Cognitive Behaviour Therapy for Addiction : Motivation and CHANGE

MSc in CBT Dublin, October 24th 2013

Frank Ryan

Overview of workshop

Welcome and introductions

Goals of workshop

Scientific perspectives on addiction

Role of cognition in addiction

Applications & competencies: Time for CHANGE

Introducing “4 Ms”

Motivation & engagement

Managing impulses and craving

Mood management

Mindful recovery

Time for CHANGE

Change

Habits

And

Negative

Generation of

Emotion(Ryan, 2006; 2013)

The Four Ms

Motivate (and engage)

Manage impulses to use

Mood management

Mindful recovery

Addiction is commonly co-morbid

75% had one or more co-occurring mental health condition

8% had a psychotic disorder,

40% had minor depression,

26% had severe depression,

37% had a personality disorder and

19% severe anxiety

(Weaver et al 2002)

4 Ms

Motivation and engagement

Manage impulsivity

Manage Negative emotions

Maintain Change (relapse

prevention)

Healthcare costs (in billions Euro)of emotional and addictive disorders in 30 European countries (27 EU Plus N, CH and Iceland) Gustavsson et al 2011

Depression Addiction Anxiety disorders0

10

20

30

40

50

60

70

80

Five things about addiction

ADDICTION IS COMPULSIVE HABIT

COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF CONSCIOUSNESS

ADDICTION IS ABOUT 50% HERITABLE

MOST PEOPLE WITH ADDICTIONS WHO PRESENT FOR HELP HAVE OTHER PSYCHIATRIC PROBLEMS AS WELL

ADDICTION IS A CHRONIC RELAPSING DISORDER

Five More things…

“COME BACK WHEN YOU’RE MOTIVATED” IS NO LONGER AN

ACCEPTABLE THERAPEUTIC RESPONSE!

DIFFERENT PSYCHOTHERAPIES APPEAR TO PRODUCE SIMILAR

TREATMENT OUTCOMES

THE MORE INDIVIDUALIZED AND BROAD-BASED THE TREATMENT A

PERSON WITH ADDICTION RECEIVES, THE BETTER THE OUTCOME

MIRACLE CURES RARELY HAPPEN

CHANGE TAKES TIME

Low Intensity Interventions

Giving accurate information about addiction, detoxification and relapse to service user & family Brief motivational interventions Contingency management  Identifying triggers and cuesCoping skills for impulse control Facilitating engagement in AA/NA/CA/GA

High Intensity Interventions

Programmed cognitive behaviour therapy sessions such as Relapse Prevention Skills Training either on one to one or group basis.

Mindfulness based cognitive therapy Behavioural Couples Therapy

Emotions MatterWhen we experience negative emotions

drugs are more rewarding, as they are reinforced both positively and negatively.

But not the full story...

Psychodynamic tradition viewed drug addiction as: “a replacement for a defect in the psychological structure”. Kohut (1971,p 46),

The question of motivation……In groups of three, discuss what drives

or motivates drug use or compulsive gambling,.

Use examples from your own work if possible.

Cognitive therapy

Addiction motivated by need to cope with or suppress the consequences maladaptive core beliefs such as ‘I am helpless’ or ‘I am unlovable’ (Beck et al. 1993, p. 52)

Cognitive behaviour therapy

“Relapse Prevention Skills Training” model (Marlatt & Gordon,1985; Marlatt & Witkiewitz, 2005 ) tackled addiction using functional behavioural analysis (antecedents, behaviour, consequences) and induction of alternative coping skills.

Focus of CBT in Substance Misuse

Motivation, Motivation, Motivation!

Conceptualising, formulating and treatment planning

Identify high risk stimuli: internal and external

Correct maladaptive beliefs about substances e.g “people would ridicule me if I did not drink at the party”

Identify the involvement of early maladaptive schemas e.g. defectiveness or unloveability as contexts for misuse

Negative automatic thoughts: “Who cares if I drink?”

