApplication toto CBTCBT techniquestechniques (2)(2)
¾ LearnLearn strategiesstrategies toto avoidavoid exposureexposure toto triggerstriggers ¾ CopeCope withwith cravingcraving toto reducereduce // eliminateeliminate conditionedconditioned cravingcraving overover timetime
21 OperantOperant conditioning:conditioning: AddictionAddiction (1)(1)
DrugDrug useuse isis aa behaviourbehaviour thatthat isis reinforcedreinforced byby thethe positivepositive reinforcementreinforcement thatthat occursoccurs fromfrom thethe pharmacologicpharmacologic propertiesproperties ofof thethe drug.drug.
22 OperantOperant conditioning:conditioning: AddictionAddiction (2)(2)
OnceOnce aa personperson isis addicted,addicted, drugdrug useuse isis reinforcedreinforced byby thethe negativenegative reinforcementreinforcement ofof removingremoving oror avoidingavoiding painfulpainful withdrawalwithdrawal symptoms.symptoms.
23 OperantOperant conditionsconditions (1)(1)
PositivePositive reinforcementreinforcement strengthensstrengthens aa particularparticular behaviourbehaviour (e.g.,(e.g., pleasurablepleasurable effectseffects fromfrom thethe pharmacologypharmacology ofof thethe drug;drug; peerpeer acceptance)acceptance)
24 OperantOperant conditionsconditions (2)(2)
PunishmentPunishment isis aa negativenegative conditioncondition thatthat decreasesdecreases thethe occurrenceoccurrence ofof aa particularparticular behaviourbehaviour (e.g.,(e.g., IfIf youyou sellsell drugs,drugs, youyou willwill gogo toto jail.jail. IfIf youyou taketake tootoo largelarge aa dosedose ofof drugs,drugs, youyou cancan overdose.)overdose.)
25 OperantOperant conditionsconditions (3)(3)
Negative reinforcement occurs when a particular behaviour gets stronger by avoiding or stopping a negative condition (e.g., If you are having unpleasant withdrawalwithdrawal symptoms, you can reduce them by taking drugs.).
26 OperantOperant conditioning:conditioning: ApplicationApplication toto CBTCBT techniquestechniques
¾ FunctionalFunctional AnalysisAnalysis –– identifyidentify highhigh-- riskrisk situationssituations andand determinedetermine reinforcersreinforcers
¾ ExamineExamine longlong-- andand shortshort--termterm consequencesconsequences ofof drugdrug useuse toto reinforcereinforce resolveresolve toto bebe abstinentabstinent
¾ ScheduleSchedule timetime andand receivereceive praisepraise
¾ DevelopDevelop meaningfulmeaningful alternativealternative reinforcersreinforcers toto drugdrug useuse
27 Modelling:Modelling: DefinitionDefinition
ModellingModelling:: ToTo imitateimitate someonesomeone oror toto followfollow thethe exampleexample ofof someone.someone. InIn behaviouralbehavioural psychologypsychology terms,terms, modellingmodelling isis aa processprocess inin whichwhich oneone personperson observesobserves thethe behaviourbehaviour ofof anotheranother personperson andand subsequentlysubsequently copiescopies thethe behaviour.behaviour.
28 BasisBasis ofof substancesubstance useuse disorders:disorders: ModellingModelling
WhenWhen appliedapplied toto drugdrug addiction,addiction, modellingmodelling isis aa majormajor factorfactor inin thethe initiationinitiation ofof drugdrug use.use. ForFor example,example, youngyoung childrenchildren experimentexperiment withwith cigarettescigarettes almostalmost entirelyentirely becausebecause theythey areare modellingmodelling adultadult behaviour.behaviour. DuringDuring adolescence,adolescence, modellingmodelling isis oftenoften thethe majormajor elementelement inin howhow peerpeer drugdrug useuse cancan promotepromote initiationinitiation intointo drugdrug experimentation.experimentation.
29 Modelling:Modelling: ApplicationApplication toto CBTCBT techniquestechniques
¾ ClientClient learnslearns newnew behavioursbehaviours throughthrough rolerole-- playsplays ¾ DrugDrug refusalrefusal skillsskills ¾ WatchingWatching clinicianclinician modelmodel newnew strategiesstrategies ¾ PractisingPractising thosethose strategiesstrategies
Observe how I say “NO!”
NO thanks, I do not smoke
30 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: FunctionalFunctional AnalysisAnalysis // thethe 55 WsWs
31 TheThe firstfirst stepstep inin CBT:CBT: HowHow doesdoes drugdrug useuse fitfit intointo youryour life?life?
¾ OneOne ofof thethe firstfirst taskstasks inin conductingconducting CBTCBT isis toto learnlearn thethe detailsdetails ofof aa clientclient’’ss drugdrug use.use. ItIt isis notnot enoughenough toto knowknow thatthat theythey useuse drugsdrugs oror aa particularparticular typetype ofof drug.drug.
