Cognitive Behavioral Therapy


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Cognitive Behavioral Therapy

  1. 1. Cognitive- Behavioral Therapy Core Competencies Instructors: Dr. Reo Leslie, LMFT, LPC, CAC III OR Evelyn Leslie, MA, CAC III, RPT-S
  2. 2. What do the instructors bring to this topic?  Dr. Reo Leslie, LMFT, LPC, CAC III has 32 years of post-masters experience in counseling, teaching, training, and supervision.  Mrs. Evelyn Leslie, M.A. CAC III, RPT-S, DAACS has 15 years of post-masters experience in counseling, teaching, training, and supervision.
  3. 3.  Upon completion of this class, students will be able to:  Define CBT and describe the basic theory behind it.  Describe the use of CBT for managing thoughts, de- escalating cravings and triggers, and handling relapse  Describe how the use of CBT helps clients increase their capacity to change thoughts, attitudes, behaviors and core beliefs.  Recognize that thoughts, feelings, and behaviors are interconnected  Recognize that lasting change occurs outside of therapy Course Goals
  4. 4. Goals cont.  Convey to clients that core beliefs and maladaptive behaviors are learned and can be unlearned, and/or replaced with adaptive, pro-social behaviors  Complete a cognitive case conceptualization that includes strenghts, deficits, and client needs and a treatment plan that addresses goals for changes in the client’s cognition and behavior  Know how to use a thought record with a client to help change cognition and behavior
  5. 5. Day One- Review of CBT Theory and Practice  Basic Concepts in CBT  Efficacy of CBT in Colorado  Theoretical Foundations of CBT  Structure of CBT Sessions  Review of Day One  Pre-Test
  6. 6. Day Two- Application and Skill Demonstration of CBT  Cultural Competency  Assessment Using CBT  Treatment Planning With CBT  Utilizing a Specific CBT Model- BECCI  Feedback to Students  Review of Day Two  Class Final Exam
  7. 7. Knowledge:  Research in support of CBT for substance use disorders and other problems- The modality is research-based and evidence-based according to Colorado studies ( Division of Criminal Justice, Department of Corrections, State Court Administrator, etc.) and National studies (SAMSHA, National Institute for Corrections, etc.)  Definition of CBT  In relation to substance use disorders, “CBT attempts to help clients RECOGNIZE the situations in which they are most likely to use, AVOID these situations when appropriate, and COPE more effectively with a range of problems and problematic behaviors associated with substance use.” (Carol. 1998, p. 1)
  8. 8. Theoretical Foundations for CBT  Cognitive Theory  “a system of psychotherapy that attempts to reduce excessive reactions and self-defeating behaviors by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions” (Beck et al. 1991, p. 10)  Disturbance in behaviors, emotions and thoughts can be modified or changed by changing and altering cognitive processes  Change your thoughts and your behavior will follow
  9. 9. Theoretical Foundations (cont)  Cognitive elements and structures  Automatic thoughts  Rules, values and attitudes  Core belief structures  Value Clarification  Behavioral Theory  Social Learning Theory  Modeling  Operant conditioning  Classical conditioning  Intrapersonal skills  Interpersonal skills
  10. 10. Essential/Active Clinical Ingredients of CBT  Collaborative, empathic relationship between therapist and client  Functional Analysis  Cognitive Reconstruction  Coping Skill Development  Training in;  Recognizing and coping with craving  Managing thoughts  Problem solving  Planning for emergencies  Recognizing seemingly irrelevant decisions  Refusal skills  Self monitoring of situations, thoughts, and behaviors  Examination of client’s cognitive processes related to substance use and/or current problem  Identification and debriefing of past and future high-risk situations  Encouragement and review of extra-sessions implementation of skills  Practice of skills within sessions
  11. 11. Basic Principles of CBT for Addiction Counseling  CBT is a research-based, evidence-based, value-driven, goal driven, psychoeducational, and collaborative therapeutic process  The psychotherapist and client decide together on appropriate treatment goals and work toward these goals as the basis of addiction counseling  CBT may be used for individual, group, couple, or family therapy with addiction and other clients  Research shows CBT must be followed, not only verbalized, in order to be effective with addiction clients