Coping with craving: e.g. “delay and distraction”

Rationalisations “ permission giving beliefs” e.g. “I deserve one…”

Circumscribing lapses/slips: One swallow doesn’t make a summer!”

Or, just do two things!

Facilitate impulse control Facilitate affective regulation

Early adverse learning experiences

•Formation of dysfunctional schemas e.g "I am not as good as other people".

Exposure to euphoric orhedonic effects of drugs such as alcohol

and cocaine

•Formation of substance related beliefs e.g. "I feel better about myself when I use cocaine or alcohol; people seem to like me more".

Critical Incident: Failed job interview

•Schema about personal inadequacies is activated and triggers automatic thoughts "I am stupid", negative affect and substance related beliefs e.g. "I can't handle this without a drink; I'll feel better if I have some cocaine"

Current case

Maria: 30 yr-old female

Single, but lives with ex-partner

Experiences depressive and angry emotions

that trigger episodes of excessive drinking> impulsive

suicidal behaviour and intent.

Shows high level of insight and motivation

but still engages in problem behaviour 3-4

times per month

Vulnerability factors include parental abandonment and

Rigid parenting style; recently disclosed sexual violence.

New Perspectives

Treatment outcomes are often poor in addiction

Treatment specific effects not demonstrated (e.g. Project Match).

This suggests key variables are not being addressed specifically.

Recent findings implicate impaired cognitive control as a factor in the persistence of addiction.

This needs to be assimilated into CBT

Vulnerability factors in addiction

Implications for psychotherapy

f.ryan@imperial.ac.uk

Why Drugs are Addictive

Drugs of abuse such as alcohol, amphetamine cocaine act as primary reinforcers.

This operates directly or indirectly through reward circuit in the brain.

Some people find this hard to resist.

Two Pathways to emotion (& craving)

Information about emotionally salient stimuli and stimuli associated with drug availability reaches the amygdala directly from the thalamus (low road) and also via the cortex (high road).This is why sometimes we feel approach (appetitive)urges or avoidant (fear ) without knowing why. Stimuli are monitored continuously but “amygdala alerts” do not necessarily generate conscious awareness.

Overview of scope and aims of CBT in Substance Misuse

Engaging and motivating individuals into therapeutic programmes

Placing substance misuse in a personal context for the individual (formulating).

Facilitating the acquisition of skills to cope with impulses driving drug seeking and taking

Enhancing affect regulation

Relapse prevention and follow-up (maintenance strategies)

Cognitive control is impaired before during and after substance misusePre-existing –dispositional deficits

Acute effects of intoxication

Withdrawal effects

Carry-over effects

Associated risk factors due to injuries or self-neglect

Executive control is impaired

Up to six 6 years in after seeking treatment alcohol dependent people who are largely abstinent show deficits in executive control despite appearing to function normally in many settings

Detoxified alcoholic men with an average of over 26 weeks abstinence and with otherwise good psychosocial functioning can nonetheless register loss of grey matter in neural structures involved in higher cognitive function: Morphological changes were highest in the DLPFC (up to 20%) but were noted also in the temporal cortex, insula, thalamus, and cerebellum. (Chanraud et al, 2007).

Volumetric reductions in grey matter, in the region of 5%-11%, have been observed with long term abstinent heroin and cocaine addicted people Franklin et al, 2002; Yuan et al 2008.

f.ryan@imperial.ac.uk

Key Concepts from psychology

Reflective system and impulsive system govern behaviour – Reflective impulsive model (RIM) (Strack and Deutsch, 2004)

Reward learning is enduring and resistant to devaluation or extinction i.e. becomes stimulus driven rather than outcome driven

(Yin & Knowlton, 2006)

Motivational dynamics: conflict between impulse and control

Attention, Motivated !“people become consciously aware of

an act only after they unconsciously decide to engage in it. In addition, at least some volitional behaviour does not require any conscious awareness at all: Goals and motivation can be unconsciously primed.”

Motivated attention is the driving force of addiction.

The key variable is motivated attention

Attention triggers action even in the absence of awareness.

Dual processing; fast and slow.

