Download Cognitive Behavioral Therapy

CHAPTER 6: Cognitive Behavior
Therapy
Substance Abuse and Addiction Treatment:
Practical Application of Counseling Theory
First Edition
Todd F. Lewis
Developed by Katie A. Wachtel, University of North
Carolina at Greensboro
Introduction
•Effective
in addressing maladaptive thinking and
behavior patterns that support the use of substances
•One
of the most empirically researched counseling
approach
•Provides
a framework that connections thinking,
feeling, and behavior
•This
chapter aims to outline the application of
cognitive and behavioral interventions with substance
abuse populations, provide information about specific
CBT interventions, and discuss the effectiveness of CBT
with diverse populations
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-2
The Major Tenets of Cognitive
Therapy
•Our
thoughts, thought patterns, and cognitive
themes (schemas) play a role in psychological
distress and behavior problems
•Clients
can be helped when thought distortions and
negative thinking patterns are pointed out and
corrected
•Cognitive
shift refers to the tendency to ignore
positive events and focus solely on negative events
•Cognitive
distortions often begin in childhood
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-3
Cognitive Schemas
•Core
beliefs that begin early in life
•Schemas
can influence the way we view self,
others, and the world (the cognitive triad)
•Substances
schemas
are used to provide relief from
•Addressing
schemas is thought to be at the core
of substance abuse treatment
•Automatic
thoughts-Develop from events in the
environment that activate unconscious schemas
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-4
Cognitive Distortions
•Thinking
errors that occur when one is
interpreting events in the environment
Overgeneralization
Interpreting the meaning of an event as if
it applies to all events or situations
All-or-Nothing Thinking
Rigid interpretations of events/behaviors
into dichotomous extremes
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-5
Cognitive Distortions Continued
Selective Abstraction
Focusing on one event to the exclusion of others
Magnification or Minimization
Magnifying negative events/attributes and
minimizing positive events/attributes
Mind Reading
Belief that one “knows” what another is thinking
about him
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-6
Cognitive Models of Substance
Abuse and Addiction
•A
barrier to discontinuing problematic substance abuse is
distorted beliefs about the use of substances and their
effects
•Dysfunctional
beliefs can distort reality, create negative
mood states, and justify using substances to cope with
problems
•These
beliefs can become self-fulfilling
•Cognitive
theory suggests that cravings and urges
develop from distorted thinking patterns rather than
physiological reactions
Beliefs lead to expectations which create urges
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-7
Cognitive Models of Substance
Abuse and Addiction Continued
•Substance-related
beliefs often center around pleasure
seeking, problem solving, relief, and escape
•These
beliefs relate to the physiological effects of specific
drugs produce
Permission-giving beliefs
Promote rationalization, risk-taking and
entitlement
Anticipatory beliefs
Relate to thoughts about what is expected to
happen when taking drugs
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-8
Cognitive Models of Substance
Abuse and Addiction Continued
Cognitive theory suggests the following process leading to
substance use of relapse, each event triggering the next:
Activating event (internal or external) 
Activation of core beliefs and schemas 
Automatic thoughts related to addiction 
Cravings and urges to use 
Permission-giving beliefs 
Thinking focused on drug-seeking behaviors 
Substance use or relapse
Note: this is a cyclical process
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-9
Application of Cognitive Therapy
with Substance Abuse Problems
•Cognitive
therapy is active, structured and goal-focused
•Aims
to eliminate faulty thinking patterns that support emotional
distress and addictive behavior
•Assessment
Relevant history
Current life difficulties
Core beliefs or schemas
Vulnerable situations
Automatic thoughts
Case conceptualization
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-10
Application of Cognitive Therapy with
Substance Abuse Problems Continued
Session structure
Setting the agenda
Mood check
Bridging from the last session
Discussion of agenda items
Use of cognitive techniques (e.g. Socratic
Questioning)
Capsule summary
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-11
Application of Cognitive Therapy with
Substance Abuse Problems Continued
•
Cognitive-Based techniques
Daily thought record
Pro-cons analysis
Examining/challenging cognitive distortions
Imagery
Downward arrow technique
•
Developing and maintaining a positive therapeutic
relationship is essential for effective cognitive
treatment
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-12
Behavior Theory, Counseling, and
Techniques
•Human
behavior is learned and substance abuse is thought to
arise from operant conditioning
•Addiction
is defined by four key elements
1. Access to substances in the environment
2. Positive reinforcement is experience from drug use
3. Lack of positive reinforcement for alternative
behaviors
4. Lack of immediate punishment for drug use
•A
person stops using when
Punishers that follow ingestion become immediate
Rewards for abstinence are realized
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-13
Behavioral Techniques
Contingency Management
Shape behavior by developing a treatment plan that
takes environmental contingencies that maintain
addictive patterns into account
Relaxation training
Deep breathing, progressive muscle relaxation (PMR),
and engage in behaviors that promote relaxation
(meditation, listening to a relaxing CD, etc.)