  12. 12. Clinical Assumptions of CBT  Anti-social behavior that is learned can be unlearned and replaced with new learned pro- social behavior  Human beings are social creatures and can be changed by changing social environments and thought processes  Psychotherapists facilitate change in clients by helping the client understand the systemic relationship between situations, thoughts, emotions, behaviors, and consequences
  13. 13. What are things I need to understand as a CBT therapist?  Modeling  Session Structure  Directive Approach  Classical Conditioning  Operant Conditioning  Functioning Analysis  Cognitive Restructuring  Coping Skill Development
  14. 14. Structure and Format of CBT  Initial session of CBT-  Develop rapport  Setting the session agenda  Reviewing client history  Educating the client about their disorder  Educating client about psychotherapy and CBT  Normalizing client issues  Instilling hope  Establishing client treatment goals  Correcting (if necessary) client’s therapy goals  Assigning homework  Summarizing  Bridging  20/20/20 Rule- Structured follow up in each subsequent session
  15. 15. 20/20/20 Rule- Structured Follow Up to the Initial Session  First 20 Minutes- Assess substance abuse, craving, and risk situations since the last session  Second 20 Minutes- Introduce the session topic, discuss the concepts, and relate discussion to current issues  Third 20 Minutes- Explore client response to the topic, assign homework for the next session, and anticipate tasks and risks ahead for the week
  16. 16. What does the State of Colorado think of CBT?  Specific CBT programs have been used and evaluated in psychotherapy with drug-related criminal offenders:  Aggression Replacement Training (ART)  Moral Reconation Therapy (MRT)  Reasoning and Rehabilitation (R and R)  Thinking for a Change (T4C)  Criminal Conduct and Substance Abuse Treatment Strategies for Self Improvement and Change (SSC)
  17. 17. How is CBT used in Colorado for treatment of our clients?  Probation  Recidivism Reduction  Assessment  Treatment Planning  Treatment Delivery  Reducing Therapeutic Resistance in the Addiction Counseling Process  Matching the level of care to the client’s motivational stage of change
  18. 18. Knowledge:  The structure and format of sessions  20/20/20 rule following the structured initial session  CBT is compatible with;  Pharmacotherapy for drug/alcohol use and/or co- occurring mental health disorders  Self-help groups such as AA and the other 12-step programs  Family and couple therapy  Vocational counseling, parenting skills, etc.  Psychoeducational approaches  Motivational Interviewing and Motivational Enhancement Therapy
  19. 19. CBT- The Clinical Approach for Our Client Population  Office of Research and Statistics Data, State of Colorado, Division of Criminal Justice (2006)  Males- 39% have a history of mental illness; 79% have drug and alcohol problems, 23% have current mental health problems  Females- 53% have a history of mental illness; 91% have drug and alcohol problems, 36% have current mental health problems  Mentally ill clients in jail have an average stay that is four times longer (120 days vs. 32 days) than the average incarcerated person
  20. 20. Knowledge:  Interventions not part of CBT  Excessive self-disclosure by the therapist  Use of confrontational style/confrontation of denial approach  Requiring the patient to attend self-help groups  Extended discussion of 12-step recover, higher power, “Big Book” philosophy  Use of disease model language or slogans  Extensive exploration of interpersonal aspects of substance abuse  Extensive discussion or interpretation of underlying conflicts or motives  Provision of direct reinforcement for abstinence (vouchers, tokens)
  21. 21. Knowledge:  Similar approaches Cognitive therapy Community Reinforcement Approach Motivational enhancement therapy  Family Psychoeducation  Dissimilar approaches Twelve-step facilitation Interpersonal psychotherapy  Confrontational approaches
  22. 22. Skills:  Initiate a collaborative working relationship with clients  Perform a functional analysis Deficiencies and obstacles Skills and strengths Determinants of Use or problem behavior  Social  Environmental  Emotional  Cognitive  Physical  Situational  Systemic or Cultural
