CiiBhiTh fSbCognitive Behavior Therapy for Substance...
Transcript of CiiBhiTh fSbCognitive Behavior Therapy for Substance...
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C i i B h i Th f S bCognitive Behavior Therapy for Substance Use Disorders
Barbara S. McCrady, PhDDistinguished Professor of Psychology and Director of the Center on
Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover
Distinguished Professor of Psychology, and Director of the Center on Alcoholism, Substance Abuse, and Addictions (CASAA) at the University of New Mexico
American Indian & Alaska Native Behavioral Health Webinar Series
This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT).
For more information on the ATTC Network, visit: attcnetwork.orgTo find your regional center, visit: attcnetwork.org/findregcenter.asp
For more information on the National American Indian & Alaska Native ATTC, visit: attcnetwork.org/americanindian, or call 319-335-5564
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Upcoming webinars from the National American Indian & Alaska Native ATTC
Overview of Fetal Alcohol Spectrum Disorders:What we are Learning about Diagnosis and Intervention
presented by: Wendy O. Kalberg, MA, LED
An Introduction to Motivational Interviewing with Native American Adaptationspresented by: Kamilla Venner, PhD, Athabascan
Clinical Evaluation: Assessmentpresented by: Denise Casillas, MA, QMHP, Cheyenne River Sioux
Tribe
Clinical Evaluation: Treatment Planningpresented by: Denise Casillas, MA QMHP, Cheyenne River Sioux Tribe
For more information about our webinar series, contact Kate Thrams at [email protected] or 319-335-5362
Webinar Follow-Up
CEHs are available upon request for $10 per session.
Continuing Education Hours (CEH)
• This session has been approved for 1.0 CEH’s by:• NAADAC: The National American Indian & Alaska Native ATTC is a NAADAC (The Association for Addiction Professionals)
certified educational provider, and this webinar has been pre-approved for 1.0 CEH.
• To obtain CEHs for this session, submit a CEH Request Form and payment to the National AI & AN ATTC. A request form is available for download in the “Files” pod in the webinar screen. If you choose to download a file, a new tab will be opened in your browser, and you will have to click on the webinar window to return to view the webinar.
• Participants are responsible for submitting state specific requests under the guidelines of their individual statestate.
Presentation handouts:• A handout of this slideshow presentation is also available by download.
If you are unable to download the documents from the webinar, please contact Kate Thrams at [email protected] or 319-335-5362
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Webinar Follow-Up
This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse
Evaluation: SAMHSA’s GPRA
Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT).
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Disclaimer
Th N ti l A i I di & Al k N ti Addi ti T h l T f
Please note:
• The National American Indian & Alaska Native Addiction Technology Transfer Center is supported by a grant from SAMHSA
• The content of this publication does not necessarily reflect the views or policies of SAMHSA or the Department of Health and Human Services (HHS).
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Today’s Speaker
Barbara S. McCrady, PhD, is a Distinguished Professor of Psychology and the Director of The Center on Alcoholism, Substance Abuse, and Addictions (CASAA) at the University of New Mexico. Prior to coming to UNM in 2007, she was the Chair of the Department of Psychology and Clinical Director of the Center of Alcohol Studies at Rutgers UniversityPsychology and Clinical Director of the Center of Alcohol Studies at Rutgers University. Dr. McCrady has focused her career on the development and testing of effective treatments for persons with substance use disorders. She created one of the first substance abuse treatment programs based on cognitive-behavioral therapy principles and tested the effectiveness and cost-effectiveness of this treatment model. She has developed an original, conjoint treatment model for substance abusers and their spouses, and has conducted programmatic research on this treatment model. Dr. McCrady also has been active in bringing scientific attention to Alcoholics Anonymous, and has conducted controlled research evaluating alternative treatment models for women withconducted controlled research evaluating alternative treatment models for women with alcohol and other substance use disorders, with a special focus on women in poverty. Her work has been funded by the NIH since 1979. Dr. McCrady has published more than 240 scientific articles, chapters, and books, and has lectured widely on her work in the United States, Canada, and Europe.