Systematic desensitization
Move clients through an anxiety hierarchy by applying
relaxation strategies to decrease anxious feelings
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-14
Cognitive-Behavior Therapy
Examples
•All
cognitive behavioral therapy (CBT) approaches share the
following characteristics:
Collaboration between clinician and client
Belief that psychological and behavioral problems are the
result of distorted cognitive thought processes
Challenging and helping clients change and restructure
thoughts helps them emotionally
Improved mood translates to more appropriate behavior
Focuses entirely on client issues and problems
•CBT
approaches are broad, short-term, and educational
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-15
Rational Emotive-Behavioral
Therapy (REBT)
•Substance
abuse is caused by human choice
•Addicted
individuals drove themselves to addiction through
their philosophical belief systems (thus can stop using by
changing these belief systems)
•Irrational
beliefs related to addiction combined with lowfrustration tolerance (LFT) lead to addiction—this can be
illustrated with the ABC’s of REBT
Activating event-not using
Belief-I can’t function without my drug (irrational)
Consequence-low frustration tolerance and increased
anxiety
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-16
Rational Emotive-Behavioral
Therapy (REBT) Continued
•LFT
can be overcome by:
--Waiting for the urge to use to pass (can eventually
lead to use)
--Immediately returning to substance use (supports
use)
--Disputing irrational beliefs (supports abstinence)
•Substance
alleviate anxiety caused by LFT
•Identifying
and describing emotions that arise when not
using substances enables identification of irrational beliefs
and more effectively decreases the potential for relapse
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-17
REBT Techniques
•Imagery
Visualizing thinking, feeling, and behaving in preferred
ways
•Role-playing
Focus on elicited emotions to assess cognitions behind
them
•Shame-attacking
exercises
Encouraging clients to participate in silly, harmless
exercises in public
•Teach
healthy coping skills
Relaxation, etc.
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-18
Dialectical Behavior Therapy
(DBT)
•A
highly structured intervention that adheres to
cognitive behavioral and mindfulness principles
•Promotes
•DBT
dialectic between change vs. acceptance
stages
1. Pretreatment-familiarize the counseling
process and
secure commitment
2. Decrease Post-traumatic stress response
3. Enhance self-respect and accomplish goals
4. Address deeper, more existential issues
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-19
Dialectical Behavior Therapy
(DBT) Continued
•DBT
Skills
Mindfulness
Interpersonal effectiveness
Emotion regulation
Distress tolerance
•Addresses
•DBT
client behaviors that might interfere with progress
skills fit well with issues of clients who abuse substances
•Push
for abstinence from substances (change), but
understand that relapse is not the end of the world
(acceptance)
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-20
Cognitive-Behavior Therapy in the
Treatment of Diverse Populations
•CBT
has been criticized for not incorporating social and
contextual issues
•CBT
is empirically supported with diverse psychological
disorders rather than multicultural populations; more
research is needed to identify the effectiveness of CBT with
diverse populations
•Behavior
therapy is helpful with cultures who are less
comfortable expressing feelings and who work well with
concrete goals and structure; however, culture can be easily
overlooked in behavior therapy
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-21
Running Case Study: Michael
•Focus
on challenging and modifying automatic
thoughts
•Clinician
sets the agenda, uses scaling questions to
check mood, bridges from the last session, explores
automatic thoughts, introduces daily thought records,
practices behavioral imagery exercises, summarizes
the session and suggests cognitive and behavioral
exercises to work on outside of the session
•With
the help of the clinician, Michael is able to
replace automatic thoughts with rational thoughts and
report a lower desire to use as a coping skill
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-22
Strengths, Limitations, and Ethical
Issues Related to Cognitive Behavior
Therapy
Strengths
Based on the interrelationship of thinking, feeling, and
behavior and how these contribute to substance use
Variety and flexibility of interventions
Value in confronting irrational beliefs and values
Allows for incorporating new insights into homework to
support abstinence
Allows clients to do therapy work outside of sessions
Effective, focused and practical
Places strong emphasis on education
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-23
Strengths, Limitations, and Ethical Issues
Related to Cognitive Behavioral Therapy
Continued
Limitations
Effectiveness is correlated with how well it is
implemented
Assumes exploration of the past is ineffective in changing
behavior
More research is needed regarding use with diverse
populations
Ethical Issues
Clinicians can impose ideas about rational thinking on
clients
Many aspects of addiction are not addressed by CBT
approaches
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights
Reserved
6-24