  23. 23. Skills:  Write treatment plan goals targeting both behaviors and cognitive structures identified through assessment and functional analysis  Ability to teach self assessment and coping skills  Ability to facilitate skill practice  Assign extra-session implementation of skills and offer appraisal as appropriate based on functional analysis and client willingness  Ability to lead clients in guided discovery  Ability to keep session focused on CBT related treatment goals  Ability to match client interventions to appropriate stage of change
  24. 24. Attitudes:  People can and do change thoughts, feelings, behaviors and beliefs  Change is a process, not an event  CBT addresses a comprehensive range of client difficulties  Thoughts, feelings and behaviors are interconnected  Lasting change occurs outside of therapy  Maladaptive and anti-social behaviors are learned and can be unlearned, and/or replaced with adaptive, pro-social behaviors  If you can learn, you and unlearn, and learn something else
  25. 25. Key Concepts of CBT for Clients  Classical conditioning- Understanding stimulus and response in triggering craving and response to triggers  Operant conditioning- Reward and punishment in relationship to antisocial behavior or pro-social behavior.  Both are essential in treatment of addictive and compulsive behavior
  26. 26. CBT Outcome Studies  From: Academy of Cognitive Therapy – For Professionals: CBT Outcome Studies  Web Address:  Cognitive Behavioral Therapy (CBT) has been demonstrated in hundreds of studies to be an effective treatment for a variety of disorders and problems for adults, older adults, children and adolescents. ADULTS  CBT has been clinically demonstrated through randomized controlled trials to be an effective treatment for the following disorders and problems:  Depression  Geriatric Depression  Relapse Prevention  Anxiety  Generalized Anxiety Disorder  Panic Disorder  Agoraphobia and Panic Disorder with Agoraphobia  Social Anxiety / Social Phobia  Obsessive-Compulsive Disorder  Post-Traumatic Stress Disorder (Trauma)  Withdrawal from Anti-Anxiety Medications
  27. 27. CBT Outcomes (cont)  ADULTS(cont)  Bipolar Disorder (in combination with medication)  Eating Disorders  Binge-eating disorder  Bulimia  Anorexia  Body Dysmorphic Disorder (extreme dissatisfaction with body image)  Substance Abuse  Cocaine abuse (CBT relapse prevention is effective)  Opiate Dependence  Smoking Cessation (Group CBT is effective, as well as CBT that has multiple treatment components, in combination with relapse prevention)  Marital discord  Anger  Borderline Personality Disorder  Atypical sexual practices/sex offenders
  28. 28. CBT Outcomes (cont)  Medically related disorders:  Chronic pain (CBT, in combination with physical therapy, is effective for chronic pain in many medical conditions)  Chronic back pain  Sickle cell disease pain (CBT that has multiple treatment components is effective)  Physical complaints not explained by a medical condition (Somatoform disorders)  Irritable-bowel syndrome  Obesity (CBT is effective in combination with hypnosis)  Rheumatic disease pain (CBT that has multiple treatment components is effective)  Erectile dysfunction (CBT is effective for reducing sexual anxiety and improving communication)  Sleep disorders  Geriatric sleep disorders  Insomnia  Vulvodynia (a chronic pain condition of the vulva)  Chronic fatigue syndrome
  29. 29. CBT Outcomes (cont)  INITIAL STUDIES CBT has been clinically demonstrated to be an effective treatment in case series, same-investigator studies, or studies without a control group for the following problems and disorders (among adults unless otherwise noted):  Geriatric Anxiety  Schizophrenia (in combination with medication)  Dissociative Disorders  Suicide attempts  Substance/alcohol abuse  Attention deficit disorder  Caregiver distress  Habit disorders  Medically related disorders:  Migraine headaches  Non-cardiac chest pain  Cancer pain  Pain relating to a disease that has no known cause (Idiopathic pain)  Hypochondriasis, or the unsubstantiated belief that one has a serious medical condition
  30. 30. CBT Outcomes (cont)  Medically related disorders: (cont)  Chronic pain (among children/adolescents)  Hypertension (CBT is effective as an adjunctive treatment)  Fibromyalgia  Colitis  Gulf War Syndrome  Tinnitus  CHILDREN AND ADOLESCENTS CBT has been clinically demonstrated in randomized controlled trials to be an effective treatment for the following disorders and problems:  Depression (among adolescents and depressive symptoms among children)  Anxiety disorders  Separation anxiety  Avoidant disorder  Overanxious disorder  Obsessive-compulsive disorder  Phobias  Post-traumatic stress disorder