¾ ItIt isis criticalcritical toto knowknow howhow thethe drugdrug useuse isis connectedconnected withwith otherother aspectsaspects ofof aa clientclient’’ss life.life. ThoseThose detailsdetails areare criticalcritical toto creatingcreating aa usefuluseful treatmenttreatment plan.plan.
32 TheThe 55 WsWs (functional(functional analysis)analysis)
TheThe 55 WsWs ofof aa personperson’’ss drugdrug useuse (also(also calledcalled aa functionalfunctional analysis)analysis) When?When?
Where?Where?
Why?Why?
WithWith // fromfrom whom?whom?
WhatWhat happened?happened?
33 TheThe 55 WsWs
PeoplePeople addictedaddicted toto drugsdrugs dodo notnot useuse themthem atat random.random. ItIt isis importantimportant toto know: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)
34 QuestionsQuestions cliniciansclinicians cancan useuse toto learnlearn thethe 55 WsWs
¾ WhatWhat waswas goinggoing onon beforebefore youyou used?used? ¾ HowHow werewere youyou feelingfeeling beforebefore youyou used?used? ¾ HowHow // wherewhere diddid youyou obtainobtain andand useuse drugs?drugs? ¾ WithWith whomwhom diddid youyou useuse drugs?drugs? ¾ WhatWhat happenedhappened afterafter youyou used?used? ¾ WhereWhere werewere youyou whenwhen youyou beganbegan toto thinkthink aboutabout using?using?
35 Functional Analysis or High-Risk Situations Record
Antecedent Thoughts Feelings and Behaviour Consequences Situation Sensations
Where was I? What was I How was I What did I do? What thinking? feeling? happened What did I use? after?
Who was with How much did I me? What signals use? How did I feel did I get from right after? my body? What paraphernalia What was did I use? How did other happening? people react to my behaviour? What did other people around me do at the Any other time? consequences ? ActivityActivity 3:3: RoleRole--playplay ofof aa functionalfunctional analysisanalysis 25 Min.
ScriptScript 11 ConductConduct aa rolerole--playplay ofof aa functionalfunctional analysis:analysis: 1.1. ReviewReview 55 WsWs withwith clientclient 2.2. ProvideProvide analysisanalysis ofof howhow thisthis informationinformation willwill guideguide treatmenttreatment planningplanning
37 ? ? ? Questions?Questions?
Comments?Comments?
38 ThankThank youyou forfor youryour time!time!
EndEnd ofof WorkshopWorkshop 11
39 WorkshopWorkshop 2:2: CognitiveCognitive BehaviouralBehavioural StrategiesStrategies
40 TrainingTraining objectivesobjectives
At the end of this workshop, you will be able to: 1. Identify a minimum of 4 cognitive behavioural techniques 2. Understand how to identify triggers and high- and low- risk situations 3. Understand craving and techniques to cope with craving 4. Present and practise drug refusal skills 5. Understand the abstinence violation syndrome and how to explain it to clients 6. Understand how to promote non-drug-related behavioural alternatives
41 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: FunctionalFunctional AnalysisAnalysis && TriggersTriggers andand CravingCraving
42 ““TriggersTriggers”” (conditioned(conditioned cues)cues)
¾ OneOne ofof thethe mostmost importantimportant purposespurposes ofof thethe 55 WsWs exerciseexercise isis toto learnlearn aboutabout thethe people,people, places,places, things,things, times,times, andand emotionalemotional statesstates thatthat havehave becomebecome associatedassociated withwith drugdrug useuse forfor youryour client.client. ¾ TheseThese areare referredreferred toto asas ““triggerstriggers”” (conditioned(conditioned cues).cues).
