VA CBT for Homelessness Prevention

An Overview of

Cognitive Behavioral Therapy for Veterans Experiencing Chronic

Homelessness (CBT-H)

National Center on Homelessness Among Veterans

Department of Veterans Affairs

VA CBT for Homelessness Prevention 1

CBT-H Faculty and Staff

National Center for Homelessness Among Veterans – Thomas O’Toole, MD – Roger Casey, PhD, LCSW – Brenda Johnson, LCSW – Michal Wilson, MD

Aaron T. Beck Psychopathology Research

Center, University of Pennsylvania – Aaron T. Beck, M.D. – Gregory K. Brown, Ph.D. – Kelly L. Green, Ph.D.

1

VA CBT for Homelessness Prevention

Goals of the Webinar

To provide an overview of several essential components of CBT and describe how these components can be used to address specific needs of Veterans experiencing chronic homelessness. To discuss how CBT could enhance usual care with

Veterans in VA homeless programs To inspire you to learn new ways to make a

difference in the lives of your Veterans, reduce burnout, and bring more vitality to your work

2

Why provide training in CBT for VA Homeless Programs?

Polling Question 1

Do you currently use CBT with Veterans on your caseload? Yes No

VA CBT for Homelessness Prevention 4

Why Is VA Promoting Use of EBPs?

EBPs take advantage of advancements from science and research about many MH conditions and make these evidence-based and highly effective treatments available to all Veterans EBPs are consistent with VA’s mission to provide

“The Best Care Anywhere” Providing high quality psychotherapy will increase

the value placed on psychotherapy in general within VA (vs. medication and case management only)

VA CBT for Homelessness Prevention 5

Why Is VA Promoting Use of EBPs in Homelessness

Prevention? The VA is committed to providing Veterans

experiencing chronic homelessness with the evidence-based mental health services that they deserve.

EBPs are consistent with a recovery model EBPs reduce staff burnout

VA CBT for Homelessness Prevention 6

VA CBT for Homelessness Prevention 7

What is Cognitive Behavioral Therapy?

CBT is based on the cognitive behavioral model which stipulates that how we feel is a product of our thoughts and our behaviors. Depression, substance use, and other mental

health problems are related to maladaptive or extreme thinking and behaviors – and how these interact with one another.

7

VA CBT for Homelessness Prevention

General Principles of CBT

Goal oriented Semi-structured, time-limited, active Clinician and patient work together,

collaboratively Educates patients on the CBT model Focuses on skill development (e.g.,

cognitive restructuring, activity scheduling, problem solving) Adopts hypothesis-testing approach

8

VA CBT for Homelessness Prevention

Why Provide CBT Training?

CBT is the most extensively tested psychosocial treatment for depression and other conditions

(DeRubeis & Crits-Christoph, 1998)

CBT has been shown to be efficacious in treating mild, moderate, and severe depression symptoms (DeRubeis et al., 2005; Elkin et al., 1989; Tang, DeRubeis, Beberman, & Pham, 2005)

9

Why provide CBT training?

CBT has also been shown to be as efficacious as psychotropic medications for depression in the short term and in the long term (DeRubeis, Gelfand, Tang, & Simmons, 1999; DeRubeis, Siegle, & Hollon, 2008; Hollon, Stewart, & Strunk, 2006)

CBT found to be strongly correlated with an individuals’ changed cognitions and their improved depression

(DeRubeis, Evans, Hollon, Garvey, Grove, & Tuason, 1990; DeRubeis, & Feeley, 1990, Oei & Free, 1995; Oei & Sullivan, 1999)

VA CBT for Homelessness Prevention 10

VA CBT for Homelessness Prevention

CBT is Effective for Numerous Conditions

Depression (Beck, 1967; Beck, Rush, Shaw & Emory, 1979) Anxiety Disorders (Beck & Emory, 1985) Substance Use Disorders (Beck, Wright Newman, &

