The document discusses using cognitive behavioral therapy (CBT) and mindfulness techniques in addiction treatment. It provides an overview of how CBT can be used to identify and modify dysfunctional thought patterns. Mindfulness is presented as a way to become more aware of thoughts and reduce judgment. Specific CBT and mindfulness strategies are outlined, such as keeping a thought record, challenging automatic thoughts, and practicing non-judgment.

1. Cognitive Behavioral Therapy and Mindfulness in Addiction Treatment Tony Pacione, LCSW, CSADC

2. Objectives On our Slate for today… Why CBT/Mindfulness for addictions? Role of automatic thoughts Identifying and changing thought patterns Self management of mood, and craving states Understand and Define Mindfulness Meditation (Dr. Angres) For HRC… Implement CBT and Mindfulness Disclaimers…

3. In Early Recovery, Cover Your… A S S ccountability tructure upport Pacione and Buino, 2009

4. Accountability… … for WHAT you are responsible in recovery Understanding your thoughts Identifying thinking patterns Willingness to change ineffective thinking

5. Structure… … HOW you achieve your goals in recovery Thought log Challenging thoughts ‘Acting as if’ strategies Meditation/mindfulness techniques

6. Support … …WHO will support your efforts Treatment Counselors Sponsor Therapist Psychiatrist Self-help Family/friends

7. Cognition How thoughts are: Formed Maintained Discontinued Intensity of thoughts

8. Cognitive Schema: A Beck, 1993 Automatic Thoughts (Mental) Reactions to situations Real Imaginary/perceived Anticipatory Association among feelings, mood, and beliefs, behaviors

9. Cognitive Schema Conditional Beliefs More general than automatic thoughts Boolean logic: “If… than; and/or” Assumptions Roles/expectations Attitudes/values

10. Cognitive Schema More general than conditional beliefs Strongly held beliefs, underlying assumptions about who we are and our world Develop early in life and are often reinforced as we age Can become a ‘filter’ for interpreting life experiences (“self-fulfilling prophecies”) Can be identified and changed! Core Beliefs (Self Efficacy)

11. Cognitive Schema: Core Beliefs Two ‘varieties’ of defective core beliefs - Beck 1993 Un-lovable unworthy; irrelevant; needy; self-centered Incompetent defective; helpless; failure; screw-up

12. The Complete Cognitive Schema Relevant Childhood and Developmental data: Core Beliefs: Conditional assumptions (if/then): Compensatory Strategy: Situation: Automatic Thoughts: Emotions: Behavior:

13. Cognitive Restructuring Observe thoughts Identify thinking patterns Identify cognitive distortions Challenge cognitive distortions Construct alternative thoughts/beliefs Complete cognitive schema Behavioral Experiments (“act as if”) Validate (#1) (DPW3 = GTH)

14. Thought Record (Steps 1-2) 42 y/o female alcoholic Situation/Event Automatic Thought Related Feeling Rating Mood and Desire/Craving (1-10) I fought with my husband over missing our son's basketball game to attend an AA meeting. “ He is not supporting my recovery." Anger Frustration Misunderstood 6 My husband invites me to his holiday work party; I remember last year’s party when I had leave because I was so intoxicated. “ I am an embarrassment to my husband and a bad wife. Guilt Depression 8 My sister is hosting the holiday dinner this year and asks me to make a run to the liquor store to buy the supplies for the event. “ She is insensitive and Putting me in a bad position for a relapse.” Anger Hurt 6 I tell me boss I’ve been struggling with my recovery and he really wants to help me get sober. “ I am a bad employee for letting my drinking affect my work.” Frustration Guilt 8 I’m celebrating my son’s birthday, and realize I’ve missed many of his achievements and milestones because of my drinking “ I am a bad mother for letting him down for so long.” Guilt Depression 10

15. Common Cognitive Distortions (Step 3) Dichotomous thinking Overgeneralization Mental filters Jumping to conclusions ‘ Catastrophizing’ Emotional reasoning Personalization Burns, D. 1999

16. Thought Record - Cognitive Distortions (Steps 3) 42 y/o female alcoholic Overgeneralization and catastrophizing Emotional reasoning and dichotomous thinking Catastrophizing Emotional reasoning and dichotomous thinking Emotional reasoning and dichotomous thinking “ He is not supporting my recovery.” “ I am an embarrassment to my husband and a bad wife.” “ She is insensitive and putting me in a bad position for a relapse.” “ I am a bad employee for letting my drinking affect my work.” “ I am a bad mother for letting him down for so long.”

