COGNITIVE BEHAVIOR THERAPY FOR SUBSTANCE USE DISORDERS:

FROM THEORY TO PRACTICE

Heather G. Fulton, PhD, RPsyc

LEARNING OBJECTIVES

• Describe overall theory of CBT, CBT for SUD specifically, and how this model guides individualized treatment

• Identify how a functional analysis can assist in conceptualization and tailoring of interventions within CBT for SUD

• Differentiate between different types of coping skills interventions

• Refer to list of resources for further information on CBT for SUDs

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CBT

• Survey question• Familiarity with CBT?

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CBT MODEL

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Thought: It’s a bear!

Thought: It’s a baby deer

Emotion: FearBehavior: Run!

Emotion: Curiosity?Excitement?

Behavior: Slowly turn around, take out camera

Same situation but how we thinkabout it changes our emotions and behaviors

CBT MODEL

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Thoughts/Cognitions

EmotionsBehaviors

CBT MODEL

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Thoughts/Cognitions

EmotionsBehaviors

Physical Sensations

“Hot cross bun” modelPadesky model

WHAT ACTUALLY HAPPENS IN CBT?• Techniques and strategies based on presenting problems

and client

• Common key elements throughout Collaborative relationship “coach” Interventions guided by individualized conceptualization Present-focused Identification of client goals Time-limited, goal-focused sessions Sessions have a collaborative agenda; are structured Psychoeducation Out of session practice & review

*avoid the term “homework”

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*

IS CBT EFFECTIVE?• MANY studies on CBT• “First line” or “best practice” for numerous disorders• Supporting evidence for:

o Depression & other mood disorderso PTSDo OCDo Anxiety disorders (GAD, phobias, etc)o Substance Useo Psychosiso Chronic Paino Etc…

For Reviews, check out: Tolin, , D.F. (2010). Is cognitive behavioral therapy more effective than other therapies? A

meta-analytic review. Clinical Psychology Review, 30, 710-720. Hoofman et al. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-

analyses. Cognitive Therapy Research, 26(5), 427-440. 9

CBT FOR SUBSTANCE USE DISORDER

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Relapse Prevention

(Marlatt)

Coping Skills Training

(Monti, Kadden, Carroll)

*Not reviewing Contingency Management, Motivational Interviewing, Community Reinforcement Approaches, Community Reinforcement and Family Training, other couple, family or child-focused therapies

CBT FOR SUD• CBT for SUD found to be effective as monotherapy & in

combination with other approaches- including pharmacotherapyo Alcohol o Cannabiso Cocaineo Opioidso Polysubstance dependence

e.g., Dutra et al., 2008; Magill & Ray, 2009; McHugh et al., 2010; Gates et al., 2016; Ray et al., 2018

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QUESTIONS SO FAR?

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CASE EXAMPLECarl Male, 30sAlcohol Use, Cocaine use (intranasal), past history of hallucinogen and cannabis use Alcohol Use Disorder – mild Cocaine Use Disorder- severe

Last use of cocaine and alcohol was 30days agoComorbid depression, GADGoal for treatment: “to get my use under control” “Probably not use any cocaine” Would like to drink alcohol socially still

13*details changed to protect confidentiality

THEORY• Addiction is a learned behavior

o Classical conditioning (learned associations), operant conditioning (learning through consequences)

o Biological, pharmacological, social contexts also play a role

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Mitcheson et al., 2010; Hendershot et al., 2011

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You feel anxious

You take substances and feel more calm

You feel anxious

You feel like you want to use substancesYou’re not sure how else to calm down

apart from using substances

Overtime this can become…

Learning by association

Learning by consequence

Emotion photo credit: Ohio State University

THEORY• Addiction is a learned behavior

o Classical conditioning (learned associations), operant conditioning (learning through consequences)

o Biological, pharmacological, social contexts also play a role

• Addiction emerges and is maintained in an environmental contexto E.g. availability of substances, learning from peers/parents, social

deprivation (e.g. other rewards), cultural influences

• Addiction is developed and maintained by thought patterns and processeso E.g. outcome expectancies, permission to use, self-efficacy, affective state

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Mitcheson et al., 2010; Hendershot et al., 2011

Marlatt & Gordon, 1985

CBT/RP Model

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18Marlatt & Gordon, 1985

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(stable over time)

(transient over time)

CBT FOR SUBSTANCE USE

Primary tasks of treatment:

(1) Identify antecedents and determinants of substance use:

-What specific needs are substances being used to meet ?

(2) Develop skills that provide alternative ways of meeting those needs

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FUNCTIONAL ANALYSIS

• Builds individualized conceptualization

• Fancy word for simple procedureo “slow mo’ replay”

What was happening: Before DuringAfter

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CBT FOR SUBSTANCE USE

Primary tasks of treatment:

(1) Identify antecedents and determinants of substance use:

-What specific needs are substances being used to meet ?

(2) Develop skills that provide alternative ways of meeting those needs

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24Marlatt & Gordon, 1985; Carroll, 1998

ID

Recognizeantecendants,determinants

Avoid triggerswhen possible

Improve Coping

Prevent lapses relapsesPractice to Increase

Challenge myths, beliefs

Understand needs that substances being used to meet

Other ways to meet needs?