Liese, 1993) Personality Disorders (Beck, Freeman, & Davis,

2004) Bipolar Disorder (Basco & Rush, 1996) Schizophrenia (Beck, Rector, Stolar, & Grant, 2009) Suicide Prevention (Wenzel, Brown, & Beck, 2009) Insomnia (Perlis, Junquist, Smith & Posner, 2005) Homelessness (Maguire, 2006)

11

CBT-H Program Evaluation

CBT-H Evaluated the implementation of Evidence-Base Practices (EBPs): – 41 VA Masters Level Social Workers in HUD-VASH who participated

in the CBT-H training program – Evidence-Based Practice Attitude Scale (Aarons, 2004) – Effective Working with Complex Clients (Maguire, 2005)

Results – Clinicians reported favorable attitudes toward EBPs before training – Clinicians reported that EBPs were more intuitively appealing and

were more open to implementing new EBPs over time. High openness is particularly associated with increased likelihood of utilizing CBT (Beidas et al., 2015)

– Clinicians became more confident in working with complex cases over time.

VA CBT for Homelessness Prevention 12

Overview of Cognitive Behavioral Therapy

14

Adapting CBT for Homeless Veterans

VA CBT for Homelessness Prevention 14

15

Why Use CBT with Formerly Homeless Veterans?

CBT is ideal for the recently-housed Veteran population because it is: – Problem-Oriented – Structured & concrete – Present-oriented, dealing with the “here and

now” – Non-pharmacological – Focused on reducing the problems that could

lead to relapse back to street homelessness

VA CBT for Homelessness Prevention 15

16

Why Use CBT with Formerly Homeless Veterans?

They could benefit from addressing maladaptive thoughts and behaviors that serve as barriers to obtaining/maintaining housing: – “There is no use in trying, I’ll just be disappointed

again by the system” – “I’ve done so much for this country and they’ve just

thrown me to the wolves!”

They often need assistance in recovery from substance use disorders

VA CBT for Homelessness Prevention 16

VA CBT for Homelessness Prevention 17

CBT Enhances Case Management

Teaches skills to address problems that impede sustained housing Addresses long-term problems that

interfere with recovery Provides ideas for addressing

inconsistent motivation

17

Therapy “On the fly”

Need to be willing to provide brief intervention on the spot – Sitting in the car while transporting to MD

office, waiting in line in the SSI office

Must have a solid conceptualization and clearly defined treatment goals to make this possible

VA CBT for Homelessness Prevention 18

VA CBT for Homelessness Prevention 19

General CBT Paradigm

Situation

Emotion

Automatic Thoughts Behavior

19

20

General CBT Paradigm

Situation Gets behind

on bills

Emotion Anxious,

depressed

Automatic Thoughts

This is hopeless; I’m failing again just like

every other time

Behavior Avoid contacting utilities; does not ask case manager

for help

VA CBT for Homelessness Prevention 20

Session Structure Checklist

VA CBT for Homelessness Prevention 21

BRIEF CBT CHECKLIST 1. Mood Check 2. Review PHQ-9 3. Medication Check 4. Drug/alcohol Check 5. Summary of Last Session 6. Set Agenda 7. Review Homework 8. Periodic Summaries/Feedback 9. Identify Key Thoughts/Behaviors 10. Implement a CBT Strategy 11. Homework Assignment 12. Final Summary 13. Session Feedback

VA CBT for Homelessness Prevention

Benefits of Session Structure in CBT

Structuring the session is a hallmark of CBT Makes efficient use of time Ensures that goals are addressed in each

session Helps to link sessions together Instills hope that even very difficult

problems can be addressed in a systematic manner

22

VA CBT for Homelessness Prevention

However…

No one CBT session ever follows this precise structure Clinical issues may arise that require

deviation from this structure CBT is fundamentally a collaborative

enterprise between the therapist and patient; a strong therapeutic relationship is essential to CBT.