  31. 31. CBT Outcomes (cont)  CHILDREN AND ADOLESCENTS (cont)  Conduct disorder (oppositional defiant disorder)  Distress due to medical procedures (mainly for cancer)  Recurrent abdominal pain  Physical complaints not explained by a medical condition (Somatoform disorders)  COGNITIVE BEHAVIORAL THERAPY IS ALSO USED FOR:  Stress  Low self-esteem  Relationship difficulties  Group therapy  Family therapy  Work problems & procrastination  Pre-menstrual syndrome  Separation and Divorce  Grief and loss  Aging
  32. 32. Colorado Research Outcome Studies  Downloadable from the Research and Article Websites at The State of Colorado Division of Public Safety  Key Resource: What Works: Effective Recidivism and Risk-Focused Prevention Programs: A Compendium of Evidence-Based Options for Preventing New and Persistent Criminal Behavior, Prepared for the Colorado Division of Criminal Justice, RKC Group, Roger Przybyiski, February, 2008, Chapter 5, pp. 61-67
  33. 33. Review of Day One  CBT Basic Concepts  Efficacy of CBT  CBT Theory  CBT Research Outcome  Pre-Test
  34. 34. DAY TWO- CBT Application and Skill Demonstration  Cultural Competency  Assessment Using CBT  Treatment Planning Using CBT  Treatment Using CBT-BECCI  Feedback to Students  Review  Final Exam
  35. 35. Cultural Competency  Research shows CBT works with a variety of addiction clients from diverse cultural backgrounds  Student discussion in small groups: How do you make allowances for CBT with culturally different clients?  What worked? What did not work?
  36. 36. Assessment Using CBT  Matching the Client’s Stage of Change and Motivational Level to Treatment Goals  Determining Dynamics of Integrated Treatment for Client (Skills and Pills)  Determining Degree of Required Cognitive Reconstruction, Functional Analysis, and Coping Skill Development  Determining the Severity of the Dysfunction  Determining if Cognitive Impairment is a Clinical Factor
  37. 37. CBT Assessment and Treatment Tools (Review of Handouts with Students)  Biopsychosocial Assessment  What Do I Want From Treatment?  Decision Balance Workshop  Change Plan  Support Plan  The Cost of My Recent DUI  Coping With Thoughts About Cocaine  All Purpose Coping Plan  Functional Analysis
  38. 38. Relevant Assessment and Treatment Domains for CBT  Cultural  Social  Situational  Environmental  Cognitive  Family Systems  Emotional  Physical
  39. 39. Treatment Planning with CBT  What are the individual counseling treatment goals?  What are the group counseling treatment goals?  What are the couple, marriage, and family therapy goals?  Is the client a substance abuser, mentally ill, in the Criminal Justice System, or all three?  Student discussion of CBT treatment planning issues at the students’ context of clinical practice
  40. 40. Application and Skill Demonstration of a Specific CBT Model- BECCI  What does doing CBT based addiction actually look like?  Behavior Change Counseling Index (BECCI) – Integrative tool for evaluation of CBT, Motivation Enhancement Therapy, and Motivational Interviewing Counseling Skills with individuals, groups, couples, and families  Students will role play and demonstrate the ability to utilize CBT counseling skills with Addictive and Compulsive Behavior Clinical Issues  Counselor, Client, and Observer Rotation
  41. 41. Behavior Change Counseling Index (BECCI) Review  D:Documents and SettingsCLocal SettingsTemporary Internet FilesContent.IE5GHIJKLMNBECCI Scale Feb 2003[1].doc © University of Wales College of Medicine 2002  For enquiries about BECCI, please contact Dr. Claire Lane  BECCI is an instrument designed for trainers to score practitioners’ use of behavior change  Counseling in consultations (either real or simulated). To use BECCI, circle a number on the scale attached to each item to indicate the degree to which the patient/practitioner has carried out the action described.  As a guide while using the instrument, each number on the scale indicates that the action was carried out: 0. Not at all 1. Minimally 2. To some extent 3. A good deal 4. A great extent  For each item, identify a score based on the scale above.
