Lecture 3: Cognitive-behavioural therapy for SUD Flashcards
CBT forms
CBT 1 and 2: individual
CBT 3 and 4: group
CBT 1 and 3: lighter problems
CBT 2 and 4: in depth (Jellinek)
de standaard behandeling voor verslaving is …
de standaard behandeling voor verslaving is CBT in nederland
most patients are …
outpatients (ambulant)
CBT 2 =
CBT2 consists of 13 sessions and is indicated when substance use is severe, or when it is already clear to the client that they want to tackle their abuse.
evidence based treatments of addiction=
- cognitive behavioural therapy
- motivational interviewing
- contingency management
motivational interviewing
a technique that is used to elicit motivation in the client to change a specific negative behavior
contingency management
desired behaviour is reinforced or rewarded
het minesota model =
self help, 12 steps facilitation, based on AA, through group therapy (vaak na jellinek). hierbij gaat het wel echt over quitting.
12 steps
- i cant make it alone
- i ask for help
- i accept the help i get
- i see the truth about myself
- i talk about my wrongdoings
- i want to change
- i ask for help in order to change
- i examine the broken relationships
- i make amends
- daily examination
- spiritual growth
- i help other dependents
jellinek also offers treatments according to …
- the minesota model
- acceptance and commitment therapy
acceptance and commitment therapy =
ACT; guiding people to accept the urges and symptoms associated with substance abuse and use psychological flexibility and value-based interventions to reduce those urges and the symptoms. (leren dat het leven niet altijd over rozen gaat)
aim of CBT for SUD
changing the pattern of problematic substance use (reducing or quitting)
Learning principles that play a role in the development of substance use:
- Social learning: observing and imitating
- Operant (i.e., instrumental) Conditioning: Substance use is rewarded
- Classical (i.e., Pavlovian) conditioning: substance use is maintained Pavlovian associations
CBT kenmerken (aantal dingen op een rijtje)
- Substance use is automatized behavior
- Using is rewarding, the disadvantages are usually not experienced until later
- Set well-considered goal(s)
- Make an inventory of risk situations (RS)
- Strengthen skills to deal with RS
- Active training in the here and now
- Practice and do homework
CBT treatment components
- Prepare for change (motivate)
- Goal setting (SMART)
- Self-control measures
- Functional analysis
- Emergency measures
- Dealing with craving
- Change thoughts
- Refusal of offered substances
- Evaluation and chose extra themes
extra themes of CBT
- Assertiveness
– Have a chat
– Receive criticism
– Giving criticism - Dealing with tension
- Dealing with feelings of depression
- Solving a problem
- Dealing with relapse (deepening)
wat als iemand bijvoorbeeld ook depressie heeft
dan dit niet treaten, sowieso eerst abstinence. maar dan verwijzen voor mdd want het is echt een hele andere therapie.
structure of the sessions
niet vragen hoe hun week was etc, maar gelijk beginnen met het huiswerk. want deze groep is heel goed in het vermijden van het praten over hun middelengebruik.
- discussing homework (registration assignment, homework related to the theme of the previous meeting)
- introducing new theme
- giving new homework (registration assignment, homework related to the new theme)
phases in CBT
- Taxation
- Interventions
- Relapse prevention
- Conclusions
- Furthermore: working with an agenda and homework
CBT is mainly like doing research, gaat heel veel om hypothesen stellen en op basis van data conclusies trekken. treatment happens at home, where the triggers are.
oke
drug abuse is vaak een gewoonte, dus ook van belang om te weten wat mensen deden in plaats van drugs te gebruiken.
bijvoorbeeld thee drinken of een boek lezen of kauwgom kauwen
ze moeten het in een paar steekwoorden neerzetten, niet belangrijk om een heel mooi verhaal neer te zetten. maar juist om het uit te kunnen leggen aan de psycholoog!
oke
use their own examples within the sessions!
oke
interventions of cbt are aimed at improving…
- self control
- coping skills
- social skills
CBT of addiction is applicable to…
- Problematic use of alcohol and drugs
- Smoking
- Gambling
- Sex addiction
- Any other addiction
registering substance use and craving: lijstje
- day, time
- external situation (who, what, where)
- internal situation (thought, feeling, bodily sensation)
- behaviour (which substance, how much, how long)
- consequence
preparing for change
eerste sessie
- first of all: increase motivation via motivational interviewing
- make a cost/benefit balance (disadvantages of use, benefits of decreasing/stopping, short term and long term)
- purpose: to provoke ‘change language’ (want als mensen twijfels hebben is het heel lastig om dit te veranderen)
predictors of treatment outcome & relapse
treatment outcome:
- change language amount
- change in ratio of change language/maintenance language
relapse:
- when abstinence is imposed (=forced)
- when clients identify the pros of using and the cons of change
setting goals =
tweede sessie
- SMART goals
- need to be important and feasible for the client
- abstinence or controlled use
- advice: 4-6 weeks of abstinence
- dus geen doelen in de trant van “ik wil nooit meer drinken”-> niet feasible en niet te checken. maar: altijd de doelen wel iets verder zetten dan ze zelf wilden (dus 2 dagen = 3 dagen voorstellen)
SMART goals =
- specific
- measurable
- achievable
- relevant
- timely
hoelang abstinence advies
4-6 weken. in 4-6 weeks your body gets the time to slowly recover, and repair the damage. any withdrawal/substance/hangover symptoms are gone.
