Cognitive Behavioral Therapy for Substance Use Disorders Among Veterans Therapist Manual Josephine M. DeMarce, Ph.D. Maryann Gnys, Ph.D. Susan D. Raffa, Ph.D. Bradley E. Karlin, Ph.D. Cognitive Behavioral Therapy for Substance Use Disorders Among Veterans Therapist Manual Suggested Citation: DeMarce, J. M., Gnys, M., Raffa, S. D., & Karlin, B. E. (2014). Cognitive Behavioral Therapy for Substance Use Disorders Among Veterans: Therapist Manual. Washington, DC: U.S. Department of Veterans Affairs. Table of Contents Table of Figures ..............................................................................................................................................vii Acknowledgements .......................................................................................................................................... ix Preface ............................................................................................................................................................... x Part 1: Background, Theory, Case Conceptualization, and Treatment Structure ....................1 Introduction ....................................................................................................................................................... 2 What is Cognitive Behavioral Therapy? ........................................................................................................ 2 About the Manual .......................................................................................................................................... 2 A Word about Language ................................................................................................................................ 2 Case Examples ............................................................................................................................................... 3 Cognitive Behavioral Theory of Substance Use Disorders .............................................................................. 4 CBT Intervention Technique ............................................................................................................................. 7 Building Rapport and the Therapeutic Alliance ................................................................................................ 7 Structure of Treatment ...................................................................................................................................... 9 Overview of Treatment Structure ................................................................................................................... 9 Treatment Considerations ............................................................................................................................ 10 General Session Structure ............................................................................................................................ 10 Bridge from Previous Session ................................................................................................................... 11 Functional Analysis ................................................................................................................................... 12 Agenda Setting .......................................................................................................................................... 12 Discussion of Agenda Items/Cognitive Behavioral Strategies ................................................................. 13 Closing the Session/Planning the Home Assignment ............................................................................... 14 Part 2: Cognitive Behavioral Treatment for Substance Use Disorders ...................................15 Initial Phase of Treatment: Preparing and Planning for Change ..................................................................... 16 Addressing Motivation ................................................................................................................................. 16 Initial Clinical Assessment ........................................................................................................................... 26 Clinical Interview ...................................................................................................................................... 26 Conducting a Functional Analysis ............................................................................................................ 27 Clinical Assessment Measures .................................................................................................................. 33 Obstacles to Treatment ................................................................................................................................. 36 Orientation to CBT ...................................................................................................................................... 36 .................................................................................................... 37 Case Conceptualization and Planning for Change ....................................................................................... 39 v Case Conceptualization ............................................................................................................................. 39 Planning for Change ................................................................................................................................. 42 Case Conceptualization and Planning for Change: Case Example #1 ...................................................... 44 Case Conceptualization and Planning for Change: Case Example #2 ...................................................... 50 Middle Phase of Treatment: Cognitive Behavioral Strategies ........................................................................ 57 Core Components ......................................................................................................................................... 57 Cravings and Urges Parts 1 and 2 ............................................................................................................. 58 Refusal Skills ............................................................................................................................................ 88 Elective Components ................................................................................................................................. 116 Mood Management ................................................................................................................................. 117 Social and Recreational Counseling ....................................................................................................... 129 Support for Sobriety ................................................................................................................................ 137 Listening Skills ....................................................................................................................................... 148 Problem Solving...................................................................................................................................... 161 Later Phase of Treatment: Maintaining Change and Termination ................................................................ 172 Maintaining Change ................................................................................................................................... 172 Termination ................................................................................................................................................ 174 Pull-Out Procedures ...................................................................................................................................... 177 Addressing Resumed/Increased Use .......................................................................................................... 177 Assessing Safety and Safety Planning ....................................................................................................... 183 Management of Acute Intoxication ............................................................................................................ 185 References ..................................................................................................................................187 Appendix A: Session Handouts ................................................................................................191 Appendix B: Additional Resources ..........................................................................................214 vi Table of Figures Figure 1. Relationship Among Thoughts, Emotions, Behaviors, and Situations ............................................ 4 Figure 2. Cognitive Model (Beck et al, 1993) of Substance Use Applied to Jim ........................................... 6 Figure 3. Suggested Timing for Administration of Clinical Assessment Measures ..................................... 35 Figure 4. Timeline of CBT-SUD: Case Conceptualization and Treatment Planning .................................... 39 Figure 5. Cognitive Conceptualization Diagram .......................................................................................... 41 Figure 6. Cognitive Conceptualization Diagram for Matt ............................................................................ 46 Figure 7. Cognitive Conceptualization Diagram for Laura .........................................................................