Week 4/5 - Adult externalising disorders Flashcards
Discuss the NHMRC guidelines for treating gambling disorder:
- individual or group CBT to reduce gambling behaviour, severity, problems and gambling distress.
- motivational interviewing and motivational enhancement therapy (as per the manual)
- Naltrexone could be used to reduce gambling severity.
- DO NOT USE anti-depressants ALONE
Only 10% of people with gambling disorder seek treatment. What are some treatment barriers when it comes to treating gambling disorder?
- their wish to handle the problem on their own
- shame/stigma
- difficulties acknowledging the problem
- treatment-resistant issues (availability of effective treatments, cost, and time concerns).
Does gambling disorder have high attrition rates for therapy? Discuss.
- high dropout rate in treatments
- associated with high impulsivity
- MI/motivational enhancement techniques showed similar outcomes but less drop out. E.g. 65% dropout CBT but 35% dropout CBT+MET
Motivational enhancements (MET) has been shown to reduce dropout, reduce gambling and $ spent. What are the MET components or focuses?
- problem solving barriers
- praise for making appointment
- provisions of prognosis after treatment
- praise and encouragement throughout
- emphasise importance of attendance
- discuss assessment results a number of times
- decisional balance sheet (like a pros and cons.. makes them write reasons FOR/AGAINST giving up gambling vs simply reducing their level).
What are the CBT components for problem gambling?
• Self-monitoring (identify high risk times, patterns of urges)
• Cognitive restructuring
• Imaginal desensitisation and desensitisation: graded
exposure to cues
• Problem solving
• Social and coping skills:
• Role play (e.g., Practicing refusal skills),
• Goal setting (e.g., Deciding limits on gambling
occasions, time & amount of money spent),
• Psycho-education (e.g., Learning the signs and
symptoms of problem and pathological gambling)
• Relapse prevention
What is Cue Desensitisation?
Desensitisation: graded exposure – habituation to
gambling cues in vivo
E.g…..
Goals (have your goals when doing exposure work)
1) sit alone $50 2x a week and leave not gambling
2) save $40 a week for family holiday
EXPOSURE: • Outside club without $ • Inside club without $ • Sitting at pokies without $ • Sitting at pokies with $5 credits • Sitting at pokies with $50 2 hrs, 2x a week
What is imaginal desensitisation?
Help the client to desensitise towards gambling using their imagination. Go through a story step by step that involves real triggers from their life. Tell the story in detail getting them to imagine they are a part of it with thoughts, feelings and imagined pictures.
Might start with…
Scene 1 ….continued
• Recall the thoughts in your mind as you think about going to the club, looking forward to putting your money though the machines. Confident that you can win this time. Also you remember that you need to pay some bills. You feel good…..
How would use a functional analysis for gambling therapy?
- Ask the client about a recent episode. Do functional analysis as we know.
- Use it to explain links between a life event and a gambling reaction (e.g. event - thought - emotion - behaviour - outcome)
- Identify situation, thought/belief, emotion)
- List behaviours
- What were the consequences?
How can you identify and challenge a client’s beliefs about gambling?
Identify:
• Ask the client to write down his/her attitude and beliefs
about gambling
Challenge:
• Explore and understand the illusion of control over
chance events
• Challenge the notion that gambling is a source of
income, rather than a source of entertainment.
• Collect evidence
• Focus on wins and losses over a 12 month period not a
single session
QUESTIONS for challenge
• Where is the OBJECTIVE evidence to support what you
are thinking?
• Where is the evidence you can actually make money?
• How many times in the past have you actually won and
used the money to pay a bill?
• How many times have you felt confident and ended up
losing?
• What are the strategies that give you the winning edge?
(look for skill vs superstition)
• Are these thoughts rational?
• What is a more realistic view?
List some CBT components for Anger Management treatment:
- Psychoeducation
- Self-monitoring – identifying triggers
- Cognitive restructuring
- Modifying dysfunctional thoughts + beliefs and move to more level-headed reflective thoughts
- Exposure and Response prevention
- Develop an anger hierarchy
- Role playing provocative situations and rehearsing alternate responses (walking away, tension reduction)
- Coping skills training
- Relaxation training
- Deep breathing and PMR
- Relapse Prevention
Notes:
- Decision balance sheet has advantage/disadvantage for ANGER and CONTROL
- CBT can help link the trigger to the behaviour via the thoughts and emotions
What would the anger management CBT sessions run when using an anger hierarchy?
Session 1 & 2:
• Identify common anger triggers (via self-monitoring and discussion)
• Collaboratively develop a hierarchy
• Generate examples of current adaptive and maladaptive coping strategies
• Introduce the cognitive model
• Discusses cognitive distortions
• (overgeneralization, demanding, misattributing cause)
Session 3:
• Develop the starting scenes from the anger hierarchy,
making each scene as vivid as possible.
• The therapist records sensory details, anger-arousing thoughts, and dysfunctional coping behaviours.
• Client encouraged to identify adaptive cognitive and behavioural responses.
• Cognitive-behavioural coping skills procedure was introduced and practiced. Client prompted with the
adaptive cognitive and behavioural responses already identified (e.g., “I am going to count to 10 to calm myself down before I confront him,”). Repeat process twice
with the two scenes.
Session 5 - 8: client begins to apply cognitive and behavioural coping skills in vivo during anger-provoking
situations, collecting data about their efficacy.
What would the anger management exposure and response prevention therapy work?
Goal: to break automatic and reinforced reactions to
cues/triggers under controlled conditions and not allowing usual responses and reinforcements to occur (response prevention)
• Expose client to a series of critical and condescending statements, delivered with a critical tone of
voice, forward –leaning posture, and pointed finger
Example: “Stephen, it was your bad choices that have created this financial mess that we know have to deal with.”
• Start with a prompt/situation the client believes they can control. The client should feel some discomfort, arousal, negative thoughts.
• Repetition
Identify some treatment goals and subsequent treatment plan for Kleptomania (stealing).
Treatment Goals:
• Reduce kleptomaniac symptoms (measured by self-reported number of urges and shoplifting episodes
• Increase social contact with friends and family (measures by number of social activities each week)
• Decrease feelings of depression and anxiety (Self report measure e.g., DASS)
• Increase assertiveness (measured by Michelle being able to tell her husband)
Treatment plan: • Psychoeducation (present formulation) • Cognitive restructuring (though records, challenge cognitive distortions) • Behavioural interventions • covert sensitization (imagining the urge, being caught, the aversive consequences); • exposure with response prevention; • alternative sources of satisfaction; • stress management) • Assertiveness training
Adult ADHD recommends medication as first line of treatment, which is different to preschoolers. What’s the evidence around the effectiveness of CBT with ADHD? Is it worth doing?
CBT is effective in reducing adult symptoms, with one study showing CBT+Meds led to better outcomes than CBT alone but following a cost benefit analysis, recommendation is for combined treatment only when medication has offered some benefit but symptoms continue to cause impairment.