mensen tekenen dan ook een soort behavioural contract, waarop ze alles aanvinken wat ze willen
oke
Risk-free alcohol/substance use: Raad voor de Volksgezondheid
- Alcohol: No alcohol at all or at least no more than one glass of alcohol per day is one of the guidelines of the Health Council and involves virtually no risk. Drinking ± 1 glass per day can even reduce the risk of some chronic diseases. On the other hand, the risk of breast cancer is already increased with 1 glass per day.
Minimally 2 substance-free days per week (preferably consecutive) - Drugs: Abstinence
multidisciplinary guideline disorders in alcohol use (dus wat is de guideline voor abuse)
men: max 21 units per week, without 2 or more consecutive days on which 6 or more standard units are consumed
women: max 14 units per week, without 2 or more days on which 5 or more standard units of alcohol are consumed
(maar deze gebruiken ze niet bij jellinek: gaat echt om het functioneren)
3 soorten self-control measures
- stimulus control (avoidance)
- stimulus-response prevention (alternative behaviour)
- response consequences (reward: negative consequence)
stimulus control voorbeelden
niet meer uitgaan, nummer van dealer weggeven, geen alcohol/drugs/sigaretten meer in huis, niet meer met mensen uitgaan waar je normaal mee gebruikt, niet alleen zijn als mensen vooral dan drinken, etc.
stimulus-response voorbeelden
lezen, douchen, joggen, rondje lopen
response consequences voorbeeld
bijvoorbeeld een cadeautje voor jezelf als je een week niets hebt gebruikt. of la opruimen tijdens een hangover, als soort punishment. add a negative consequence to the behaviour
functional analysis=
echt inventariseren hoe de verslaving er voor die persoon uitziet
dus welke twee soorten interventies heb je voor wanneer
self control measures: prevention of relapse
emergency measures: during relapse
emergency measures metafoor
flight attendant metafoor: tijdens een crash moet je ook weten wat je moet doen. het liefste gebeurt het niet, maar je moet wel voorbereid zijn
abstinence violation effect=
when feelings of guilt/shame lead to more relapses, but they actually only slipped up once
this is 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.
to conquer: they need to see relapse as part of the process!
functional analysis kenmerken
- FA: the common thread of the treatment
- One FA per substance
- Determining function of use
- Sd = risk situations
- Choosing interventions on the basis of FA
- Invite support person
“classical” functional analysis
specific context (Sd) : Dysfunctional behavior (R) -> cogn. repr. pos. consequences (SR-representation) & factual neg. consequences
functional analysis onderdelen & vragen
external situation - with who? where? when?
internal situation - thoughts? physical sensations? emotions?
behaviour - what substance? how much? how long?
consequences - short term? long term?
emergency plan
- how do you prevent a slip from turning into a relapse?
- emergency measures
- thoughts
- who can help?
- medication
dealing with cravings:
- distraction
- surfing the urge (learning to experience and accept craving as a normal response to conditioned stimuli, that will subside by itself.
- alternative thoughts
- mindsurfing (positive consequences of not using, negative consequences of using)
- seek social support
surfing the urse phases
- Phase 1: The craving presents itself.
- Phase 2: The craving gets bigger and bigger as long as you don’t do anything about it and don’t give in to what you normally would
- Phase 3: And eventually the craving diminishes.
intervention: challenging thoughts
- Thoughts probably play no role as a trigger of substance use: habit behavior
- Clients do mention this, interpreting afterwards (selfperception theory of Bem, 1967)
- Challenging thoughts does not have an added value
- Purpose: Formulate a helpful thought
- List dangerous thoughts
formulating a helpful thought
- What would you think if the drug 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?
declining/refusing offered substances
- Important: this is not an exposure exercise
- Practice with the client in role play
- Using attributes that are reminiscent of use
- Watch out for avoidance (by both client and
therapist)!
declining or refusing offered substances
- How you do it
– React quickly
– Be clear, don’t hesitate
– Make eye contact - What you say
– First say “no”
– Suggest an alternative
– When pressured: ask the other to stop
– Change topic of conversation, avoid discussion
– Don’t apologize or give vague answers