  42. 42. BECCI Items  The Items:  1. Practitioner invites the patient to talk about behavior change  2. Practitioner demonstrates sensitivity to talking about other issues  3. Practitioner encourages patient to talk about current behavior or status quo  4. Practitioner encourages patient to talk about change  5. Practitioner asks questions to elicit how patient thinks and feels about the topic  6. Practitioner uses empathic listening statements when the patient talks about the topic  7. Practitioner uses summaries to bring together what the patient says about the topic  8. Practitioner acknowledges challenges about behavior change that the patient faces  9. When practitioner provides information, it is sensitive to patient concerns and understanding  10. Practitioner actively conveys respect for patient choice about behavior change  11. Practitioner and patient exchange ideas about how the patient could change current behavior
  43. 43. BECCI Scoring  Practitioner BECCI Score: (based on totals from item list)  Practitioner speaks for (approximately):  More than half the time  About half the time  Less than half the time  Student/Observer/Instructor Review of Roleplaying
  44. 44. REVIEW OF DAY TWO  CBT and Cultural Competency  CBT Assessment  CBT Treatment Planning  CBT Treatment  CBT Skill Demonstration and Roleplaying- BECCI  Final Exam
  45. 45. Resources (Handout)  Beck, A.,Wright, F., Newmand, C., & Liese, B. Cognitive Therapy of Substance Abuse. New York: Guildford Press, 1993.  Beck, J.S. Cognitive Therapy: Basics and Beyond. New York: Guildford Press, 1995.  Carroll, K. M. NIDA Therapy Manuals for Drug Addiction: Manual 1: A Cognitive Behavioral Approach: Treating Cocaine Addiction. #98-4308.  Dobson, K. S. Editor. Handbook of Cognitive Behavioral Therapies: Second Edition. New York: Guildford Press, 2002.
  46. 46. Resources, cont. (Handout)  Leahy, R. L. Overcoming Resistance in Cognitive Therapy. New York: Guildford Press, 2003.  Leahy, R. L. Roadblocks in Cognitive Behavioral Therapy: Transforming Challenges in Opportunities for Change. New York: Guildford Press, 2003.  Miller, W. & Rollnick, S. Motivational Interviewing: Preparing People to Change Addiction Behaviors, 2nd Edition. New York: Guildford Press, 2002.  SAMHSA Treatment Protocols. Tip 8: Intensive Outpatient Treatment for Alcohol and Other Drug Abuse.
  47. 47. Resources cont. (Handout)  SAMHSA Treatment Protocols. Tip 21: Combining Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles in the Justice System.  SAMHSA Treatment Protocols. Tip 34: Brief Interventions and Brief Therapies for Substance Abuse.  SAMHSA Treatment Protocols. Tip 39” Substance Abuse Treatment and Family Therapy.  Straussner, S. L. Clinical Work with Substance Abuse Clients, 2nd Edition. New York: Guildford Press, 2004.  Wright, J.H., Basco, M.R. & Thase, M.E. Learning Cogivitve Behavioral Therapy: An Illustrated Guild. Washington DC: American Psychiatric Publishing, Inc., 2006.