43 ““TriggersTriggers”” forfor drugdrug useuse
¾ AA ““triggertrigger”” isis aa ““thingthing”” oror anan eventevent oror aa timetime periodperiod thatthat hashas beenbeen associatedassociated withwith drugdrug useuse inin thethe pastpast
¾ TriggersTriggers cancan includeinclude people,people, places,places, things,things, timetime periods,periods, emotionalemotional statesstates
¾ TriggersTriggers cancan stimulatestimulate thoughtsthoughts ofof drugdrug useuse andand cravingcraving forfor drugsdrugs
44 ExternalExternal triggerstriggers
¾ PeoplePeople:: drugdrug dealers,dealers, drugdrug--usingusing friendsfriends
¾ PlacesPlaces:: bars,bars, parties,parties, drugdrug useruser’’ss house,house, partsparts ofof towntown wherewhere drugsdrugs areare usedused
¾ ThingsThings:: drugs,drugs, drugdrug paraphernalia,paraphernalia, money,money, alcohol,alcohol, moviesmovies withwith drugdrug useuse
¾ TimeTime periodsperiods:: paydays,paydays, holidays,holidays, periodsperiods ofof idleidle time,time, afterafter work,work, periodsperiods ofof stressstress
45 InternalInternal triggerstriggers
¾ AnxietyAnxiety ¾ AngerAnger ¾ FrustrationFrustration ¾ SexualSexual arousalarousal ¾ ExcitementExcitement ¾ BoredomBoredom ¾ FatigueFatigue ¾ HappinessHappiness
46 TriggersTriggers && CravingsCravings
Trigger Thought Craving Use
47 Activity 3: Role-playing Activity 3: Role-playing 35 Min.
UsingUsing thethe InternalInternal andand ExternalExternal TriggerTrigger Worksheets:Worksheets: Observe the role-play and how the clinician identifies triggers. Practise the role-play for 10 minutes
48 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: HighHigh--RiskRisk && LowLow--RiskRisk SituationsSituations
49 HighHigh-- andand lowlow--riskrisk situationssituations (1)(1)
¾¾ SituationsSituations thatthat involveinvolve triggerstriggers andand havehave beenbeen highlyhighly associatedassociated withwith drugdrug useuse areare referredreferred toto asas highhigh--riskrisk situations.situations.
¾¾ OtherOther places,places, people,people, andand situationssituations thatthat havehave nevernever beenbeen associatedassociated withwith drugdrug useuse areare referredreferred toto asas lowlow--riskrisk situations.situations.
50 HighHigh-- andand lowlow--riskrisk situationssituations (2)(2)
AnAn importantimportant CBTCBT conceptconcept isis toto teachteach clientsclients toto decreasedecrease theirtheir timetime inin highhigh--riskrisk situationssituations andand increaseincrease theirtheir timetime inin lowlow-- riskrisk situations.situations.
51 Activity 4: Role-playing Activity 4: Role-playing 35 Min.
UsingUsing thethe ““highhigh--riskrisk vs.vs. lowlow--riskrisk”” continuumcontinuum (see(see TriggersTriggers charts),charts), useuse informationinformation fromfrom thethe functionalfunctional analysisanalysis (5Ws)(5Ws) andand thethe triggertrigger analysisanalysis toto constructconstruct aa highhigh--riskrisk vs.vs. lowlow--riskrisk exercise.exercise. RoleRole--playplay thethe constructionconstruction ofof aa highhigh-- vs.vs. lowlow--riskrisk analysis.analysis.
52 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: StrategiesStrategies toto CopeCope withwith CravingCraving
53 UnderstandingUnderstanding cravingcraving
CravingCraving (definition)(definition) ¾ ToTo havehave anan intenseintense desiredesire forfor ¾ ToTo needneed urgently;urgently; requirerequire ManyMany peoplepeople describedescribe cravingcraving asas similarsimilar toto aa hungerhunger forfor foodfood oror thirstthirst forfor water.water. ItIt isis aa combinationcombination ofof thoughtsthoughts andand feelings.feelings. ThereThere isis aa powerfulpowerful physiologicalphysiological componentcomponent toto cravingcraving thatthat makesmakes itit aa veryvery powerfulpowerful eventevent andand veryvery difficultdifficult toto resist.resist.
54 Craving:Craving: DifferentDifferent forfor differentdifferent peoplepeople
CravingsCravings oror urgesurges areare experiencedexperienced inin aa varietyvariety ofof waysways byby differentdifferent clients.clients. ForFor some,some, thethe experienceexperience isis primarilyprimarily somatic.somatic. ForFor example,example, ““II justjust getget aa feelingfeeling inin mymy stomach,stomach,”” oror ““MyMy heartheart races,races,”” oror ““II startstart smellingsmelling it.it.”” ForFor others,others, cravingcraving isis experiencedexperienced moremore cognitivelycognitively.. ForFor example,example, ““II needneed itit nownow”” oror ““II cancan’’tt getget itit outout ofof mymy headhead”” oror ““ItIt callscalls me.me.””
55 CopingCoping withwith cravingcraving
¾ ManyMany clientsclients believebelieve thatthat onceonce theythey beginbegin toto cravecrave drugs,drugs, itit isis inevitableinevitable thatthat theythey willwill use.use. InIn theirtheir experience,experience, theythey alwaysalways ““givegive inin”” toto thethe cravingcraving asas soonsoon asas itit beginsbegins andand useuse drugs.drugs.
