L3 - CBT in Addiction Flashcards

Question

What is the *relapse and emergency measures* intervention about?

Answer 1

- Complicated topic for clients! - Comparison: safety instructions when you fly - think about what they can do if things go wrong while things are going well because when things are going badly, their mind is clouded by shame and guilt - Beware of **abstinence violation effect**: a negative emotional and cognitive response to relapsing after a period of abstinence ↪ A person may feel guilt, shame, and self-doubt, and this may increase the risk of further relapses and hinder the recovery process ↪ Feeling of shame and guilt is very important because that means that there is cognitive dissonance - they don't feel good about what they've done and don't want to do it again; if there is no shame, it might not be the time for the person to want to change ↪ The very first lapse is the most important one because there you have to prepare the client that it's part of the process - To counter this, see lapses as part of the process (a lapse is a learning moment), and plan emergency measures to prevent a full relapse

Answer 2

Ask the patient to formulate a detailed emergency plan to prevent that a lapse becomes a relapse… Ask about: - Behavior (e.g., doing a useful but laborious chore following a lapse) - Helpful thoughts - motivational speeches for yourself - Help> who? - will they know what to do and will it be helpful? - Medication - anticraving and aversion You have to be very critical and realistic about the plan

Answer 3

- Self-control measures: Prevent use - Emergency measures: Interrupt use during a (re)lapse - E.g. When winter comes you wear a scarf to prevent catching a cold but when you get a cold you take a larger measures to overcome the cold and recover

Answer 4

- Seek distraction: do something to take your mind of the urge - Seek social support - talk about that you have a craving or just talk about something else to distract yourself - Mind surfing - look at the first assignment ↪ Positive consequences of not using ↪ Negative consequences of using - Alternative thoughts: patients often think that craving can only be reduced by using. These thoughts are dysfunctional. An alternative, helpful thought is “it’s a disagreeable feeling, but I can tolerate it” or “the craving will subside eventually”.

Answer 5

- Very powerful intervention - Psycho-education + exercise helps clients to recognize, experience and accept craving as a normal response to conditioned stimuli, that will subside by itself ↪ the exercise: let the client experience it by closing their eyes and imaging a high risk situation for use (not using, just the cues that elicit craving to use). Then you ask them to rate the craving and if it's just a 7 for example you ask them what would you have to do to increase the craving and they should imagine that. After about 7 minutes the craving will diminish on its own and you will tell them get it up again and they see that it's very difficult and it takes about 20 minutes to get up again ↪ If they experience this then the thought that the craving will only end, if they use is not as strong anymore - Rather than giving into the urge, you ride it out, like a surfer riding a wave. After a short time, the urge will pass on it’s own - This technique can be used to deal with craving, in SUD and behavioral addictions (but also emotional reactions such as ‘blowing up’ when angry) - Picture 3

Answer 6

- Research has shown that the thoughts are consequence of the craving, the bodily sensations and emotions instead of the triggers for bodily sensations - first craving happens and then we interpret the craving with the thought - Thoughts probably play no major causal role as a trigger of substance use: habit behavior - Clients do mention this, as a post-hoc rationalization to reduce cognitive dissonance - Challenging thoughts doesn't have an added value - In CBT, if the thoughts are triggering something then you want to challenge that thought because then you realise that this thought is not 100% true but in addiction it doesn't work that way because the thoughts are a consequence of craving and not the trigger for craving - So now in CBT aimed at SUD, in dealing with dysfunctional thoughts, you want the person to recognise it and then put some other thought against it - this is a behavioural intervention, there is nothing cognitive about that

Answer 7

- I need something to feel better - When I feel the urge, it cannot be suppressed, I need to use (or: ‘everyone knows that...) - I must be capable of limiting use to the weekends, everyone cando that - I should have been able to stay clean… now everything is lost - When I use, the pain disappears - I worked so hard… now I deserve a treat - I feel bad, and I already suffered enough

Answer 8

- What would you think if the drugs were not present? - What will a non-user think in this situation? - What does a non-user say to himself in this situation? - What helpful thoughts can you come up with? - What would say to a dear friend in the same situation?

Answer 9

- Important: this is not an exposure exercise - It’s based on the same principle as Stimulus Response prevention (e.g., if a person offers me alcohol, I will ask for a fruit juice) - This also increases self-efficacy (a person's belief in their ability to succeed in a particular situation)

Answer 10

- Practice with the client in role play - short, fast, and covered with confidence (e.g. 'here's a bear' and they look you in the eyes and you say 'well done you made eye contact. Now again, here's a beer' and they say 'no, I don't want to.' You say: 'Great, amazing, you said now'... and it goes on - quick and short like in real life so that they train when it happens outside of therapy) - During the role play you show them a slide with the steps of declining/refusing offered substances - Using attributes that are reminiscent of use - Watch out for avoidance (by both client and therapist)!

