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 i...
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% ...
4 Ms
Motivation and
engagement

Maintain
Change
(relapse
prevention)

Manage
impulsivity

Manage
Negative
emotions
Healthcare costs (in billions Euro)of emotional and addictive disorders in 30
European countries (27 EU Plus N, CH and Ice...
Five things about addiction
ADDICTION IS COMPULSIVE HABIT
COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF
CONSCIOUSNESS
AD...
Five More things…
“COME BACK WHEN YOU’RE MOTIVATED” IS NO LONGER AN
ACCEPTABLE THERAPEUTIC RESPONSE!
DIFFERENT PSYCHOTHERA...
Low Intensity
Interventions

Giving accurate information about
addiction, detoxification and relapse to
service user & fam...
Emotions Matter
When we experience negative emotions
drugs are more rewarding, as they are
reinforced both positively and
...
But not the full story...
Psychodynamic
tradition viewed drug
addiction as: “a
replacement for a
defect in the
psychologic...
The question of motivation……
In groups of three, discuss what drives
or motivates drug use or compulsive
gambling,.
Use ex...
Cognitive therapy

Addiction motivated by
need to cope with or
suppress the
consequences
maladaptive core
beliefs such as ...
Cognitive behaviour therapy
“Relapse Prevention
Skills Training” model
(Marlatt & Gordon,1985;
Marlatt & Witkiewitz,
2005 ...
Focus of CBT in Substance Misuse
Motivation, Motivation, Motivation!
Conceptualising, formulating and treatment planning
I...
Or, just do two things!
Facilitate impulse
control

Facilitate affective
regulation
• Formation of dysfunctional schemas e.g "I
am not as good as other people".
Early adverse learning
experiences

• Formati...
Current case
Maria: 30 yr-old female
Single, but lives with ex-partner
Experiences depressive and angry emotions
that trig...
New Perspectives
Treatment outcomes are often poor in addiction
Treatment specific effects not demonstrated (e.g.
Project ...
Vulnerability factors in addiction
Implications for psychotherapy
Why Drugs are Addictive
Drugs of abuse such as alcohol,
amphetamine cocaine act as
primary reinforcers.

This operates dir...
Two Pathways to emotion (& craving)
Information about emotionally
salient stimuli and stimuli
associated with drug availab...
Overview of scope and aims of CBT in Substance Misuse

Engaging and motivating individuals into therapeutic
programmes
Pla...
Cognitive control is impaired before during and after
substance misuse
Pre-existing –dispositional deficits

Acute effects...
Executive control is impaired
Up to six 6 years in after seeking treatment alcohol dependent people who are
largely abstin...
Key Concepts from psychology
Reflective system and impulsive system govern
behaviour – Reflective impulsive model (RIM) (S...
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...
Dual processing; fast and slow.

Cognitive
appraisal

Level of
processing

Controlled
processing
(slow)

Activation of
add...
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 defic...
Accordingly....
Result is distinctive “cognitive signature” and
behavioural dysregulation.
Remediation needs to overcome a...
Work in progress…..

Working

Top down
Processes
(goals and coping
strategies)

Memory

Bottom up
Processes
“Reward Radar”...
Cycle of pre-occupation
Attribution of incentive
salience

Attentional bias
Contents of
Working memory

Attentional bias

...
Any Questions?
Themes applied
Importance of goal maintenance
Rehearsal+ repetition+ reinforcement =
Reversal.
Importance of identifying a...
Cognitive biases are linked to craving
Cognitive biases are associated with
increased craving.
Increased craving leads to ...
But “reward radar” is always on!
Emphasis on reversal of
implicit cognitive
biases.
Focus on enhancing
cognitive control (...
Assessment and engagement
Begin with current concerns
Explore personal history
Elicit history of substance misuse:
Functio...
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...
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
powe...
Motivational Interviewing 1
Opening strategy:
ask about lifestyle, stresses and problem behaviour
A typical day
The good t...
Motivational interviewing 2
Elicit self-motivational statements:
e.g.” Its sounds like your partner is worried about your ...
Motivational interviewing 3
Roll with resistance: “you‟re not sure you want
to make a commitment to quit today”
Point out ...
Brief motivational encounters….
Establish rapport through empathy
Focus on raising the issue (i.e. substance misuse)
Build...
Assessing readiness and building
commitment to change
Importance
Readiness
Confidence
Ask: How important/ready/confident a...
Dealing with ambivalence

