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