CBT WORKSHOP - DTCB
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Cognitive Behavioural Therapy (CBT) Workshop
The purpose of this workshop exercise is to give delegates a general introduction to the basic principles of CBT as applied to adolescent substance misuse.
In addition to a basic theoretical review of CBT principles, delegates will also get the opportunity to experience conducting an interview with the aim of (i) developing a functional analysis explaining a client’s difficulties from a learning theory perspective and (ii) suggest the development and implementation of skills based interventions that will benefit the client.
It is hoped that this experience will enable delegates to gain an understanding of Beck et al's. thoughts as expressed below.
"By weaving together the patients history, constellation of beliefs and rules, coping strategies, vulnerable situations, automatic thoughts and images, and maladaptive behaviours, the therapist has a better understanding of how patients become drug dependent ... The therapist is guided to ask important relevant questions and to develop strategies that are most likely to succeed "
(Beck et al. 1993, pg. 80)
General Introduction to CBT
Basic CBT principles and foundations will be reviewed prior to commencing the practical aspects of the workshop. It will be stressed that CBT is a heterogeneous approach combining the principles of Cognitive Therapy and Behaviour Therapy. Behaviour Therapy is a psychotherapy that seeks to extinguish or inhibit abnormal or maladaptive behaviour by reinforcing desired behaviour and extinguishing undesired behaviour. Cognitive Therapy is “a system of psychotherapy that attempts to reduce excessive emotional reactions and self defeating behaviour by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions” (Beck et al. 1991, pg. 10)
During treatment abnormal thinking is changed by verbal techniques (i.e. explanation, discussion, questioning of assumptions) as well as by behavioural actions which modify the way someone thinks (i.e. the client learns from their experience). There is an emphasis on learning and practising a variety of coping skills (some cognitive and some behavioural). At a “deeper level”, schema (fundamental core beliefs) which give rise to enduring assumptions, attitudes and thoughts which set in motion problematic behaviours such as drug misuse may also be a focus of attention.
Major Historical Figures
Some of the contributions of major figures in the development of CBT will also be briefly discussed.
Epictetus who lived between 55AC- 135 AC is often regarded as being the first cited “cognitive psychologist” given his quote that “People are not disturbed by things but by the view they take of them”.
In the 20th Century Albert Ellis explored the relationship between thoughts, beliefs, feelings and behaviour, noting that one's past experiences shape one’s belief system and thinking patterns. He argued that illogical, irrational thinking patterns cause negative emotions and further irrational cognitions. He described the manner in which irrational assumptions could produce maladaptive emotions and behaviours.
Ellis is well known for his useful “A- B- C- D- E” model which showed how “Activating Events” could stimulate “Beliefs” (rational, flexible, realistic and undemanding or irrational, rigid, unrealistic and demanding). Depending on the nature of the beliefs held by the individual, the consequences (A+ B= C) could either be the experience of healthy negative emotions (sadness, concern, regret, disappointment, healthy anger) or unhealthy negative emotions (depression, anxiety, shame, hurt, jealousy, envy). The therapeutic process entails disputing (D) irrational beliefs with the effect of creating rational beliefs thus generating new more adaptive emotions (E).
Seligman’s notion of “learned helplessness” and how client perceptions about their helplessness, the “futility of their actions”, their perceived lack of control and how pessimistic “explanatory styles” (personal, pervasive, or permanent) that are correlated with depression can be modified, will also be briefly covered.
Meichenbaum similarly identified the recurring thoughts of anxious people and how individual actions can result from “self talk”. Arising from this finding, “instructional” or “self talk” (changing internal and external dialogue together with the teaching of coping skills) was developed. Thus “Self Instructional Inner Dialogue”- a method to talk oneself through a problem or situation as it arises, was established.
Aaron Beck discovered two cognitive abnormalities with depressed patients. That is they tended to suffer from repeated intrusive thoughts (i.e. low self-regard, self-criticism, self-blame and critical injunctions) as well as cognitive distortions (“errors of logic”). Arising from the above he developed the notion of the “cognitive triad” with depressed patients viewed as holding a negative view of the self, a negative interpretation of current experience (world/ others) and a negative view of the future.
Beck’s proposed model of the cognitive processes salient to drug misuse will also be discussed. This includes “Core Beliefs” (or “Maladaptive Schema), those psychological templates developed as a consequence of "messages" received from life experiences as expanded by the work of Jeffrey Young, former Director of Aaron Beck's CBT Institute in Philadelphia. Also covered will be ‘Conditional Assumptions’ or ‘Rules’; ‘Compensatory Strategies’; ‘ Addictive or Drug beliefs’; ‘Automatic thoughts’; Emotions (associated with the aforementioned); ‘Vulnerable Situations or Triggers’ (which activate drug related cognition) and the drug- related behaviours which are the resultant end product of the above process.