COPING SKILLS TRAINING

• Use tracking/ functional analysiso Thoughts, emotions and behaviors before, during, & after

craving or useo Positive and negative consequences of use/no use

• Focus on present, current symptoms (thoughts, feelings, behaviors)

• Psychoeducation & address skill deficitso PRACTICE

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BASIC COPING SKILLSEveryone is different- ‘different tools in toolbox’

ExperimentEmotion Regulation Distraction (esp. exercise)

Talk to someone

Mindfulness urge-surfing

Examine & challenge self-talk, beliefs (outcome expectancy, permission giving, etc.)

Keeping slip/lapse/use in perspective F#%* it Factor

Interpersonal Refusal Skills

Assertiveness

Organizational/problem solving difficulties Scheduling, agenda disorganization & time spent using

Remember the negative consequences “play the tape through”

Remembering values & goals

Increasing pleasurable, meaningful activities including social connection and belonging alternative reinforcers

Carroll, 1998; McHugh, Hearon & Otto, 2010; Mitcheson et al., 2010;Allen et al., 2018; Ellingsen et al., 2018

BASIC COPING SKILLS CONTINUED…Adjust for cognitive/learning abilities Rehearsal

Imaginal exposure and/or rehearsal

Behavior experiments

Repetition

Reminders can help

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Modified from SUBI Workbook, 2005; Carroll’s work

CARLKey coping skills Identifying high risk situations Alone Using alcohol Feeling guilty, ashamed, hopeless, out of control

Testing thoughts I’m just going to mess up later anyways, it’s hopeless I need a break (and cocaine will give it to me) People will judge me if they knew my history

Doing fun activities that give a sense of mastery and pleasure Laundry, organizing things Biking Referral to couples counselling; meeting with partner about how to help cope

Reviewed successful coping in high risk situations

28*details changed to protect confidentiality

CARL• Tapered last sessions (1x/week, 1x/2-3weeks, 1x/month)

• Had not used cocaine for 7months – despite encountering high risk situations (e.g. offers, seeing former dealer)

• Decided to avoid alcohol use for now

• Ongoing couples therapy

• Promoted in job

29*details changed to protect confidentiality

RESOURCES

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https://archives.drugabuse.gov/sites/default/files/cbt.pdf

REFERENCES• Allen, A.M., Abdelwahab, N.M., Carlson, S., Bosch, T.A., Eberly, L.E., & Okuyemi, K. (2018). Effect of brief

exercise on urges to smoke in men and women smokers. Addictive Behaviors, 77, 34-37.

• Carroll KM. A cognitive-behavioral approach: Treating cocaine addiction (NIH Publication 98-4308) Rockville, MD: National Institute on Drug Abuse; 1998

• Dutra, L., Stathopoulou, G., Basden, S., Leyro, T.M., Powers, M.B., & Otto, M.W. (2008). A Meta-Analytic Review of Psychosocial Interventions for Substance Use Disorders. The American Journal of Psychiatry, 165(2), 179-187.

• Ellingsen, M.M., Johannesen, S.L., Martinsen, E.W., & Hallgren, M. (2018). Effects of acute exercise on drug craving, self-esteem, mood and affect in adults with poly-substance dependence: Feasibility and preliminary findings. Drug and Alcohol Reviews, 37(6), 789-793.

• Gates, P.J., Sabionoi, P., Copeland, J., Le Foll, G., & Gowing, L. (2016). Psychosocial interventions for cannabis use disorders Psychosocial interventions for cannabis use disorder. Cochrane Database of Systematic Reviews 2016(5), 1-135. DOI: 10.1002/14651858.CD005336.pub4

• Hendershot C. S., Witkiewitz K., George W. H., & Marlatt G. A. (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention, and Policy, 6(1), 17.

• Hoofman et al. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy Research, 26(5), 427-440.

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REFERENCES• Magill, M. & Ray, L.A. (2009). Cognitive-Behavioral Treatment With Adult Alcohol and Illicit Drug Users: A Meta-

Analysis of Randomized Controlled Trials. Journal of Studies on Alcohol and Drugs, 70(4), 516-527).

• Marlatt G.A. & Gordon, J.R. (1985). Relapse prevention. New York: Guilford Press.

• McHugh, R.K., Hearon, B.A., & Otto, M.W. (2010). Cognitive-Behavioral Therapy for Substance Use Disorders. Psychiatric Clinics of North America, 33(3), 511-525.

• Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R., & Wanigaratne, S. (2010). Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: A Practical Treatment Guide. Chichester, UK: John Wiley & Sons.

• Padesky, C.A., & Mooney, K.A. (1990). Clinical tip: Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13-14.

• Ray, L.A., Bujarski, S., Grodin, E., Hartwell, E., Green, R., Venegas, A., Lim, A.C., Gillis, A., & Miotto, K. (2018). State-of-the-art behavioral and pharmacological treatments for alcohol use disorder. The American Journal of Drug and Alcohol Abuse, 45(2), 124-140.

• The Substance Use Brain Injury Project Team. (2005) Client Workbook. Retrieved from: https://www.brainline.org/sites/default/files/SUBIClientWorkbook.pdf

Tolin, D.F. (2010). Is cognitive behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30, 710-720.

Witkiewitz, K., & Marlatt, G. A. (2004). Relapse Prevention for Alcohol and Drug Problems: That Was Zen, This Is Tao. American Psychologist, 59(4), 224-235.

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