Module 3: Cognitive behavioural treatment of substance abuse Flashcards
Describe the components of cognitive-behavioral treatment of substance abuse [paraphrasing] and indicate how these work and how these could be a 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 [paraphras
CBT principles
- recognizes problematic situations and triggers or avoiding or learning how to deal with their problematic behaviour
- based on client’s ability to change and appeals to commitment to stop or reduce problematic behaviour through self-perception, improving self-insight and adjusting dysfunctional cognitions and behavioural exercises
How can aversive therapy be used to treat alcohol abuse?
By combining disulfram with alcohol could produce a negative physical reaction
Contingency management
Focusses on positive reinforcement of desired behaviour with direct and small rewards and is based on behavioural contract. Rewards can be withheld if behaviours are not performed. Has been found to be effective but has not been applied systematically.
Motivational interviewing
This can be defined as “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”. Individuals are asked about the discrepancy between now and the desired situation and improve competence by identifying main obstacles. So change is being guided here. Change talk and sustain talk is used, and the helper achieves this through asking open questions. After this, the therapist can create a plan of change.
Detoxification
The patient stops using drugs. When medication is used to reduce withdrawal symptoms, prevent seizures and delirium. Opiates can be replaced with methadone or buprenorphine/naloxone and then this can be reduced.
Anti-craving medication
Naltrexone leads to obstruction of the mu-opioid receptor which is indirectly involved with regulating dopamine and reduces the rewarding effect of alcohol. But ineffective for chronic alcoholics, but can be useful in treating gambling. Acamprosate has an inhibitory effect on the glutamatergic system and can reduce craving for alcohol. Nalmefene is fast acting and can be taken preventatively to reduce risk of relapse.
Preservation treatment
Prescribing medication with same chemical properties to addicted drug to reduce withdrawal symptoms and craving. Methadone and buprenorphine/naloxone are the most common.
How does motivation manifest for addicted individuals?
They have different, powerful and conflicting sources of reinforcement as can activate the central reward system, social reinforcement and modelling, physiological dependence and withdrawal resulting in negative reinforcement. Also progressive detachment from other natural sources of positive reinforcement. Can involve behaviours which present harm or risk with sense of compromised personal control.
What were the historical methods used to treat substance abuse?
Addictions were said to be related to pathological personality with immature defense mechanisms like denial, so most treatments were confrontational to overcome this denial
Rationale for motivational interviewing in addiction treatment
- some programmes require readiness for change as a prerequisite
- but, readiness to change is malleable and resistance is due to confrontational counselling style
- clients talk themselves into change
- those with more empathic and client-centred counselling led to better outcomes
- can use coercive interventions but is no longer used
What has research found?
MI is effective in addressing substance use problems, no difference in outcomes of MI with other evidence-based methods compared to MI with less sessions. MI can enhance retention and adherence in other treatments. There can be variation in location and skills and fidelity in practice
How can clients be more engaged?
By providing motivational interviewing on their first visit which already facilitates change, develops a collaborative alliance and increases likelihood of clients coming back
Focusing
There can be differing goals as the goal of the provider may not be shared by the prospective client. The goals can be different when the substance use is not the primary issue and can be related to medical issues. The level of motivation can differ based on the drugs used-> can use this to start on the changes they are willing to make-> harm reduction. Focussing involves the changes that people are willing to make and develop agreed upon goals.
Evoking
Illustrating the client’s own reasons for change, this is usually neglected as the therapist provides own reasons and expects resistance. Can ask more about it, reflect the change, affirm it and summarize. Another way is to ask client to look ahead for the future, if there is defensiveness and justification then a new approach is needed. Delusional balance can be done which is to explore all pros and cons but found to reduce commitment to change and different from MI
Planning
With enough readiness and engagement, planning is the next step. Most professionals take an expert approach which involves being told what to do and many don’t respond well to this, can show resistance. Another approach is to not have enough planning and do not account for possible obstacles, needs to be specific and state their attention. Has black and white thinking as any diversion of the goal is seen as a relapse. Normally progressive: episodes are shorter, less severe, less frequent and remission becomes longer. Planning should take place over time and motivation for change can change.
How did CBT change over time?
Started at rational emotive behaviour therapy (REBT). Following development is in mindfulness based therapies like DBT and mindfulness-based relapse prevention and acceptance and commitment therapy. So CBT is more of an umbrella term that focusses on cognitions and behaviour to resolve emotional and behavioural dysregulation
Assumptions behind cognitive behavioural therapies
- argues that alcohol and drug use are considered to be learned behaviours which emerge and can be unlearned. They operate within a context of environmental influences
-behavioural therapies do not rely on the therapeutic alliance to create change but is viewed as neccessary (use collaboration and active participation, goal-directed and problem-solving) - focus on the present rather than past difficulties
- developing skills in reflection and self-management, with emphasis outside of therapy (homework)
- guided discovery in which therapist is a guide and requires genuine collaboration and curiosity
- pose hypotheses which need to be collaboratively tested (collaborative empiricism) and review of science to maintain best practice
How is CBT in practice?