¾ InIn CBT,CBT, itit isis importantimportant toto givegive clientsclients toolstools toto resistresist cravingcraving
56 TriggersTriggers && cravingscravings
Trigger
Thought
Craving
Use 57 StrategiesStrategies toto copecope withwith cravingcraving
CopingCoping withwith Craving:Craving: 1.1. EngageEngage inin nonnon--drugdrug--relatedrelated activityactivity 2.2. TalkTalk aboutabout cravingcraving 3.3. ““SurfSurf”” thethe cravingcraving 4.4. ThoughtThought stoppingstopping 5.5. ContactContact aa drugdrug--freefree friendfriend oror counsellorcounsellor 6.6. PrayPray
58 Activity 5: Role-playing Activity 5: Role-playing 20 Min.
UseUse thethe ““TriggerTrigger--ThoughtThought--CravingCraving--UseUse”” sheetsheet toto educateeducate clientsclients aboutabout cravingcraving andand discussdiscuss methodsmethods forfor copingcoping withwith craving.craving. RoleRole--playplay aa discussiondiscussion ofof techniquestechniques toto copecope withwith craving.craving.
59 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: DrugDrug RefusalRefusal SkillsSkills——HowHow toto SaySay ““NoNo””
60 HowHow toto saysay ““NoNo””:: DrugDrug refusalrefusal skillsskills
¾ OneOne ofof thethe mostmost commoncommon relapserelapse situationssituations isis whenwhen aa clientclient isis offeredoffered drugsdrugs byby aa friendfriend oror aa dealer.dealer.
¾ ManyMany findfind thatthat theythey dondon’’tt knowknow howhow toto saysay ““No.No.””
¾ Frequently,Frequently, theirtheir ineffectiveineffective mannermanner ofof dealingdealing withwith thisthis situationsituation cancan resultresult inin useuse ofof drugs.drugs.
61 DrugDrug refusalrefusal skills:skills: KeyKey elementselements
ImprovingImproving refusalrefusal skills/assertiveness:skills/assertiveness: ThereThere areare severalseveral basicbasic principlesprinciples inin effectiveeffective refusalrefusal ofof drugs:drugs: 1. Respond rapidly (not hemming and hawing, not hesitating) 2. Have good eye contact 3. Respond with a clear and firm “No” that does not leave the door open to future offers of drugs 4. Make the conversation brief 5. Leave the situation
62 DrugDrug refusalrefusal skills:skills: TeachingTeaching methodsmethods
AfterAfter reviewingreviewing thethe basicbasic refusalrefusal skills,skills, clientsclients shouldshould practisepractise themthem throughthrough rolerole-- playing,playing, andand problemsproblems inin assertiveassertive refusalsrefusals shouldshould bebe identifiedidentified andand discussed.discussed. 1. Pick an actual situation that occurred recently for the client. 2. Ask client to provide some background on the target person.
63 RoleRole--play:play: DrugDrug--offeroffer situationsituation
RoleRole--playplay aa situationsituation wherewhere aa drugdrug useruser friendfriend (or(or dealer)dealer) makesmakes anan offeroffer toto givegive oror getget drugs.drugs. RoleRole--playplay anan ineffectiveineffective responseresponse andand rolerole--playplay anan effectiveeffective useuse ofof howhow toto saysay ““No.No.””
64 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: PreventingPreventing thethe AbstinenceAbstinence ViolationViolation EffectEffect
65 AbstinenceAbstinence ViolationViolation SyndromeSyndrome
IfIf aa clientclient slipsslips andand usesuses drugsdrugs afterafter aa periodperiod ofof abstinence,abstinence, oneone ofof twotwo thingsthings cancan happen.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.
66 AbstinenceAbstinence ViolationViolation Syndrome:Syndrome: WhatWhat peoplepeople saysay
¾ One lapse means a total failure. ¾ I’ve blown everything now! I may as well keep using. ¾ I am responsible for all bad things. ¾ I am hopeless. ¾ Once a drunk / junkie, always a drunk / junkie. ¾ I’m busted now, I’ll never get back to being straight again. ¾ I have no willpower…I’ve lost all control. ¾ I’m physically addicted to this stuff. I always will be.
67 PreventingPreventing thethe AbstinenceAbstinence ViolationViolation SyndromeSyndrome
ClientsClients needneed toto knowknow thatthat ifif theythey slipslip andand useuse drugsdrugs // alcohol,alcohol, itit doesdoes notnot meanmean thatthat theythey willwill returnreturn toto fullfull--timetime addiction.addiction. TheThe clinicianclinician cancan helphelp themthem ““reframereframe”” thethe drugdrug--useuse eventevent andand preventprevent aa lapselapse inin abstinenceabstinence fromfrom turningturning intointo aa fullfull returnreturn toto addiction.addiction.