Cue detected

Controlled processing(slow)

Activation of addiction related beliefs. e.g "I will have more fun if I use cocaine"

Automatic processing(fast)

Conditioned cue reactivity : somatovisceral arousal and approach tendency

Cognitive appraisal

Level of processing

Prelude to passion:Limbic activation by “unseen” sexual and drug cues. Childress et al 2008

Neural response at 33ms exposure specific to drug and sexual cues.

Implications of recent cognitive neuroscience findings

Addiction is maintained by enduring changes in priorities and deficits in information processing.

Therapies that infiltrate and modify this, i.e. increase cognitive control, are more likely to be effective.

There is therefore a potential role for “neurocognitive rehabilitation” using the prototype described here

Conversely, changes in attentional and mnemonic functioning, especially implicit processes, will index and predict therapeutic gain.

Accordingly....

Result is distinctive “cognitive signature” and behavioural dysregulation.

Remediation needs to overcome automatic tendencies that are often implicit.

The neural networks subserving drug seeking and taking endure (excessive “wanting”) long after the pleasure or liking is gone.

Exposure, the most potent weapon in CBT is ineffective, or at least inconsistent.

Work in progress…..

Working Memory

f.ryan@imperial.ac.uk

Top downProcesses

(goals and coping strategies)

Bottom upProcesses

“Reward Radar”

Cycle of pre-occupation

Attentional bias

Contents of

Working memory

Attentional bias

f.ryan@imperial.ac.uk

Attribution of incentive salience

Any Questions?

Themes applied

Importance of goal maintenance

Rehearsal+ repetition+ reinforcement =

Reversal.

Importance of identifying alternative goals and pursuing these in a systematic manner

Cognitive biases are linked to craving

Cognitive biases are associated with increased craving.

Increased craving leads to increased cognitive bias.

Increased cognitive bias leads to increased craving.

Bias predicts outcome.

Field, Mogg & Bradley, 2006 Attention to drug-related cues in Wiers, R.W., & Stacey, A.W Handbook of implicit cognition and addiction.(Eds)

Sage. London.

f.ryan@imperial.ac.uk

But “reward radar” is always on!

Emphasis on reversal of implicit cognitive biases.

Focus on enhancing cognitive control (STM and attention ) mechanisms via goal maintenance

Prioritises impulse control strategies

Assessment and engagement

Begin with current concerns

Explore personal history

Elicit history of substance misuse:

Functional analysis (ABC)is helpful

Work towards formulation

Formulation

Building resilience

Conclusion:You know most of it already! (but please stay until end of workshop just to make sure)

From a CBT perspective, there are no entirely novel mechanisms or compensatory strategies involved in the acquisition, maintenance or regulation of

addictive behaviour.

The first M: Motivation and how to foster it

Treatment barriers:The possible effects of repeated setbacks

Scenario 1: Client blames themselves: “I’m lacking will power and I’m useless anyway…”

Scenario 2: Therapist blames client ( sometimes with their full agreement/collusion : “ You are not motivated or committed, come back when you’re ready (i.e. stop wasting my time!)

Scenario 3: Therapist blames themselves: “I’m no good at this, my clients never seem to improve”

Scenario 4: Client blames therapist : “ You don’t understand me or my problems and the treatment is useless”.

Motivational Interviewing 1

Opening strategy: ask about lifestyle, stresses and problem behaviourA typical dayThe good things and the less good things about the current drug useCurrent concerns

Motivational interviewing 2

Elicit self-motivational statements:

e.g.” Its sounds like your partner is worried about your drinking, but I was wondering how you feel about it?”

Listen with accurate empathy:

“It sounds like you want to quit but when you tried treatment before you went back to using cocaine”

Motivational interviewing 3

Roll with resistance: “you’re not sure you want to make a commitment to quit today”

Point out discrepancies: “ You’re not sure your drinking is a big problem, but people who care about you seem to be concerned”

Clarify free choice: “In the end, its down to you to make the decision….”

Brief motivational encounters….