OUTPATIENT COGNITIVE BEHAVIOR THERAPY FOR ALCOHOL AND OTHER SUBSTANCE USE DISORDERS
Barbara S. McCrady, Ph.D.Center on Alcoholism, Substance Abuse, and AddictionsUniversity of New [email protected]
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Objectives of the webinar
Overview the CBT model for conceptualizing drinking and drug use.
Integrate unique aspects of CBT with American Indian/Alaskan Native (AI/AN) clients into the presentation.
Illustrate the use of functional analysis for case conceptualization and treatment planning.
Provide CBT treatment tools.
Good CBT manuals
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Some introductory comments
Cognitive behavior therapy (CBT):P id f k li l h l d d bl Provides one framework to conceptualize alcohol and drug problems
Provides a set of techniques to help people change
The content of treatment is individualized and adapted to the individual’s needs and cultural context
Is provided in the context of a welcoming and client-centered therapeutic relationshiprelationship
Basic assumptions of the CBT model for AUDs and other SUDs
Basic Assumptions Historical factors may be important to understanding how or why someone Historical factors may be important to understanding how or why someone
developed a drinking problem However, changing drinking/drug use can best be accomplished by examining a
person’s current situation, including how historical factors affect the person in the present
Drinking/drug use occurs in the context of multiple systems Factors that maintain current drinking/drug use may be related to the individual Factors that maintain current drinking/drug use may be related to the individual,
the family, or other social systems
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The organizing model – functional analysis as a line
Trigger Negative
consequencesThoughts & Feelings Behavior Positive
consequencesconsequences
The organizing model –functional analysis as a circle
TriggerTrigger
Thoughts & Feelings
Negative Consequences
ActionsPositive Consequences
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Basic assumptions of the CBT model - 2
Triggers Triggers Events and situations that occur before drinking and increase an individual’s
desire to drink
Triggers may be related to the individual, family, or other social systems
Basic assumptions of the CBT model - 3
Thoughts, feelings, and physiology Understanding internal reactions to triggers may help a client understand his or her useg gg y p
Internal reactions may be physical, such as withdrawal symptoms, or urges or cravings
Internal reactions may be emotional, such as depression, anxiety, or happiness
Internal reactions may be self-evaluative, such as negative self-statements, low efficacy expectations
Internal reactions may focus on expectations about the positive effects of alcohol/drugs
Some research suggests that AI/AN clients find the focus on thoughts & feelings less h l f l h h f CBThelpful than other aspects of CBT
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Basic assumptions of the CBT model - 4
Consequences D i ki /d i d t b i t i d b it Drinking/drug use is assumed to be maintained by its consequences
Consequences may be physical, cognitive, affective, or environmental
Some positive consequences come from reactions to drinking/drug use by the social network
Positive consequences are more immediate than negative consequences
Negative consequences are what drive changeNega ve co seque ces a e w a d ve c a ge
Examples of a linear functional analysis for “Daniel”
Ashamed Still not ready Mom nagsme to get a job
Ride my bike by theliquor store
Haven’t had
Drink
Drink
Shakingf d ll h
Shaking goes Still addicted
I’ll justget a 4-packI like the guyswho hang there
AngryNot ready to work
I can ignore her
yto workMom madBrother critical
Tastes goodNo withdrawalGood to hang out
Wasting my lifeNot hangingout with positive people
Drink
Drink
Haven t hada drink for 4 hours
Home alonewith nothingto do
Afraid will havea seizureWant to drink
awayKnow I won’t have a seizure
Mom angryAshamed
DepressedBored
Forget myproblems
Still depressedLetting everyonedown
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Example of a circular functional analysis for “Daniel”
Ride my bike by the liquor storeq
I’ll just get a 4-pack; I like the guys who hang there
Wasting my life; Not
hanging out with positive
people
Drink
Tastes good; No withdrawal; Good to hang
out
Getting started
Begin to establish rapport
D d d d h li ’ Do a good assessment to understand the client’s: Concerns
Life context – work, family, community
Develop a CBT conceptualization of what’s maintaining the drinking or drug problem Share your conceptualization with the client, inviting his or her perspective (e.g.,
“Here’s how I’m thinking about your drinking…how do you think about it?”)