68 AbstinenceAbstinence violationviolation effect:effect: ExamplesExamples ofof ““reframingreframing”” (1)(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.
69 AbstinenceAbstinence violationviolation effect:effect: ExamplesExamples ofof ““reframingreframing”” (2)(2)
Learning to get sober is like riding a bicycle. Mistakes will be made. It is important to get back up and keep trying.
70 AbstinenceAbstinence violationviolation effect:effect: ExamplesExamples ofof ““reframingreframing”” (3)(3)
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.
71 CBTCBT TechniquesTechniques forfor AddictionAddiction Treatment:Treatment: MakingMaking LifestyleLifestyle ChangesChanges
72 DevelopingDeveloping newnew nonnon--drugdrug--relatedrelated behaviours:behaviours: MakingMaking lifestylelifestyle changeschanges
¾¾CBTCBT techniquestechniques toto stopstop drugdrug useuse mustmust bebe accompaniedaccompanied byby instructionsinstructions andand encouragementencouragement toto beginbegin somesome newnew alternativealternative activities.activities. ¾¾ManyMany clientsclients havehave poorpoor oror nonnon--existentexistent repertoiresrepertoires ofof drugdrug--freefree activities.activities. ¾¾EffortsEfforts toto ““shapeshape andand reinforcereinforce”” attemptsattempts toto trytry newnew behavioursbehaviours oror returnreturn toto previousprevious nonnon--drugdrug-- relatedrelated behaviourbehaviour isis partpart ofof CBT.CBT.
73 ? ? ? Questions?Questions?
Comments?Comments?
74 ThankThank youyou forfor youryour time!time!
EndEnd ofof WorkshopWorkshop 22
75 WorkshopWorkshop 3:3: MethodsMethods forfor UsingUsing CognitiveCognitive BehaviouralBehavioural StrategiesStrategies
76 TrainingTraining objectivesobjectives
AtAt thethe endend ofof thisthis workshop,workshop, youyou willwill bebe ableable to:to: 1.1. UnderstandUnderstand thethe clinicianclinician’’ss rolerole inin CBTCBT 2.2. StructureStructure aa sessionsession 3.3. ConductConduct aa rolerole--playplay establishingestablishing aa clinicianclinician’’ss rapportrapport withwith thethe clientclient 4.4. ScheduleSchedule andand constructconstruct aa 2424--hourhour behaviouralbehavioural planplan
77 RoleRole ofof thethe ClinicianClinician inin CBTCBT
78 TheThe clinicianclinician’’ss rolerole
ToTo teachteach thethe clientclient andand coachcoach herher oror himhim towardstowards learninglearning newnew skillsskills forfor behaviouralbehavioural changechange andand selfself--control.control.
79 TheThe rolerole ofof thethe clinicianclinician inin CBTCBT
¾ CBTCBT isis aa veryvery activeactive formform ofof counsellingcounselling..
¾ AA goodgood CBTCBT clinicianclinician isis aa teacher,teacher, aa coach,coach, aa ““guideguide”” toto recovery,recovery, aa sourcesource ofof reinforcementreinforcement andand support,support, andand aa sourcesource ofof correctivecorrective information.information.
¾ EffectiveEffective CBTCBT requiresrequires anan empatheticempathetic clinicianclinician whowho cancan trulytruly understandunderstand thethe difficultdifficult challengeschallenges ofof addictionaddiction recovery.recovery.
80 TheThe rolerole ofof thethe clinicianclinician inin CBTCBT
TheThe CBTCBT clinicianclinician hashas toto strikestrike aa balancebalance between:between: BeingBeing aa goodgood listenerlistener andand askingasking goodgood questionsquestions inin orderorder toto understandunderstand thethe clientclient TeachingTeaching newnew informationinformation andand skillsskills ProvidingProviding directiondirection andand creatingcreating expectationsexpectations ReinforcingReinforcing smallsmall stepssteps ofof progressprogress andand providingproviding supportsupport andand hopehope inin casescases ofof relapserelapse
81 TheThe rolerole ofof thethe clinicianclinician inin CBTCBT
¾ TheThe CBTCBT clinicianclinician alsoalso hashas toto balance:balance:
TheThe needneed ofof thethe clientclient toto discussdiscuss issuesissues inin hishis oror herher lifelife thatthat areare important.important.
TheThe needneed ofof thethe clinicianclinician toto teachteach newnew materialmaterial andand reviewreview homework.homework.