Identify an issue or
situation about which
you are ambivalent
about taking steps to
change.
In p...
Tried & Tested:
Summary of useful CBT techniques
Recognising or “capturing” automatic thoughts
Goal setting
Reality testin...
Five facets of impulsivity
Negative urgency: the tendency to act rationally when experiencing negative
emotions e.g. “When...
Structuring the session
•

•

•
•
•
•
•

Update on developments since previous encounter, with particular emphasis on
any ...
In summary:
the “20 20 20” rule
20 minutes: Review substance
misuse, give motivational
feedback, note current concerns
20 ...
Session by session monitoring:
COMET
Continuous
Outcome
Monitoring
During

Engagement
In

Treatment
Outcome Monitoring
Percentage days abstinent (PDA)

e.g. Client reports alcohol use on 4/7 days
(3/7)X100= 43% approximate...
Contingency management
Identify target behaviour e.g.
supplementary drug use;
testing or treatment for
hepatitis C. Emphas...
Just say no!
When offered drugs:
Say no first
Make direct eye contact
Don‟t be afraid to ask the person
to stop offering
D...
Manage impulses (urges) and craving: the “Reward
Radar” never switches off!
Stimulus Control
Implementation intentions
Be ...
Managing craving
Recognise thinking about drugs e.g “life is boring without cocaine”
or “I deserve a drink”. Include categ...
Implementing intentions to change
If situation X occurs I will
perform behaviour Y
e.g.
“If I have money I will do
my shop...
The Third M:
Manage mood
Conventional CBT
techniques: correcting
cognitive distortions;
problem solving;
exposure & behavi...
Three vulnerabilities
-genetic loading contributing to neurobiological vulnerability;
-exposure to adversity in childhood ...
Three sources of negative emotion
•
•
•

pre-existing negative affect due to dispositional traits and/or exposure
to adver...
Mindfulness
Mindfulness disrupts
automatic flow of cognitions
< contrasts with ironic or
paradoxical effects of effortful
...
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 ...
Mindful Recovery
Relapse Prevention Skills Training: identify high risk situations and
how to deal with them.
Goal Mainten...
“Road to recovery……is paved with good rehearsals.”
Successful execution of any task
requires both controlled and
automatic...
The Future:
Neuro-Cognitive Behaviour Therapy?
Emphasis both on remediation
of cognitive deficits and
reversal of cognitiv...
Summary
Impulse control and emotional control strategies should be
addressed sequentially, but as part of a formulated tre...
References
Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R. and
Wanigaratne, S. (2010) Applied Cognitive and ...
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Cognitive Therapy for Addiction

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Training on MSc in Cognitive Psychotherapy Course at Trinity College, Dublin 24th October 2013

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  • Stepped care framework is useful.
  • Implication here is that effective therapy for substance misuse needs to address negative emotions.
  • Mention my client who avoided wedding.
  • This is an example of the “biased competition” model of attention.
  • Reversing or modifying cognitive biases is likely to play an increasing role in this.
  • Cognitive Therapy for Addiction