Develop a treatment plan that is deliberate in including the client’s family and community
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Developing a CB treatment plan
Always: Use m ltiple so rces of information Use multiple sources of information
Interviews Questionnaires Self-recording cards Family input
Develop a sobriety plan Develop a sobriety plan Enhance motivation
Developing a CB treatment plan - 2
Depending on the client, focus on: Changing triggers Changing thoughts and feelings Changing behavior – alcohol/related Changing behavior – general coping skills Changing consequences Changing the social environment
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Treatment Planning Sheet for “Daniel”
Sobriety Plan y__Challenge: Drinking every day; has had seizures in the past when stopping __
__Possible solution: Inpatient detox______________________________________
___________________________________________________________________
Changing High Risk Situations__Challenges: Mother upset; no car; doesn’t know nondrinkers; no job; hangs out
at home a lot________________________________________________________________________________________________________________
__Possible solutions: Learn how to talk to mom; have mom come to therapy; find a
low-stress job and save money for a car or own apartment; find ways to meet__
nondrinkers through interests (e.g. sculpting, music)________________________
___________________________________________________________________
Treatment Planning Sheet for “Daniel” (cont.)
Changing Cognitions
__Challenges: Sees self as a person who is letting down his family and community; wants to drink – afraid of seizures; “I’m a hopeless alcoholic, just like my_______
father”_______________________________________________________________
__Possible solutions: Think about what would help him feel he’s a positive part of__
community and family; identify positive values and goals; think about father’s____
positive qualities to emulate; think about positive people in community wants to be
like
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Treatment Planning Sheet for Daniel (cont.)
Changing BehaviorChanging Behavior
__Challenges: limited job skills, doesn’t know how to talk_________
with mom and brother when they say upsetting things; lack of____
positive and meaningful ways to spend time___________________
___Possible solutions: once have some sobriety, look at job training__
programs; get basic job in the meantime; learn communication skills
– involve family in treatment; consider personally and culturally___
meaningful ways to be involved with community _______________
Treatment Planning Sheet for Daniel (cont.)
Changing Social Environments
Ch ll li i h d fi d h f l ll d i k __Challenges: lives with mom and finds that stressful; all drinkers____
among the men he knows and hangs out with; shy and feels________
uncomfortable with going to AA meetings alone__________________
___Possible solutions: involve mom in treatment; work towards having_
money to live in own place or with other family/kin; look for________
nondrinkers in the community; find someone to go with to AA meetings;
learn about AI/AN meetings and types of meetings with more learn about AI/AN meetings and types of meetings with more________
comfortable formats______________________________________
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Enhancing Motivation
Motivational interviewing style
Feedback
Decisional balance
Feedback from family, friends, community
Feedback
Information needed: Number standard drinks consumed per day
Hours over which consumed alcohol
Gender
Weight
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Session 1 – Feedback - 2
Standard Drinks:Standard Drinks:
Beverage Type Size Standard Drinks
Beer 12 oz. 116 oz. 1.3
Wine 5 oz. 11 fifth 5
Hard Liquor 1.5 oz. Shot 1Hard Liquor 1.5 oz. Shot 11 pint 91 fifth 17
100 120 140 160 180 200 220 2400 .00 .00 .00 .00 .00 .00 .00 .001 .04 .03 .03 .02 .02 .02 .02 .022 .08 .06 .05 .05 .04 .04 .03 .033 .11 .09 .08 .07 .06 .06 .05 .05
4 .15 .12 .11 .09 .08 .08 .07 .065 .19 .16 .13 .12 .11 .09 .09 .086 .23 .19 .16 .14 .13 .11 .10 .097 .26 .22 .19 .16 .15 .13 .12 .11
8 .30 .25 .21 .19 .17 .15 .14 .139 34 28 24 21 19 17 15 14
Sample Behavioral Effects
Only completely safe limitImpairment begins
Approximate Blood Alcohol PercentageMen
Body Weight in Pounds
Driving skills significantly affected;
Information processing altered
Legally intoxicated; Criminal penalties;
Reaction time slowed; Loss of balance;
Drinks
9 .34 .28 .24 .21 .19 .17 .15 .1410 .38 .31 .27 .23 .21 .19 .17 .16
One drink is 1.5 oz. shot of hard liquor, 12 oz. of beer, or 5 oz. of table wine.