23

VA CBT for Homelessness Prevention

Individuals with Low Motivation for Treatment

May not be ready to engage in CBT or make healthy changes in their lives

May not understand that their symptoms are part of a problem/disorder

May not understand what CBT involves May agree to attend CBT sessions to

appease a family member or other clinician May not see how treatment can help them

maintain housing 24

VA CBT for Homelessness Prevention 25

Motivational Enhancement

Addressing the Veteran’s motivation and readiness to change may increase the likelihood that therapy will be successful Goal is to elicit the Veteran’s internal

motivation to change rather than his or her agreement to change because of a response to persuasion, coercion, or external contingencies

25

VA CBT for Homelessness Prevention

Motivational Enhancement Strategies

Identify short-term goals in several areas, compare with Veteran’s current functioning, and discuss how therapy could help: Identify consequences of symptoms and benefits

of reducing symptoms Assess barriers for attending sessions and use

problem-solving to address these barriers Assess attitudes and expectations for therapy.

Explore the pros and cons of therapy to increase internal motivation.

26

Cognitive Model

Why think about thoughts?

Cognitive strategies allow us to intervene in the thoughts and beliefs, which can lead to changes in behaviors and feelings

Feelings

Thoughts Behavior

VA CBT for Homelessness Prevention 27

VA CBT for Homelessness Prevention

Guided Discovery

Questions promote reflection, which produces new knowledge Empowers the patient to provide his or her

own answers rather than relying on the therapist’s interpretations Facilitates the patient seeing multiple

perspectives or understanding more deeply his or her own personal beliefs What Guided Discovery is not:

– Persuading, convincing, giving advice

28

VA CBT for Homelessness Prevention 29

Testing Thoughts with Guided Discovery

Therapist and patient collaboratively test a thought’s validity or usefulness Collaboratively develop an alternative or

adaptive response Therapist does not directly challenge the

thought but instead uses collaborative empiricism

29

VA CBT for Homelessness Prevention 30

Cognitive Strategies

Identifying Automatic Thoughts Recognizing Cognitive Distortions

(unhelpful thinking styles) Cognitive Restructuring Coping Cards Problem Solving Evaluating Pros and Cons

30

Behavioral Model

Why think about behavior?

Behavioral strategies allow us to address behaviors, which can lead to changes in thoughts and feelings

Feelings

Thoughts Behavior

VA CBT for Homelessness Prevention 31

The Role of Behaviors

VA CBT for Homelessness Prevention 32

Many behaviors are done automatically, like a habit

Goal is to increase awareness of these behaviors and break maladaptive patterns so that behavior change can promote more flexible, adaptive thoughts and fewer intense, negative emotions

VA CBT for Homelessness Prevention 33

Behavioral Strategies

Behavioral Activation Activity Monitoring Activity Scheduling Graded Task Assignment Behavioral Experiments Communication (assertiveness) training Sleep hygiene

33

VA CBT for Homelessness Prevention

CBT Case Conceptualization

34

VA CBT for Homelessness Prevention 35

Case Conceptualization-Driven Psychotherapy

“Calls for the therapist to develop an individualized formulation of each case that serves as a guide to treatment planning and intervention and to use a hypothesis-testing empirical approach to each case.”

Persons (2006)

35

36

Case Example: Relevant Life History

45 year old male Veteran Alcoholic father, strict mother Divorced; 2 adult children Worked as mechanic until 5 years ago 1 year sober from cocaine and alcohol Has been housed in the community for

6 months

VA CBT for Homelessness Prevention 37

VA CBT for Homelessness Prevention 38

Automatic Thoughts

• They are quick, evaluative thoughts or images that are situation specific

• They are the most superficial level of cognition, closest to conscious awareness

• Veterans may not be aware of the thoughts impact on mood

38

VA CBT for Homelessness Prevention 39

Identifying Automatic Thoughts

When you notice a reaction (emotional, behavioral, physiological) ask yourself:

“What was going through my mind just then?”