- relatively brief in length and not more than 12-16 sessions
-structured in sections- 20 mins on review, homework, 20 mins on discussion of a skill and 20 on recapping and agreeing on homework
- setting agenda and recap, dealing with specific agenda items, planning for next session and session review
- lack of well-develop skills normally and provides a model-> setting an agenda
Relapse prevention
- main goal is to identify and prepare for high-risk situations that lead to relapse
- can be influence by many factors like self-efficacy, outcome expectancies, craving, motivation, coping, emotional states, interpersonal factors and lifestyle
- found to be most effective in abstinence post-treatment, but CBT therapies in general had lower drop out rates and equivalent effect sizes
Cognitive therapy
Not the same as CBT, and focusses on proximal situational factors like cognitive, behavioural, emotional and physiological variables that are immediate triggers. Also distal background factors like personal history, cognitive and behavioural variables, personality traits that provide a context or vulnerabilities for alcohol
Coping skills therapy
- relapse prevention training, social and communication skills training, training in coping with urges, craving and mood management.
- cue exposure shows less effectiveness in alcohol and drug use
Mindfulness-based cognitive behavioural approaches
- mindfulness-based relapse prevention has found significant improvements on withdrawal and craving symptoms, negative consequences of substance use compared to other approaches
- DBT found to be effective, ACT has good outcomes but not much good research into it
- research finds similar outcomes for CBT and mindfulness-based therapies
Brief cognitive behavioural therapies
Best utilised for moderate to high risk use and with people who are dependent but not ready to engage in intensive treatment. Found to be effective for range of individuals. There are many brief therapies being developed, one is based on social learning and CBT principles
Low intensity CBT
Low intensity for practitioner, can be delivered by non-specialists in the field, through psycho-educational groups and advice clinics. Can be delivered remotely and through self-directed technologies like books and computers. So they have high reach, access, flexibility, responsiveness, patient choice and cost-effectiveness.
Guided self-help cognitive behavioural therapies
Involve self-directed learning materials combined with lower-intensity guidance from a practitioner
Digital cognitive behavioural therapies
Barriers of availability and accessibility, anonymity and recognising problematic behaviours have been overcome with digital therapies which will reach more people who would benefit from treatment. Can also be more consistent and so same quality of service would be found. Has been found to be just as effective but issues with literature. Has been some variation in sessions which assess at discrete times or more frequent less intensive interactions. Can vary in the level of involvement from the clinician
What influences the applicability of evidence?
- wide variety of digital interventions
- variations in terminology used to describe interventions
- applicability varies according to intention and limitations of the technology used
- unclear whether clinician or input is involved
- small effect sizes were found for the interventions
What has research found about digital treatment approaches?
There are few quality studies and found to have small but significant effect sizes, there are weak or inconsistent control conditions and infrequent reporting of follow-up outcomes
Why are cognitive behavioural therapies ideally suited to alcohol and drug populations?
These tend to be comorbid as they usually experience traumatic events, they are highly structured, well-researched in population when these disorders are primary and these disorders co-occur
Cognitive behavioural model for alcohol and drug disorders
Early experience is important in the development of positive beliefs which can be positive or negative which feel like facts or truths to the persons. They are usually triggered by certain situations or emotions which lead to thoughts connected to feelings and behaviours.
Triggers
Careful identification of triggers and patterns of thoughts feelings and behaviour after the triggers is important to treat and can be a useful first step for clients to make changes and develop control over behaviour. This is the primary focus of relapse prevention and involves developing coping strategies
Thoughts and beliefs
Need to identify thoughts and beliefs with clients. Analyzing involves identifying thoughts and beliefs and the relationship to feelings and behaviour and their helpfulness. Coping and self-efficacy, positive outcome expectancy and craving and withdrawal should be paid attention to. Challenging involves asking for evidence for beliefs and look for exceptions and developing modified or alternative thoughts and beliefs. Abstinence violation effect is identifying thoughts when moving towards relapse. Accepting is noticing and accepting thoughts and beliefs without judgement or further action
Feelings
Negative emotional states can trigger and maintain alcohol. Emotions should be understood and the relationship between emotions and substance use, emotion regulation, distress tolerance and mindfulness, coaching and psychoeducation may be needed. DBT could be an option for therapy as they combine strategies for emotion regulation and mindfulness. Used when emotion regulation is a key factor in relapse.
Behaviour
Should be intervened at a behavioural level on drinking behaviours and other related behaviours which can lead to behaviour change. Relapse prevention can be used to change or modify behaviour to reduce impact of trigger. There are behavioural strategies to manage cravings. Coping skills therapy is based on social learning theory but focusses on learning coping skills and less on cognitive skills. Also teaches specific social skills to improve relationships. Can have other issues like activity scheduling, anger, depression and anxiety management
International considerations
CBT does have the ability to accommodate many cultural influences and has been used in many. But could be adapted to be more instructive to suit the need for certainty and authority and can reduce stigma through coaching style. Mindfulness strategies are also included which should be well suited to Asian cultures. Has also been applied successfully in a narrative style of delivery-> bush CBT.