Impaired movement; Slurred speech
90 100 120 140 160 180 200 220 240
0 .00 .00 .00 .00 .00 .00 .00 .00 .00
1 .05 .05 .04 .03 .03 .03 .02 .02 .02
2 .10 .09 .08 .07 .06 .05 .05 .04 .04
3 .15 .14 .11 .10 .09 .08 .07 .06 .06
4 .20 .18 .15 .13 .11 .10 .09 .08 .085 .25 .23 .19 .16 .14 .13 .11 .10 .09
6 .30 .27 .23 .19 .17 .15 .14 .12 .11
Women
Approximate Blood Alcohol Percentage
Body Weight in Pounds
Only completely safe limit
Sample Behavioral Effects
Drinks
Driving skills significantly affected;
Information processing altered
Legally intoxicated;
Impairment begins
7 .35 .32 .27 .23 .20 .18 .16 .14 .13
8 .40 .36 .30 .26 .23 .20 .18 .17 .15
9 .45 .41 .34 .29 .26 .23 .20 .19 .17
10 .51 .45 .38 .32 .28 .25 .23 .21 .19
One drink is 1.5 oz. shot of hard liquor, 12 oz. of beer or 5 oz. of table wine.
g y ;Criminal penalties;
Reaction time slowed; Loss of balance;
Impaired movement; Slurred speech
Subtract .015 for each hour that you take to consume the number of drinks listed in the table. For example, if you are a 160 pound woman and have two drinks in two hours, your BAC would be .06 - (2 x .015) = .03
NOTE: Blood Alcohol Level (BAL) charts do not take into consideration a wide range of additional variables that contribute to the determination of BAL's achieved and the behavioral effects experienced at a given BAL. These additional variables include: age, water-to-body-mass ratio, ethanl metabolism, tolerance level, drugs or medications taken amount and type of food in the stomach during consumption speed of consumption, and general physical condition. Thus, BAL charts only provide extremely rough estimates and should never be used alone to determine any individual's safe level of drinking.
Adapted from BAC Charts produced by the National Clearinghouse for Alcohol and Drug Information.
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Feedback sheet
1. Based on the information you gave during the assessment, I calculated the number of “standard drinks” y g g ,you consumed in a typical week, during the last month:
Total number of standard drinks per week _____ Average number of standard drinks per day _____
2. I also estimated your highest and average blood alcohol level (BAL) in the past month. Your BAL is based on how many standard drinks you consume, the length of time over which you drink that much, whether you are a man or a woman, and how much you weight. So,
Y i d k BAL i k Your estimated peak BAL in an average week was _____ Your estimated average BAL in an average week was_____
This is a measure of how intoxicated you typically become. In New Mexico, the legal intoxication limit is 80 mg % or higher.