39

VA CBT for Homelessness Prevention 40

Case Example: Situation 1 Situation

Left message for daughter 3 days ago; hasn’t called back

Automatic Thought “She’s ignoring me”

Emotion sad; angry

40

Behavior Isolate; send her angry message

on Facebook

VA CBT for Homelessness Prevention 41

Case Example: Situation 2 Situation

Received shut-off notice for electric service

Automatic Thought “I can never do anything

right”

Emotion Sad; anxious

41

Behavior Avoids calling utility company; asks case manager to handle it

VA CBT for Homelessness Prevention 42

Case Example: Situation 3 Situation

VA primary care clinic rescheduled appointment

Automatic Thought “They always screw me over”

Emotion Angry; frustrated

42

Behavior cancels appointment; drinks a

beer

VA CBT for Homelessness Prevention

Core Beliefs

Intermediate Beliefs

Compensatory Strategies

Situation

Automatic Thoughts

Reaction: Emotional, Behavioral

43

VA CBT for Homelessness Prevention

Core Beliefs

Most central, fundamental beliefs about ourselves, others, and our world Absolute and rigid beliefs (+ or -) Usually developed in childhood Become active during external life events Core Beliefs represent content (meaning)

44

Case Example: Core Beliefs

VA CBT for Homelessness Prevention 45

Automatic Thought “She’s ignoring me”

Automatic Thought “I can never do anything

right”

Automatic Thought “They always screw me over”

Core Belief “I’m unlovable”; “I’m

worthless”

Core Belief “The future is hopeless”;

“I’m a failure”

Core Belief “Others can’t be

trusted”

VA CBT for Homelessness Prevention 46

Intermediate Beliefs

Conditional Rules or Statements (+ or -)

“If people don’t admire me, then I am a failure.” “If I don’t complete this task perfectly, then I am incompetent.” “If I work very hard, then my hard work will pay off.”

46

Case Example: Intermediate Beliefs

If I don’t give people a chance, then they can’t hurt me If I don’t try, then I can’t fail If I don’t get something right the first

time, then I never will If I were a good person, then my kids

would want to talk to me VA CBT for Homelessness Prevention 47

VA CBT for Homelessness Prevention 48

Compensatory Strategies

Which behavioral strategies are linked to the specific core belief? Think of these as the person’s coping strategies. Typically the behaviors that bring them into treatment

48

VA CBT for Homelessness Prevention

Compensatory Strategies

1. Maintaining Strategies that support the core belief Vulnerable Belief Aggression 2. Opposing Strategies that prove the core belief is wrong Inadequate Belief Overachieve 3. Avoiding Strategies that do not activate the core belief Unlovable Belief Avoid Intimacy

49

Case Example: Compensatory Strategies

Avoids going out/being around people Gives up on solving problems Asks case manager to fix things Uses substances Acts aggressively

VA CBT for Homelessness Prevention 50

Polling Question 2

What CBT strategy would be most effective to target the compensatory strategy of isolating and not leaving the house? Problem Solving Activity Monitoring and Scheduling Recognizing Cognitive Distortions VA CBT for Homelessness Prevention 51

Polling Question 3

What CBT strategy would be most relevant to helping the Veteran tackle important problems like his bills and reduce avoidance? Behavioral activation Evaluating Pros and Cons Graded Task Assignment VA CBT for Homelessness Prevention 52

Polling Question 4

What CBT strategy would be most effective in helping the Veteran improve his sense of self-worth? Cognitive Restructuring Problem Solving Communication Training

VA CBT for Homelessness Prevention 53

VA CBT for Homelessness Prevention 54

Summary

CBT is based on the cognitive behavioral model which states that our interpretation of situations (i.e., thoughts and beliefs) impact our feelings and behaviors. CBT is collaborative, semi-structured, goal-oriented,

and focused on developing skills to address current life problems, including those that could impede recovery from depression, substance use, and chronic homelessness CBT enhances usual care case management by

teaching skills to address problems that impact sustained housing.

54

VA CBT for Homelessness Prevention 55

Polling Question 5

How interested would you be in receiving intensive training and consultation to implement CBT with Veterans in homeless programs? Not at all interested Somewhat Interested Interested Very Interested VA CBT for Homelessness Prevention 56

VA CBT for Homelessness Prevention 57

Questions

For questions about the training program, contact:

Roger Casey

roger.casey@va.gov

57