Establish rapport through empathy

Focus on raising the issue (i.e. substance misuse)

Build commitment

Agree goal

Use self-monitoring and reinforcing feedback

Assessing readiness and building commitment to change

Importance

Readiness

Confidence

Ask: How important/ready/confident are you on a scale of 0-10? Then “Why not lower/higher …? ”

Identify and challenge negative thoughts about change

Encourage re-attribution of past failures (prevent the cultivation of internal, global and general attributions of impulsivity)

Express accurate empathy

Dealing with ambivalence

Identify an issue or situation about which you are ambivalent about taking steps to change.

In pairs: One to explore the pros and cons of changing

f.ryan@imperial.ac.uk

Tried & Tested:Summary of useful CBT techniques

Recognising or “capturing” automatic thoughts

Goal setting

Reality testing/behavioural experiments

Cognitive rehearsal

Identifying underlying beliefs and assumptions

Coping skills (e.g. relaxation therapy; “distancing”)

Problem solving skills

Relapse prevention skills: identifying high risk situations and rehearsing how to cope with them.

Five facets of impulsivity

Negative urgency: the tendency to act rationally when experiencing negative emotions e.g. “When I am upset, I often act without thinking and sometimes reach for a drink”.

Lack of Perseverance: the tendency to give up on a task more easily, in effect a lack of willpower. The manifestation of this personality trait could be endorsing the item “I tend to give up easily” strongly discounting the statement “Once I start something I'm determined to finish it”

Lack of Premeditation: the tendency to act without considering the consequences, especially those in the medium to long-term, e.g. strongly disagreeing with a statement such as “before deciding to do something I carefully weigh up the “pros and cons”.

Sensation seeking: essentially the same as the FFM construct reflecting a preference for novelty seeking, risk-taking and openness to new experience.

Positive urgency: this disposition refers to the tendency to act rashly when experiencing positive affect feeling excited in response to positive life events (see also Lynam, 2011)

Structuring the session

• Update on developments since previous encounter, with particular emphasis on any expression of addictive behaviour, negative mood states and current concerns.

• Setting the agenda, possibly asking the client to specify the priorities if the list of concerns or problematic issues is extensive. Specifying the stage of CHANGE (one of the 4Ms) of treatment e.g. managing impulses, managing mood maintaining change

• Reviewing any between session assignments homework• Introducing and then elaborating on the primary topic of the session e.g. coping

with impulses• Negotiating homework for coming week e.g. an implementation strategy or a

behavioural experiment• Summary and feedback • Schedule next appointment, reinforcing the importance of attendance even if

the therapeutic objectives are met by the homework is not accomplished.

In summary: the “20 20 20” rule

20 minutes: Review substance misuse, give motivational feedback, note current concerns

20 minutes: Introduce session topic (e.g. coping with craving) & relate to current concerns

20 minutes: assign homework /practice exercise for coming week & anticipate high risk situations

Overall, always apply social reinforcement to “shape “ behaviour. A client who presents for an appointment is always welcomed warmly!

Session by session monitoring: COMET

Continuous

Outcome

MonitoringDuring

EngagementIn

Treatment

Outcome Monitoring

Percentage days abstinent (PDA)

e.g. Client reports alcohol use on 4/7 days

(3/7)X100= 43% approximately=PDA

This can be applied to various time intervals such as change since baseline.

Feedback to clients can be provided in a motivational context.

Contingency management

Identify target behaviour e.g. supplementary drug use; testing or treatment for hepatitis C. Emphasise collaborative dimension.

Reinforce frequently and according to pre-ordained schedule.

Maintain for up to twelve weeks

Just say no!

When offered drugs:Say no first

Make direct eye contact

Don’t be afraid to ask the person to stop offering

Don’t leave the door open to future offers (e.g. I don’t feel like it today)

Be assertive, not aggressive!

Manage impulses (urges) and craving: the “Reward Radar” never switches off!