¾ TheThe clinicianclinician hashas toto bebe flexibleflexible toto discussdiscuss crisescrises asas theythey arise,arise, butbut notnot allowallow everyevery sessionsession toto bebe aa ““crisiscrisis managementmanagement session.session.””
82 TheThe rolerole ofof thethe clinicianclinician inin CBTCBT
¾ TheThe clinicianclinician isis oneone ofof thethe mostmost importantimportant sourcessources ofof positivepositive reinforcementreinforcement forfor thethe clientclient duringduring treatment.treatment. ItIt isis essentialessential forfor thethe clinicianclinician toto maintainmaintain aa nonnon-- judgementaljudgemental andand nonnon--criticalcritical stance.stance.
¾ MotivationalMotivational interviewinginterviewing skillsskills areare extremelyextremely valuablevaluable inin thethe deliverydelivery ofof CBT.CBT.
83 HowHow toto ConductConduct aa CBTCBT SessionSession
84 CBTCBT sessionssessions
¾ CBTCBT cancan bebe conductedconducted inin individualindividual oror groupgroup sessions.sessions. ¾ IndividualIndividual sessionssessions allowallow moremore detaileddetailed analysisanalysis andand teachingteaching withwith eacheach clientclient directly.directly. ¾ GroupGroup sessionssessions allowallow clientsclients toto learnlearn fromfrom eacheach otherother aboutabout thethe successfulsuccessful useuse ofof CBTCBT techniques.techniques.
85 HowHow toto structurestructure aa sessionsession
TheThe sessionssessions lastlast aroundaround 6060 minutes.minutes.
86 HowHow toto organiseorganise aa clinicalclinical sessionsession withwith CBT:CBT: TheThe 2020 // 2020 // 2020 rulerule
¾ CBTCBT clinicalclinical sessionssessions areare highlyhighly structured,structured, withwith thethe clinicianclinician assumingassuming anan activeactive stance.stance. ¾ 6060--minuteminute sessionssessions divideddivided intointo threethree 2020--minuteminute subsub--sessionssessions ¾ EmpathyEmpathy andand acceptanceacceptance ofof clientclient needsneeds mustmust bebe balancedbalanced withwith thethe responsibilityresponsibility toto teachteach andand coach.coach. Avoid being non-directive and passive Avoid being rigid and machine-like
87 FirstFirst 2020 minutesminutes
¾ Set agenda for session ¾ Focus on understanding client’s current concerns (emotional, social, environmental, cognitive, physical) ¾ Focus on getting an understanding of client’s level of general functioning ¾ Obtain detailed, day-by-day description of substance use since last session. ¾ Assess substance abuse, craving, and high-risk situations since last session ¾ Review and assess their experience with practise exercise
88 SecondSecond 2020 minutesminutes
¾ IntroduceIntroduce andand discussdiscuss sessionsession topictopic ¾ RelateRelate sessionsession topictopic toto currentcurrent concernsconcerns ¾ MakeMake suresure youyou areare atat thethe samesame levellevel asas clientclient andand thatthat thethe materialmaterial andand conceptsconcepts areare understoodunderstood ¾ PractisePractise skillsskills
89 FinalFinal 2020 minutesminutes
¾ ExploreExplore clientclient’’ss understandingunderstanding ofof andand reactionreaction toto thethe topictopic ¾ AssignAssign practisepractise exerciseexercise forfor nextnext weekweek ¾ ReviewReview plansplans forfor thethe periodperiod aheadahead andand anticipateanticipate potentialpotential highhigh--riskrisk situationssituations ¾ UseUse schedulingscheduling toto createcreate behaviouralbehavioural planplan forfor nextnext timetime periodperiod
90 ChallengesChallenges forfor thethe clinicianclinician
¾ DifficultyDifficulty stayingstaying focusedfocused ifif clientclient wantswants toto movemove clinicianclinician toto otherother issuesissues ¾ 2020 // 2020 // 2020 rule,rule, especiallyespecially ifif homeworkhomework hashas notnot beenbeen done.done. TheThe clinicianclinician maymay havehave toto problemproblem-- solvesolve whywhy homeworkhomework hashas notnot beenbeen donedone ¾ RefrainingRefraining fromfrom conductingconducting psychotherapypsychotherapy ¾ ManagingManaging thethe sessionssessions inin aa flexibleflexible manner,manner, soso thethe stylestyle doesdoes notnot becomebecome mechanisticmechanistic
91 PrinciplesPrinciples ofof UsingUsing CBTCBT
92 MatchMatch materialmaterial toto clientclient’’ss needsneeds
¾ CBTCBT isis highlyhighly individualisedindividualised
¾ MatchMatch thethe content,content, examples,examples, andand assignmentsassignments toto thethe specificspecific needsneeds ofof thethe clientclient