18. Challenging Automatic Thoughts (Steps 4-5) Using I.C.E. to cool off ‘Hot’ thoughts I – Identify/rate the thought C – Challenge the thought E – Evaluate/re-rate the truthfulness of the thought A. Pacione, 2003

19. I.C.E. (Steps 4-5) I dentify and rate the thought: “I’ve missed so many of my son’s achievements because of drinking. I I am a bad mother.” truthfulness rating = 90% (of the time) C hallenge the thought: I didn’t attend a single one of his basketball games last season, when all the other mothers were there. I realized I had a problem and sought treatment; If I am sober I can be there for him from now on. He did poorly in math class because I wasn’t there to help him with his homework. I have made sure he always had a roof over his head and food on his plate. I couldn’t chaperone his class field trip because I didn’t want anyone to see me with the shakes. I’ve always made sure to tell him he is loved and that he is an extraordinary person. EVIDENCE FOR EVIDENCE AGAINST

20. I.C.E. cont. (Step 4-5) E valuate/re-rate the thought: Post challenge truthfulness rating = 30% Revise the thought: “I’ve let him down in the past, but I am doing everything I can now to stay sober; I can be more present for my son.”

21. Practice Time! ICE your colleague

22. Cognitive Grid (Step 6) Relevant Childhood and Developmental Data: Absent mother; alcoholic father Core Belief: “I’m un-lovable.” Conditional assumptions (if/then): “If I am a good mother I will feel loved by my son; then I am lovable!” Compensatory strategy: “Make sure I am always available for him, whatever he needs.”

23. Cognitive Grid continued Situation: Missed a lot of my son’s achievements while drinking. Automatic Thoughts: “I am a bad mother.” “My son doesn’t love me” Emotions: “Depression and guilt” Behavior(s): Increased potential for isolation, self-sabotage, and relapse

24. Challenging Core Beliefs (‘acting as if’ - Step 7) Amended Core Belief: “If I remain sober, I’ll be a better mother. I can be loved for who I am.” How to ‘act as if’ you’re a good mother: Attend my son’s basketball games when I can Offer to help him with his homework Tell him I love him and praise his good work Set limits and rules for him to follow

25. Practice Time! Create a Cognitive Grid

26. Mindfulness = Becoming More Aware More Often “ A powerful influence taking us away from being ‘fully present’ in each moment is our automatic tendency to judge our experience as being not quite right in some way—that it is not what should be happening, not good enough, or not what we expected or wanted. These judgments can lead to sequences of thoughts about blame, what needs to be changed or how things could or should be different. Often, these thoughts will take us, quite automatically down some fairly well-worn paths in our minds. In this way, we may lose awareness of the moment, and also the freedom to choose what if any, action needs to be taken.” Segal, et al. 2002

27. Mindfulness in recovery Thoughts  Judgments  Actions  Consequences Becoming more aware more often of Thinking patters Situations that activate your core belief Urges and craving to use

28. CBT + Mindfulness CBT = modifying perception beliefs and thoughts judgment Mindfulness = being more aware more often less interested in thought content focus on arising and ceasing of thought (DPW3= GTH)

29. Principles of Mindfulness Non-judging Patience Fresh Mind Trust Non-striving Acceptance Letting Go Kabat-Zinn, 1990

30. 1. Non-judging Become aware of the judging thoughts Notice how often we label and categorize – assigning value to people and experiences Pain Vs. Suffering

31. 2. Patience Be completely open to each moment Accept each moment in its fullness Know that life can only unfold in its own time

32. 3. Fresh Mind See things as if for the first time Be receptive to new possibilities – prevents getting stuck Experiment Try having a fresh mind with your partner, child, patient, or someone else familiar to you

33. 4. Trust Develop trust within yourself Knowing when to seek help You can’t have all the answers Don’t compare yourself to others The more we trust ourselves, the easier it is trust others and seek help

34. 5. Non-striving Allowing anything we experience from moment to moment to just be here Thinking of how you “should” be implies you are not ok right now “ IF I weren’t so stressed at work, THEN I would be able to stay sober.”

35. 6. Acceptance We have to accept ourselves and situations as they really are before things can change. Acceptance does NOT mean: You have to like everything That you have to tolerate things as they “have to be” That you should stop trying or give up

36. 7. Letting Go Pay attention to inner experience to discover what thoughts and feelings the mind wants to hold on to Holding on is the opposite of letting go Example: Catching monkeys

37. Practice Time! De-centering Meditation

38. CBT and Mindfulness Observe thoughts - Centering meditation/ non-striving Identify thinking patterns - “If your mind has wandered…” Identify cognitive distortions -Non-judging/accepting mind Challenge cognitive distortions -Fresh mind Construct alternative thoughts - Letting go Complete cognitive schema Behavioral Experiments (“act as if”) - T rust/patience (DPW3 = GTH)

39. Bibliography Beck, A., Wright, F., Newman, C. Liese, B. (1993). Cognitive Therapy of Substance Abuse . New York: The Guilford Press, Inc. Burns, David. (1999). Feeling Good (revised edition) . New York: Avon Books. Kabat-Zinn, John. (1994). Wherever you go there you are: mindfulness meditation in everyday life . New York: Hyperion. Kabat-Zinn, John. (1990). Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness . New York: Dell Publishing. Project MATCH Research Group. (1993 and 2000). Project MATCH: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 17, 1130-1145. Segal, ZV, Williams, JM, Teasdal, JD. (2002). Mindfulness-Based Cognitive therapy for Depression: A new approach to preventing relapse. New York: The Gilford Press.