Stimulus Control

Implementation intentions

Be aware of and attempt to correct cognitive biases

Identify alternative rewards

Self monitoring

Distance /de- centre / mindfulness meditation

Challenge expectancies and implicit cognitions via behavioural experiments

Support self-efficacy

Goal specificity

Managing craving

Recognise thinking about drugs e.g “life is boring without cocaine” or “I deserve a drink”. Include categories of testing personal control and permission giving beliefs.

Avoid situations rich in drug cues e.g. parties where drugs are ubiquitous- setting alternative goals is often a good strategy

Identify and rehearse coping strategies e.g. drink refusal skills; distraction; challenging your thoughts ; review negative consequences focus on benefits of restraint; talk to supportive friends or associates on programme

Implementing intentions to change

If situation X occurs I will perform behaviour Y e.g.

“If I have money I will do my shopping before visiting the cocaine dealer”

If I am offered alcohol to drink at the party I will say “no thanks, but I would love a mineral water”.

Prestwich et al (2006)

The Third M:Manage mood

Conventional CBT techniques: correcting cognitive distortions; problem solving; exposure & behavioural experiments

Pharmacotherapy

Three vulnerabilities

-genetic loading contributing to neurobiological vulnerability;

-exposure to adversity in childhood and at early developmental stages;

-subsequent exposure to negative life events.

Assessment should explore these in detail.

Three sources of negative emotion

• pre-existing negative affect due to dispositional traits and/or exposure to adverse life events both historically and concomitant with recovery;

• negative emotions stemming from the after effects of drug intoxication; • negative emotions arising from setbacks or lapses when self-control

fails.

 

Assessment should aim to distinguish between these.

Mindfulness

Mindfulness disrupts automatic flow of cognitions < contrasts with ironic or paradoxical effects of effortful suppression>

Mindful acceptance should influence outcomes by reducing intrusion

Sober breathing space

S top

O bserve

B reathe

E xpand

R espond (not react!)

Four components

Educate about emotions

Antecedent cognitive appraisals° Probability errors° Catastrophising

Prevention of emotional avoidance° Behavioural avoidance e.g . avoiding eye contact° Cognitive avoidance e.g. thought suppression ,

rumination° Safety signals e.g. Carrying a bottle of water or a pill

Modification of emotionally driven behaviours° Hypervigilance° Health anxiety behaviours

Mindful Recovery

Relapse Prevention Skills Training: identify high risk situations and how to deal with them.

Goal Maintenance (therapies that foster this are more effective)

Attend Twelve Step based groups such as AA/NA

Use self-help materials

Practice mindfulness meditation or other meta-cognitive techniques

Remember that addiction casts a long shadow: appetitive responses are enduring and can be re-established by exposure to stress, small amounts of the drug of choice (possibly accidental?) and slight or ambiguous stimulation associated with drug.

“Road to recovery……is paved with good rehearsals.”

Successful execution of any task requires both controlled and automatic processing- Treatment for addiction requires that automatic processes are recruited through practice, implementation intentions, programmed cue exposure and stimulus control.

Robust practice has been shown to increase automatic inhibition of competing goals (Palfai, p 416, Wiers & Stacey 2006)

The Future:Neuro-Cognitive Behaviour Therapy?

Emphasis both on remediation of cognitive deficits and reversal of cognitive biases.

Focus on goal maintenance and working memory mechanisms.

Prioritises impulse control strategies.

Summary

Impulse control and emotional control strategies should be addressed sequentially, but as part of a formulated treatment plan in a framework that accentuates cognitive control.

Particular attention must be given to enhancing therapeutic alliance: Continuous feedback is used to motivate the client to remain engaged in treatment despite the inherent treatment resistant nature of addiction.

Addiction, once established, is an enduring condition because of the powerful learning mechanisms it subverts. Help seekers and their carers need to remain mindful of this in the years following treatment.

References

Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R. and Wanigaratne, S. (2010) Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: a Practical Treatment Guide, Wiley-Blackwell, Chichester.

Miller, W.M. & Rollnick, S. (2013) Motivational Interviewing, Third Edition: Helping People Change. Guilford Press, New York.

Ryan, F. Cognitive therapy for Addiction: Motivation and Change (2013). Wiley Blackwell.