¾ PacePace deliverydelivery ofof materialmaterial toto insureinsure thatthat clientsclients understandunderstand conceptsconcepts andand areare notnot boredbored withwith excessiveexcessive discussiondiscussion
¾ UseUse specificspecific examplesexamples providedprovided byby clientclient toto illustrateillustrate conceptsconcepts
93 RepetitionRepetition
¾ HabitsHabits aroundaround drugdrug useuse areare deeplydeeply ingrainedingrained
¾ LearningLearning newnew approachesapproaches toto oldold situationssituations maymay taketake severalseveral attemptsattempts
¾ ChronicChronic drugdrug useuse affectsaffects cognitivecognitive abilities,abilities, andand clientsclients’’ memoriesmemories areare frequentlyfrequently poorpoor
¾ BasicBasic conceptsconcepts shouldshould bebe repeatedrepeated inin treatmenttreatment (e.g.,(e.g., clientclient’’ss ““triggerstriggers””))
¾ RepetitionRepetition ofof wholewhole sessions,sessions, oror partsparts ofof sessions,sessions, maymay bebe neededneeded
94 PractisePractise
MasteringMastering aa newnew skillskill requiresrequires timetime andand practise.practise. TheThe learninglearning processprocess oftenoften requiresrequires makingmaking mistakes,mistakes, learninglearning fromfrom mistakes,mistakes, andand tryingtrying againagain andand again.again. ItIt isis criticalcritical thatthat clientsclients havehave thethe opportunityopportunity toto trytry outout newnew approaches.approaches.
95 GiveGive aa clearclear rationalerationale
CliniciansClinicians shouldshould notnot expectexpect aa clientclient toto practisepractise aa skillskill oror dodo aa homeworkhomework assignmentassignment withoutwithout understandingunderstanding whywhy itit mightmight bebe helpful.helpful. CliniciansClinicians shouldshould constantlyconstantly stressstress thethe importanceimportance ofof clientsclients practisingpractising whatwhat theythey learnlearn outsideoutside ofof thethe counsellingcounselling sessionsession andand explainexplain thethe reasonsreasons forfor it.it.
96 ActivityActivity 7:7: ScriptScript 11
“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.”
97 CommunicateCommunicate clearlyclearly inin simplesimple termsterms
¾ UseUse languagelanguage thatthat isis compatiblecompatible withwith thethe clientclient’’ss levellevel ofof understandingunderstanding andand sophisticationsophistication
¾ CheckCheck frequentlyfrequently withwith clientsclients toto bebe suresure theythey understandunderstand aa conceptconcept andand thatthat thethe materialmaterial feelsfeels relevantrelevant toto themthem
98 MonitoringMonitoring
Monitoring:Monitoring: toto followfollow--upup byby obtainingobtaining informationinformation onon thethe clientclient’’ss attemptsattempts toto practisepractise thethe assignmentsassignments andand checkingchecking onon tasktask completion.completion. ItIt alsoalso entailsentails discussingdiscussing thethe clientsclients’’ experienceexperience withwith thethe taskstasks soso thatthat problemsproblems cancan bebe addressedaddressed inin session.session.
99 PraisePraise approximationsapproximations
CliniciansClinicians shouldshould trytry toto shapeshape thethe clientclient’’ss behaviourbehaviour byby praisingpraising eveneven smallsmall attemptsattempts atat workingworking onon assignments,assignments, highlightinghighlighting anythinganything thatthat waswas helpfulhelpful oror interesting.interesting.
100 ExampleExample ofof praisingpraising approximationsapproximations
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!
Oh, thanks! Yes, you are right. I will do my best to get all assignments done by next week.
101 OvercomingOvercoming obstaclesobstacles toto homeworkhomework assignmentsassignments
FailureFailure toto implementimplement copingcoping skillsskills outsideoutside ofof sessionssessions maymay havehave aa varietyvariety ofof meaningsmeanings (e.g.,(e.g., feelingfeeling hopeless).hopeless). ByBy exploringexploring thethe specificspecific naturenature ofof thethe clientclient’’ss difficulty,difficulty, cliniciansclinicians cancan helphelp themthem workwork throughthrough it.it.
102 ExampleExample ofof overcomingovercoming obstaclesobstacles
I could not do the assignments…I am very busy But it was and, besides, my children are something at home now so I do not have very easy. time….
I understand, Anna. How can we make the assignments easier to complete Well, I think that if I tomorrow? just start by doing one or two days of assignments…no more.