Feedback sheet - 2
3 You have experienced many negative consequences from drinking Here are some of 3. You have experienced many negative consequences from drinking. Here are some of the ones you said are most important to you:
___________________ _______________________
___________________ _______________________
___________________ _______________________
___________________ __________________________________________ _______________________
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Decisional Balance Sheet
P iti N tiPositive Negative____ Drinking/Drugs
Abstinence
Changing Triggers
Identifying high-risk situations
f Creating a list of triggers
Plans for dealing with situational triggers
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Identifying High Risk Situations
f Self-recording
Questionnaires
Anticipate high-risk situations each week
Client Monitoring Card:
Self-monitoring
Client Monitoring Card:
Urges Drinks/Drugs
TimeStrength(1-7) Trigger? Trigger?Time Type Amount
%Alcohol
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Creating a list of triggers
Environmental
Interpersonal
Emotional/thoughts
Physical
Planning to handle environmental triggers
A f Alternatives for handling environmental triggers: Avoid a situation
Leave a situation
Rearrange the environment
Behave differently in the environment
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Self-Management Planning Worksheet
Trigger Plan +/- Consequencesgg q
Changing internal reactions
Coping with cravings and urges
Changes thoughts about drinking
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Drinker coping with cravings and urges
TechniquesCh ll i h h Challenging thoughts
Thinking about negative consequences of drinking
Behavioral alternatives
Using meditative or spiritual approaches
Changing thoughts about drinking
Help the client learn to “think through” the drink
f f Review the decisional matrix to identify negative consequences of drinking and positive reasons to change
Write these on an index card and devise a plan for the drinker to review the card several times a day
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Learning new behaviors
Refusing drinks
Coping skills
Drink refusal
Learn to say “no” in a way that is comfortable for the client and respectful to the other personrespectful to the other person
Suggest an alternative Change the subject Feel good, not guilty, about refusing
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Coping skills
Mood management (e.g. anger, depression, anxiety)
Social interpersonal skills
Problem solving skills
Relationship enhancement
Job skills
Changing consequences
Finding alternative ways to experience positive consequences
Helping others to be more supportive and positive
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Developing alternatives
Positive Consequence AlternativePositive Consequence Alternative
Fills the time Think about what I value and enjoy; find ways to do things that fit with those values
Way to be with people Find positive ways to be part of community; find nondrinking groups, get involved with AA
Developing social networks to support sobriety
Modifying current social context Drink refusal skills
Nondrinking activities with social group
Informing family, friends, community of new status
Seeking new social networks – self-help groups Alcoholics Anonymous; Other 12-Step groups
Non 12-Step groups – SMART Recovery, Women for Sobriety
Seeking new social environments Shared leisure activities
Shared community interests
Shared religious interests
Shared intellectual interests
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General summary
CBT model is readily applicable to alcohol and other substance use CBT model is readily applicable to alcohol and other substance use disorders and for clients with different backgrounds, values, and cultures
The functional analysis provides the therapist and client with a common language to understand the client’s use
The functional analysis also provides a framework for selecting and y p gplanning interventions based on the unique pattern of variables maintaining the client’s drinking
Basic behavioral principles can guide the management of challenging client situations
Questions and discussion
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Questions and Discussion
Please type your questions or comments for the
presenter in the Q&A pod at this time…
Email Follow-up
Within the next 24 hours, you will receive an email from the National AI & AN ATTC which will include:
• Link to the recording of this webinar
We appreciate your participation in our survey, it should take you no more than 10 minutes to complete, and lets SAMHSA know:
• How many people attended our webinar
• How satisfied you are with our webinar
• How useful our webinars are to you
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Upcoming webinars from the National American Indian & Alaska Native ATTC
Overview of Fetal Alcohol Spectrum Disorders:What we are Learning about Diagnosis and Intervention
presented by: Wendy O. Kalberg, MA, LED
An Introduction to Motivational Interviewing with Native American Adaptationspresented by: Kamilla Venner, PhD, Athabascan
Clinical Evaluation: Assessmentpresented by: Denise Casillas, MA, QMHP, Cheyenne River Sioux
For more information about our webinar series, contact Kate Thrams at [email protected] or 319-335-5362
Tribe
Clinical Evaluation: Treatment Planningpresented by: Denise Casillas, MA QMHP, Cheyenne River Sioux Tribe
Th kThank youfor taking time out of your very important
work to ensure quality service through education in collaboration with the persons
you serve
Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover
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