CHAPTER 6: Cognitive Behavior Therapy

1. 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

2. 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

3. 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

4. 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 are used to provide relief from schemas • 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 low-frustration 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

17. 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

18. 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.

19. Dialectical Behavior Therapy (DBT) • A highly structured intervention that adheres to cognitive behavioral and mindfulness principles • Promotes dialectic between change vs. acceptance • DBT 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

20. Dialectical Behavior Therapy (DBT) Continued • DBT Skills • Mindfulness • Interpersonal effectiveness • Emotion regulation • Distress tolerance • Addresses client behaviors that might interfere with progress • DBT 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)

21. 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

22. 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

23. 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

24. 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