Answer 11

How you do it: - react quickly - be clear and don't hesitate - make eye contact What you say: - first say ''no'' - suggest alternative - When pressured: ask the other to stop - Change topic of conversation, avoid discussion - Don't apologize or give vague answers

Answer 12

1. The Minnesota model (12 step) 2. Acceptance and Commitment therapy

Answer 13

- 12- step facilitation through group therapy, based on the Alcoholics Anonymous - The Minnesota model is an abstinence-orientated, comprehensive, multi-professional approach to the treatment of the addictions - It espouses a disease concept of drug and alcohol dependency with the promise of recovery, but not cure, for those who adhere to it - The program is intensive (way more than CBT), offering group therapy with fellows, lectures, and counselling - The latter two prepare the client to be able to go to self-help meeting after treatment for the rest of their life because that's the best after-care that has high long-term efficacy and low relapse rates - the steps in picture 4 - In treatment, they use the first 3 steps: admitting you have a problem, asking for help, accept the help you're given

Answer 14

- It has a broader spectrum, it doesn't focus on one set of symptoms rather it's a lifestyle change - ACT comprises a combination of acceptance, mindfulness (to know what you're feeling), and value-based therapeutic processes and how does your addiction work for you - ACT guides people to accept the urges and symptoms associated with substance abuse, fosters psychological flexibility, and uses valuebased interventions to reduce those urges and the symptoms

Answer 15

- **Contact with the present moment**: focusing on the here and now, rather than dwelling on the unchangeable past or the possible future - **Values**: having a clear understanding of what it is that you want your life to be about - directons rather than goals - **Committed action**: setting achievable goals that further your values and committing to act in ways that help you reach them - **Self-as-context** (as opposed to self-as-content): a sense that you are the context in which the events of your life unfold, rather than an idea about your life ('I'm a good person', 'I'm a failure') - refers also to fostering a transcendent sense of self - **Defusion**: the ability to recognize thoughts 'in flight' as juts thoughts rather than 'fusing' with their content as absolute reality - **Acceptance**: the willingness to not avoid the painful experiences that are natural part of living Picture 5

Answer 16

- Focus on addiction behavior - Give insight on the process of addiction through PE (?) - Reshape (part of) the clients lifestyle - Different names for comparable interventions - e.g. CBT has emergency measure and in MM it's called prevention plan

Answer 17

**CBT** - Focus on the behavior and triggers - Focus on learning new coping strategies - CBT has long been the first choice of treatment for SUD **ACT** - Focus on psychological flexibility - Focus broader than just the addictive behavior - Combines CBT with mindfulness - ACT is a relatively new treatment, especially in addiction care **Minnesota model** - Focus on (re)connecting with self and others - Based on self-help-groups - Integrates the physical, emotional and spiritual processes of addiction - Has a worldwide network for lifelong aftercare - The oldest way of treatment - Most common way of treatment is the USA and the UK (probably in the rest of the world as well)

Answer 18

an umbrella term for a broad group of therapies that focus on cognitions (thoughts, beliefs, schemas, and metacognitions) as the central element driving and resolving emotion regulation

Answer 19

- Early CBT evolved from behaviour therapy, incorporating the concept of cognition - Developed by Aaron Beck (cognitive therapy) and Albert Ellis (Rational emotive behaviour therapy - REBT) - Recent developments: mindfulness-based therapies (Dialectical Behaviour Therapy (DBT) and Mindfulness-Based Relapse Prevention (MBRP)) and Acceptance and Commitment Therapy (ACT)

Answer 20

1. T**houghts, behaviours and emotions are learned** - so can be unlearned ↪ genetic, biological, and temperamental factors are risk factors rather than determinants 2. **Therapeutic Alliance Is a Necessary but Not Sufficient for Change** - initial focus is to develop problem-solving skills to address client's immediate goals; therapeutic alliance naturally develops alogside it through collaboration and active participation 3. **Focus on the here and now** - emphasises the present, at least intially ↪ especially important with SUD as day-to-day substance use must be addressed first 4. **The Client as Their Own Therapist and the Importance of Homework** - focused on developing clients' self-reflection and self-management skills and emphasizes what happens outside sessions, making homework critical 5. **Guided Discovery as a Self-Reflection Tool** - therapists is a guide, not an expert and is curious and asks questions to promote thinking and reflection 6. **The Scientist-Practitioner Approach and Collaborative Empiricism** - therapists generate and collaboratively test hypotheses (collaborative empiricism) ↪groundes practice in evidence