As CBT- based practitioners consider adolescent substance misuse behaviours (and related problems) as learned behaviours, initiated and maintained in a particular environmental context, those learning principles salient to the genesis (and therefore treatment) of addiction such as ‘Operant Conditioning’, ‘Classical Conditioning’ and the ‘Social Learning Model’ will be discussed.
Whilst CBT is not a single unitary approach, the two shared hallmarks of CBT are the performance of a ‘Functional Analysis’ and ‘Skills Training’. In conducting a Functional Analysis the therapist attempts to discover “why” clients are using drugs? What do they need to do to recognise, avoid and cope with triggers? What are their obstacles to abstinence/ reduction and what are the determinants of their drug use (social, environmental, emotional, cognitive and physical)?
During the process of Skills Training, the client and therapist implement strategies and interventions which will assist with modifying or reducing identified problem behaviours. A wide range of techniques such as: Self Monitoring, Graded Task Assignment, Activity Scheduling, Behavioural Contracting, Modelling, Refusal Skills, Communication Skills, Social Skills Training, challenging and correcting inaccurate distorted thoughts and maladaptive core beliefs as well as Relapse Analysis (preparation, prevention and feedback), Psycho- education and Relaxation Training may be utilised
A proposed model of treatment based on NIDA treatment foundations and the work of Beck et al. (1993) will also be outlined. Key aspects of treatment such as the importance of the therapist- client relationship; using Motivational Interviewing strategies to when starting treatment; working towards early abstinence; maintaining abstinence and ensuring relapse prevention; establishing healthy behaviours and a more balanced lifestyle after cessation of a drug focussed lifestyle; developing those skills required to more effectively cope with life's problems; managing underlying or related co- morbid conditions; and employing skills to effectively manage (ad hoc) crises will be outlined.
Having reviewed this background information, delegates will be invited to participate in a practical exercise integrating the above theoretical material.
Kevin Ducray
Senior Clinical Psychologist
The Drug Treatment Centre Board
November 2006
References:
Beck, A.T., Rush, A., Shaw, B.F. & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press.
Beck T. A., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive Therapy of Substance Abuse. New York: Guilford Press.
Carroll, K.M. (1996). Relapse prevention as a psychosocial treatment approach: A review of controlled clinical trials. Exp Clin Psychopharmacol 4:46-54.
Carroll, K.M., Rounsaville, B.J.and Keller, D. (1991) Relapse prevention strategies for the treatment of cocaine abuse. Am J Drug Alcohol Abuse 17(3): 249- 265
Ellis, A. (1962). Reason and Emotion in Psychotherapy. New York: Lyle Stuart
Ellis A. & Harper R. (1975) A New Guide to Rational Living, Hollywood, Wilshire Book Company.
Kaminer, Y. & Burleson, J. A. (1999). Psychotherapies for adolescent substance abusers: 15 month follow-up of a pilot study. American Journal on Addictions, 8, 114-119.
Kaminer, Y., Burleson, J. A., Blitz, C., Sussman, J., & Rounsaville, B. J. (1998). Psychotherapies for adolescent substance abusers: A pilot study. Journal of Nervous and Mental Disorders, 186, 684-690.
Marlatt, G.A., and Gordon, J.R., (Eds.) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford, 1985.
Marlatt, GA. (Ed.) (1998). Harm Reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guildford Press.
National Institute on Drug Abuse.Therapy Manual For Drug Addiction (Manual 1) “A Cognitive- Behavioral Approach: Treating Cocaine Addiction”. NIH Publication Number (98- 4308). Printed April 1998.
Seligman M. (1992) Learned Optimism, Sydney, Random House, 1992.
Waldron, B. W.and Kaminer, Y. (2004) On the learning curve: the emerging evidence supporting cognitive- behavioral therapies for adolescent substance abuse. Addiction, 99 (Suppl. 2), 93- 105.
Williams, C. J. and Garland, A. (2002). A cognitive- behavioural therapy assessment model for use in everyday clinical practice. Advances in Psychiatric Treatment, 8: 172- 179.
Wright, B., Williams, C. J. and Garland, A. (2002) Using the Five Areas cognitive- behavioural model with psychiatric patients. Advances in Psychiatric Treatment, 8: 307 - 315.
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