103 WhatWhat makesmakes CBTCBT ineffectiveineffective
BothBoth ofof thethe followingfollowing twotwo extremesextremes ofof clinicianclinician stylestyle makemake CBTCBT ineffective:ineffective:
NonNon--directive,directive, passivepassive therapeutictherapeutic approachapproach
OverlyOverly directive,directive, mechanicalmechanical approachapproach
104 Activity 6: Observe a role-play Activity 6: Observe a role-play 15 Min.
ObserveObserve clinicianclinician AA andand clinicianclinician BB conductingconducting aa sessionsession withwith aa client:client: HowHow diddid theythey dodo inin session?session? WhatWhat wouldwould youyou dodo differentlydifferently andand why?why?
105 CreatingCreating aa DailyDaily RecoveryRecovery PlanPlan
106 DevelopDevelop aa planplan (1)(1)
EstablishEstablish aa planplan forfor completioncompletion ofof thethe nextnext sessionsession’’ss homeworkhomework assignmentassignment..
107 DevelopDevelop aa planplan (2)(2)
¾ ManyMany drugdrug abusersabusers dodo notnot planplan outout theirtheir day.day. TheyThey simplysimply dodo whatwhat theythey ““feelfeel likelike doing.doing.”” ThisThis lacklack ofof aa structuredstructured planplan forfor theirtheir dayday makesmakes themthem veryvery vulnerablevulnerable toto encounteringencountering highhigh--riskrisk situationssituations andand beingbeing triggeredtriggered toto useuse drugs.drugs.
¾ ToTo counteractcounteract thisthis problem,problem, itit cancan bebe usefuluseful forfor clientsclients toto createcreate anan hourhour--toto-- hourhour scheduleschedule forfor theirtheir time.time.
108 DevelopDevelop aa planplan (3)(3)
¾ PlanningPlanning outout aa dayday inin advanceadvance withwith aa clientclient allowsallows thethe CBTCBT clinicianclinician toto workwork withwith thethe clientclient cooperativelycooperatively toto maximisemaximise theirtheir timetime inin lowlow--risk,risk, nonnon--triggertrigger situationssituations andand decreasedecrease theirtheir timetime inin highhigh--riskrisk situations.situations.
¾ IfIf thethe clientclient followsfollows thethe schedule,schedule, theythey typicallytypically willwill notnot useuse drugs.drugs. IfIf theythey failfail toto followfollow thethe schedule,schedule, theythey typicallytypically willwill useuse drugs.drugs.
109 DevelopDevelop aa planplan (4)(4)
AA specificspecific dailydaily schedule:schedule: ¾ EnhancesEnhances youryour client'sclient's selfself--efficacyefficacy ¾ ProvidesProvides anan opportunityopportunity toto considerconsider potentialpotential obstaclesobstacles ¾ HelpsHelps inin consideringconsidering thethe likelylikely outcomesoutcomes ofof eacheach changechange strategystrategy
NothingNothing isis moremore motivatingmotivating thanthan beingbeing wellwell preparedprepared!!
110 StayStay onon schedule,schedule, staystay sobersober
¾ EncourageEncourage thethe clientclient toto staystay onon thethe scheduleschedule asas thethe roadroad mapmap forfor stayingstaying drugdrug--free.free. StayingStaying onon scheduleschedule == StayingStaying sobersober IgnoringIgnoring thethe scheduleschedule == UsingUsing drugsdrugs
111 DevelopDevelop aa plan:plan: DealingDealing withwith resistanceresistance toto schedulingscheduling
¾ ClientsClients mightmight resistresist schedulingscheduling ((““II’’mm notnot aa scheduledscheduled personperson”” oror ““InIn ourour culture,culture, wewe dondon’’tt planplan ourour timetime””).).
¾ UseUse modellingmodelling toto teachteach thethe skill.skill.
¾ ReinforceReinforce attemptsattempts toto followfollow aa schedule,schedule, recognizingrecognizing perfectionperfection isis notnot thethe goal.goal.
¾ OverOver time,time, letlet thethe clientclient taketake overover responsibilityresponsibility forfor thethe schedule.schedule.
112 Activity 7: Exercise Activity 7: Exercise 25 Min.
HaveHave pairspairs ofof participantsparticipants sitsit togethertogether andand practisepractise thethe creationcreation ofof aa 2424--hourhour behaviouralbehavioural planplan usingusing thethe DailyDaily // HourlyHourly ScheduleSchedule form.form.
113 ? ? ? Questions?Questions?
Comments?Comments?
114 Post-assessment Post-assessment 10 Min.
PleasePlease respondrespond toto thethe postpost--assessmentassessment questionsquestions inin youryour workbook.workbook.
(Your(Your responsesresponses areare strictlystrictly confidential.)confidential.)
115 ThankThank youyou forfor youryour time!time!
EndEnd ofof WorkshopWorkshop 33
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