Answer 21

- Length: typically 12-16 sessions but can be briefer (1-6 session) for lower-intensity needs - Strucure: important to model structuring skills which clients often lack ↪ structured but flexible to the client's needs ↪ Two models to structure: 1. **20-20-20 model**: review past week and homework, address key issues, recap + set homework 2. **Four-part model**: set agenda and recap previous sess, address agenda items, plan next session, review

Answer 22

1. Relapse prevention 2. Cognitive therapy 3. Coping skills therapy 4. Mindfulness-based CBT approaches

Answer 23

- Goal: develop skills to identify and prepare for high-risk situations that lead to relapse - Also adresses factors influencing relapse: self-efficacy, craving, and outcome expectancies - RP has shown strong results in maintaining abstinence, especially when compared to other behavioural interventions

Answer 24

1. *proximal situational factors* (cognitive, behavioural, emotional, physiological variables that are immediate triggers) 2. *distal background factors* (personal history, long-standing cognitive/behavioural variables, personality traits) that provide context or set of vulnerabilities that maintain substance use

Answer 25

1. Relapse prevention training 2. Social/communication skills training 3. Training in coping with urges and cravings 4. Mood management Cue Exposure Therapy is sometimes included but has shown limited success in substance use contexts

Answer 26

- Integrate CBT with mindfulness practice which involves purposeful attention to the present and an openness to accept things as they are - It includes: Mindfulness-based relapse prevention (MBPR), Acceptance and Commitment Therapy (ACT) and Dialectical Behaviour Therapy (DBT; blends CBT with Zen Buddhism) - These are particularly helpful for managing cravings, relapse, and co-occurring disorders (DBT for borderline PD)

Answer 27

1. Brief CBT 2. Low-intensity CBT 3. Digital CBT

Answer 28

- Useful for people not ready for intensive treatment - Includes 1–6 session interventions and can blend with Motivational Interviewing and Relapse Prevention - Helps with drug-related problems such as insomnia and drug-related harms - Effective with moderate/high-risk users and specific drugs (e.g., cannabis, amphetamines)

Answer 29

- Usually delivered by non-specialists or via self-help materials (e.g. booklets, group education, guided self-help) - Helps increase accessibility, flexibility, cost-effectiveness and patient choice

Answer 30

- Aim: decrease barriers to treatment through increasing availability, accessibility, anonymity (reduction of stigma), autonomy - Web- and app-based CBT interventions vary in structure (structured vs flexible modules) and clinician involvement (self-guided vs clinician-supported) - Results are promising but effect sizes are small, and methodological issues (weal control conditions and infrequent follow-up reporting) limit generalizability

Answer 31

- Lot of comorbidity: any mental health issues (up to 80%), trauma exposure (up to 80%), and functional cognitive impairment (50-80%) - CBT is well-suited for these populations due to its structured nature (beneficial for cognitive deficits) and extensive research in both primary and co-occurring disorder populations

Answer 32

Picture 6 1. Early experiences 2. Beliefs/schemas 3. Triggers 4. Thoughts 5. Feelings 6. Behaviours These elements interact to sustain substance use - so their understanding is crucial for change

Answer 33

Although mostly present-focused, CBT acknowledges the importance of **early experiences** in shaping fundamental **beliefs** about oneself, others, and the world. These beliefs can be triggered by external or internal events, leading to daily **thoughts** connected to **feelings** and **behaviours**

Answer 34

- To select appropriate interventions, identifying triggers and subsequent patterns of thoughts, feelings and behaviours are the foundation - Managing triggers can be an initial step for clients to gain control - **Relapse prevention** primarily focuses on understanding triggers (high-risk situations like locations, people, emotions) and developing behavioural coping strategies, such as avoidance or changing routines

Answer 35

1. **Analyzing** thoughts and their relation to feelings/behaviours and their helpfulness (e.g. exploring cognitive biases) ↪ categories: coping/self-efficacy, positive outcome expectancy (these two are the main treatment target), and craving/withdrawal beliefs ↪ RP considers beliefs about substance effects which can increase lapse/relapse risk 2. **Challenging** beliefs by seeking evidence and looking for exceptions and developing alternative thoughts (e.g. addressing thoughts underlying the 'abstinence violation effect') 3. **Accepting** thoughts without judgment or action, using cognitive diffusion (i.e. not placing importance on thoughts) and commitment to values ↪ consistent with ACT