    1. 1. Cognitive Behaviour Therapy for Addiction : Motivation and CHANGE MSc in CBT Dublin, October 24th 2013 Frank Ryan
    2. 2. 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
    3. 3. Time for CHANGE Change Habits And Negative Generation of Emotion (Ryan, 2006; 2013)
    4. 4. The Four Ms Motivate (and engage) Manage impulses to use Mood management Mindful recovery
    5. 5. 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)
    6. 6. 4 Ms Motivation and engagement Maintain Change (relapse prevention) Manage impulsivity Manage Negative emotions
    7. 7. 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 80 70 60 50 40 30 20 10 0 Depression Addiction Anxiety disorders
    8. 8. 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
    9. 9. 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
    10. 10. Low Intensity Interventions Giving accurate information about addiction, detoxification and relapse to service user & family Brief motivational interventions Contingency management Identifying triggers and cues Coping 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
    11. 11. Emotions Matter When we experience negative emotions drugs are more rewarding, as they are reinforced both positively and negatively.
    12. 12. But not the full story... Psychodynamic tradition viewed drug addiction as: “a replacement for a defect in the psychological structure”. Kohut (1971,p 46),
    13. 13. 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.
    14. 14. 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)
    15. 15. 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.
    16. 16. 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!”
    17. 17. Or, just do two things! Facilitate impulse control Facilitate affective regulation
    18. 18. • Formation of dysfunctional schemas e.g "I am not as good as other people". Early adverse learning experiences • Formation of substance related beliefs e.g. "I feel better about myself when I use cocaine or alcohol; people seem to like me more". Exposure to euphoric orhedonic effects of drugs such as alcohol and cocaine 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"
    19. 19. 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.
    20. 20. 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
    21. 21. Vulnerability factors in addiction
    22. 22. Implications for psychotherapy
    23. 23. 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. f.ryan@imperial.ac.uk
    24. 24. 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.
    25. 25. 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)
    26. 26. Cognitive control is impaired before during and after substance misuse Pre-existing –dispositional deficits Acute effects of intoxication Withdrawal effects Carry-over effects Associated risk factors due to injuries or self-neglect
    27. 27. 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
    28. 28. 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)
    29. 29. Motivational dynamics: conflict between impulse and control
    30. 30. 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.
    31. 31. Dual processing; fast and slow. Cognitive appraisal Level of processing Controlled processing (slow) Activation of addiction related beliefs. e.g "I will have more fun if I use cocaine" Cue detected Automatic processing (fast) Conditioned cue reactivity : somatovisceral arousal and approach tendency
    32. 32. Prelude to passion:Limbic activation by “unseen” sexual and drug cues. Childress et al 2008
    33. 33. Neural response at 33ms exposure specific to drug and sexual cues.
    34. 34. 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.
    35. 35. 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.
    36. 36. Work in progress….. Working Top down Processes (goals and coping strategies) Memory Bottom up Processes “Reward Radar” f.ryan@imperial.ac.uk
    37. 37. Cycle of pre-occupation Attribution of incentive salience Attentional bias Contents of Working memory Attentional bias f.ryan@imperial.ac.uk
    38. 38. Any Questions?
    39. 39. Themes applied Importance of goal maintenance Rehearsal+ repetition+ reinforcement = Reversal. Importance of identifying alternative goals and pursuing these in a systematic manner
    40. 40. 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
    41. 41. 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
    42. 42. Assessment and engagement Begin with current concerns Explore personal history Elicit history of substance misuse: Functional analysis (ABC)is helpful Work towards formulation
    43. 43. Formulation
    44. 44. Building resilience
    45. 45. 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.
    46. 46. The first M: Motivation and how to foster it
    47. 47. 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”.
    48. 48. Motivational Interviewing 1 Opening strategy: ask about lifestyle, stresses and problem behaviour A typical day The good things and the less good things about the current drug use Current concerns
    49. 49. 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”
    50. 50. 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….”
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. 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. f.ryan@imperial.ac.uk
    55. 55. 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)
    56. 56. 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.
    57. 57. 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!
    58. 58. Session by session monitoring: COMET Continuous Outcome Monitoring During Engagement In Treatment
    59. 59. 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.
    60. 60. 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
    61. 61. 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!
    62. 62. 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
    63. 63. 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
    64. 64. 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)
    65. 65. The Third M: Manage mood Conventional CBT techniques: correcting cognitive distortions; problem solving; exposure & behavioural experiments Pharmacotherapy
    66. 66. 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.
    67. 67. 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.
    68. 68. Mindfulness Mindfulness disrupts automatic flow of cognitions < contrasts with ironic or paradoxical effects of effortful suppression> Mindful acceptance should influence outcomes by reducing intrusion
    69. 69. Sober breathing space S top O bserve B reathe E xpand R espond (not react!)
    70. 70. 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
    71. 71. 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.
    72. 72. “Road to recovery……is paved with good rehearsals.” Successful execution of any task requires both controlled and automatic processingTreatment 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)
    73. 73. 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.
    74. 74. 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.
    75. 75. 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.

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