Answer 36

- CBT now considers feelings essential - Clinicians need to explore and intervene with feelings using strategies like understanding emotions, identifying the relationship between emotions and substance use, emotion regulation, distress tolerance (mood/urge surfing), and mindfulness - DBT and ACT are especially helpful for clients with complex emotional dysregulation

Answer 37

- Changing behaviour is essential for reducing substance use and improving health - Interventions can target the substance use itself and related behaviours that contribute to use - Relapse prevention helps clients to identify triggers (e.g., people, places, emotions) and avoid or manage them (e.g., using relaxation or distraction techniques) - Coping skills therapy is similar to relapse prevention but based on social learning theory ↪ Focuses on learning new behavioural responses in high-risk situations annd helps build healthy, non-using social networks - Other helpful CBT techniques include: Activity scheduling to promote positive routines and managing anger, depression, and anxiety (especially when mood is a trigger for use)

Answer 38

Though rooted in Western psychology, CBT is flexible and has been adapted to: - Indigenous contexts (e.g., narrative or “bush CBT” styles) - Asian cultures valuing discipline, conformity, and authority - Muslim and Latina populations, where cultural beliefs and spiritual frameworks are integrated CBT’s structured format, emphasis on psychoeducation, and mindfulness-based therapies make it culturally adaptable

Answer 39

CBT: - is effective, flexible, and well-researched - works in individual, group, brief, and digital formats - addresses co-occurring conditions (e.g., trauma, mental illness, cognitive impairment) - can be culturally adapted - empowers clients through structure, collaboration, and self-management

Answer 40

1. **Contingency Management** - desired behavior is 'reinforced' or rewarded (e.g. you pay the person if they don't use heroin) ↪ extremely helpful but politically difficult because most healthcare insurance won't pay for not using drugs 2. **Motivational Interviewing** - a technique that is used to elicit motivation in the client to change a specific negative behavior ↪ only helpful for people with mild symptoms, those who only need a nudge to get better - CBT is too complicated for that ↪ it's a very good technique that's basis of almost all treatments

Answer 41

A collaborative, goal-oriented conversation style with special attention to change language. It is designed to enhance personal motivation and commitment to a particular goal by eliciting and exploring a person's reasons for change in an atmosphere of acceptance and compassion.

Answer 42

- Addresses ambivalence by exploring values, goals, and self-efficacy - Elicits change talk (e.g., reasons to quit) and reduces sustain talk (e.g., reasons to keep using) - Therapists use open-ended questions, reflective listening, and avoid pushing change too soon - In the last phase, the client and therapist together create a plan of change - Enhances commitment and adherence when combined with CBT - Core skill in most Dutch addiction treatment centers

Answer 43

- Addiction is a problem of motivation; it involves powerful and often conflicting sources of reinforcement - Physiological dependence and withdrawal is a negative reinforcement for continued use - Drugs activate central reward channels in the brain - Substance use is also strongly influenced by social reinforcement and modelling - In society and justice system, addiction is treated as a matter of choice (e.g. courts rarely find people not guiltu by reason of alcohol/drug intoxication)

Answer 44

- There are lot of evidence-based treatments for addicitons - e.g. medication to block some of the incentive properties of alcohol and drugs... - MI is just one clinical tool within an array of options - It can be combined with other evidence based treatment methods and by doing so increase the efficacy of both treatments - It can also be delivered effectively within brief health care consultation

Answer 45

- Historically, many addiction programs have assumed and even required readiness for change as a prerequisite for treatment - People who didn't appear to be adequately motivated or compliant were sometimes told ''Come back when you're ready'' - However, transtheoretical model of change suggested that people's readiness for change is malleable and it's important part of the clinician's task to help increase clients' readiness for change

Answer 46

- Within MI, the interviewer seeks ot arrange the conversation so that it's the client who makes the arguments for change - Clients talk themselves into (rather than out of) change by voicing their own motivation - There is strong correlation between client speech and treatment outcome - The MI-consistent counseling increases client change talk which results in better treatment outcomes - The treatment outcome is also influenced by the therapist's level of empathy and other client-centered counseling skills

Answer 47

Community reinforcement and family training (**CRAFT**) approach is effective in engaging about 2/3 of initially unmotivated alcohol/drug users in treatment by working unilaterally through concerned family members

Answer 48

- Significant benefit from MI as a brief intervention in addressing alcohol, tobacco, and other substance use problems as compared to no intervention or simple advice talk - Typically no difference between MI and other evidence-based treatments despite MI's lesser intensity - MI is preffered however due to involving less sessions and being less intense - Combining MI with other treatments shows good results: MI enhances retention and adherence to the other treatment ↪ E.g. Motivational enhancement therapy (MET) combines the clinical style of MI with personalised assessment feedback and it may be particularly useful in developing discrepency with clients who show little to no initial readiness for change - Variations in therapists' MI skills and fidelity in practice contributes to variability in findings across MI outcome trials

Answer 49

1. Engaging 2. Focusing 3. Evoking 4. Planning

Answer 50

- Engaging with the client in the first intake session is often overlooked as intake is seen as fact-gathering enterprise that precedes treatment - Treatment should begin with the first contact - at the intake - Providing MI in the first visit can facillitate change, and increase likelihood that clients will come back - Therefore, MI begins with a process of engaging, developing a collaborative working alliance - The primary objective is to understand the clients' own experience and perspective on their life situation - It involves establishing trust and a working relationship through active listening - It's fostered by OARS skills (open-ended questions, affirmations, reflective lists, and summaries) which is derived from person-centered approach developed by Rogers

Answer 51

- Focusing on the clients goals rather than prescribing them what they should do - The clients' level of motivation for change often varies across the drugs that they use ↪ Therefore, from an MI perspective, one starts with people where they are, working on the changes they are willing to make (sometimes referred to as harm reduction because persuing an intermediate goal is preferable to offering no treatment at all) ↪ Focusing then involves exploring what changes people are willing to consider and then developing agreed-upon goals - People get to make their own choices and the therapist has to honour clients' autonomy which can be done by asking permission and prefacing your concern with language that respects the client's autonomy

Answer 52

''There's something that worries me here. It may not concern you, but I wonder if it's OK for me to tell you what's on my mind.'' ''I'd like to ask you a little more about your drinking. What you decide to do is up to you, of course, but I wonder if alcohol might be making your depression worse. Can you see how it might?''

Answer 53

- The process of evoking in MI is about eliciting the client's own reasons for change - It involves asking and being curious about what clients themselves percieve as possible reasons for change - If you push ahead into planning before your client is on board and sufficiently motivated to move forward, change is unlikely to occur - The most common way to evoking **change talk** is to ask for it - ask open-ended questions the natural answer to which is change talk (e.g. ''What would you say are the three best reasons to but back on drinking?'' ''If you decide to stop using cocaine, what do you think would be the best way to do it?'') - Another way is to ask the client to look ahead - explore the person's hopes, goals and dreams: ''How does your drug use fit into these goals?'' ↪ !!Ask questions with open curiosity and no tone of sarcasm or cynicism

Answer 54

1. Ask more about it. Ask for an example or for elaboration 2. Reflect the change talk by using complex reflection that makes a guess about what the person may mean 3. Affirm it 4. Summarize the change talk you have heard and then ask ''What else?''

Answer 55

- Doing *decisional balance* - asking about and exploring all reasons for change and all reasons not to change - It's a useful tool if you want to maintain neutrality and help someone make difficult decision without infleuncing the choice they make - But if you hope to help someone who is ambivalent to move forward making a particular change, using MI is preferable because decisional balance intervention tends to decrease commitment to change

Answer 56

- Once there seems to be sufficient motivation in place, MI moves ahead to the planning process of considering how best to proceed toward change - If planning is premature it will become clear soon enough - Good planning process thinks through how best to proceed and anticipates possible obstacles along the way - What would be one good next step? How and when will the person do it? - People are more likely to follow through with an action when they have a specific plan of action and state their intention to accomplish it - Planning is not a one-time event but rather a process that occurs over time - in the course of implementing change, people run into obstacles that require new planning ↪ Often, to clients, any diversion from a goal is though of as a relapse ↪ It's important to work with the client on understanding that relapse is a natural part of the process and unfair black-and-white ''relapse'' thinking can undermine perfectly good progress

Answer 57

- Describe the components of cognitive-behavioral treatment of substance abuse [paraphrasing] and indicate how these work and how these could be applied in the context of a case study [analyzing] - Be able to distinguish between the different self-control measures (to prevent use) and emergency measures (to interrupt use), as well as ways to deal with craving! - Formulate a functional analysis based on a case study [independent thinking] - Name SMART criteria that treatment goals must meet [paraphrasing] - Define the 'abstinence-violation effect' [paraphrasing] - Describe the Minnesota Model and Acceptance Commitment Therapy, and explain what the main differences are with CBT [paraphrasing and evaluating]