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  1. 1. Cognitive BehavioralTherapy and Mindfulness in Addiction Treatment Tony Pacione, LCSW, CSADC
  2. 2. Objectives Why CBT/Mindfulness for addictions? Define and ID automatic thoughts and core beliefs in addictions Cognitive Restructuring: Identifying and changing dysfunctional thought patterns Mindfulness in addiction treatment Integration of CBT and Mindfulness
  3. 3. What is CBT? Identify distorted or dysfunctional thinking Influences mood and behavioral Common to all psychological disturbances; including addiction “Collaborative empiricism” Identify, challenge and change thinking
  4. 4. What is the Mindfulness? “Moment to moment awareness On purpose In a particular way Without judgment” Clinical uses of Mindfulness J Kabbot-Zinn 1990
  5. 5. Principles (skill set) of Mindfulness1. Non-judging 5. Non-striving2. Patience 6. Acceptance3. Fresh Mind 7. Letting Go4. Trust J. Kabat-Zinn 1990
  6. 6. CBT + Mindfulness CBT = (Identifying and modifying) – perception – beliefs and thoughts – Cognitive appraisals Mindfulness = – Fully present to the moment – Less interested in thought content – Observing the arising and ceasing of thought Both Assume: Thoughts / judgments are NOT facts
  7. 7. Why CBT/Mindfulness Focused; limited resources Empirical support Clear goals, immediate impact, skill development Compatible with Self-help; Other EBT, and Pharmacotherapy Flexible and individualized
  8. 8. Improvement in “Mindfulness” QA study HRC 3.6 4 2.7 3Ave Score 2MAAS 1 0 Adm D/C pre and post test 6 weeks (N =23)
  9. 9. Cognitive Schema: A Beck, 1993 Automatic Thoughts: “Mental” Reactions to situations – Real; Imaginary/perceived; Anticipatory Not fully conscious or deliberate Instantaneous and immediate Emotional associations
  10. 10. Cognitive Schema Conditional Beliefs: More general than automatic thoughts – Boolean logic: “If… than; and/or” Assumptions: taken at face value, as “truths;” rarely questioned Roles/expectations Attitudes/values
  11. 11. Cognitive Schema Core Beliefs: More general than conditional beliefs Strongly held beliefs, underlying assumptions about who I am Develop early in life and are reinforced as we age Can become a ‘filter’ for interpreting life experiences (“self-fulfilling prophecies”) Can be identified and changed Self Efficacy (A. Bandura)
  12. 12. Cognitive Schema: Core BeliefsTwo ‘varieties’ of dysfunctional core beliefs -1. Un-lovable  unworthy; irrelevant; needy1. Incompetent  defective; helpless; failure; “screw-up” A. Beck 1993
  13. 13. Cognitive Schema (A. Beck)Relevant Childhood and Developmental data (30y/o male): Addicted mom, neglected by dadCore Beliefs: I’m unlovable and irrelevantConditional Assumptions: If I please others thanI’ll be liked, and be importantCompensatory Strategy: Avoid displeasingothers at all costsSituation: Co-worker asks me to stay late to helpAutomatic Thoughts: I won’t be liked if I say “no”Emotions: Fear and anxietyBehavior: Stay late at work (anger your date)
  14. 14. Cognitive Restructuring1. Observe 5. Construct thoughts/emotions alternative thoughts/beliefs2. Identify thinking patterns (ATs) 6. Complete cognitive schema3. Identify cognitive distortions 7. Behavioral Experiments4. Challenge cognitive distortions 8. Validate Change (#1)
  15. 15. Thought Record (Steps 1-2) 49 y/o female alcoholic Mood Rating or Automatic and Craving Situation/Event Thought Related Feeling (1-10) “I will probably lose my job if I’m off ofRecommended to take time off work for more than Fear work for treatment a few days." Panic 10 “I feel trapped; I want to help but the are taking advantage AngerFamily members keep asking of me, but I can ‘t Guilt me for money and support say no.” Depression 8 “He knows I’m alcoholic now, andBoss suggested I have a he’ll try to get rid of Fear problem with alcohol me” Depression 9 Other patients don’t respond “No one is warming up the way I want them to, to me; they think when I approach them I’m a ‘bitch’!” Anxiety 7
  16. 16. Common Cognitive Distortions (Step 3) Dichotomous  ‘Catastrophizing’ thinking  Emotional Overgeneralization reasoning Mental filters  Personalization Jumping to conclusions D Burns 1999
  17. 17. Thought Record - Cognitive Distortions (Step 3) 49 y/o female alcoholic“I’ll lose my job if I take time off.” Overgeneralization and catastrophizing“They all think I’m a ‘bitch’!” Personalizing “I can’t say no to my family when jumping to conclusionsthe ask for something.” “My boss no longer respects me, Emotional reasoningbecause he thinks I’m alcoholic; aloser.”
  18. 18. Identifying Automatic Thoughts (Steps 4-5) Affective shift in session Describe problematic situations Guided imagery Role-play Focus on high value ATs; intense affect
  19. 19. Challenging Automatic Thoughts (Steps 4-5) Using I.C.E. to cool off ‘Hot’ thoughtsThoughts/feelings NOT equal to Facts I – Identify the thought C – Challenge the thought E – Evaluate the thought A. Pacione 2003
  20. 20. I.C.E. (Steps 4-5)Identify (and rate) the thought:“I’ll lose my job if I take time off for treatment now.” Truthfulness rating = 80%Challenge the thought: EVIDENCE FOR EVIDENCE AGAINST •Iseen my boss get rid of someone •My boss also encouraged me to get else before help •My boss and his boss told me “we support you” •There’s been threats of lay offs •I have others who depend on me •They told me “Im a valuable working employee” • Boss has been watching me lately • He knows I’m alcoholic Boss won’t talk to me about returning
  21. 21. I.C.E. cont. (Step 4-5)Evaluate (re-rate) the thought:a) Post challenge truthfulness rating = 45%b) Revise thought to make it more truthful: “There is a higher probability I can lose my job if I don’t get help and continue to drink, than if I take time off to get help”
  22. 22. Practice I. C. E.
  23. 23. Cognitive Grid (Step 6) Situation: My boss cryptically said “that alcohol is not a treatment for stress” Automatic Thoughts: “My boss thinks I’m alcoholic; I have to show him I’m always a reliable employee” Emotions: fear and panic Behavior(s): can’t take time off; work harder
  24. 24. Cognitive Grid (continued) Relevant Childhood and Developmental Data: both parents abused alcohol; neglected; had to care for myself and sibs Core Belief: “I’m unlovable; defective and lonely” Conditional assumptions (if/then): “If I care for and give to others, than I’m worthy of love!” Compensatory strategy: “Make sure I am always available to others/family what ever the cost.”
  25. 25. Identifying Core Beliefs Cognitive Grid (Step 5-6) Start with the AT- common themes Completion of a “If” clause Eliciting a rule You and the client complete/compare Grid Strength of belief and associated affect
  26. 26. Amending Core Beliefs (Step 5-6) Options: “I’m worthy of love; even if I don’t always please others.” “I’m worthy of love; someone will always love me.” “I’m lovable; regardless of what I give or don’t give to others”
  27. 27. Amending Core Beliefs via ‘Experiments’ (Step 7) MI or Socratic questions Act as if… Others as reference points Cognitive Continuum Self disclosure- use with caution!
  28. 28. Maintenance and Validate (Step 8) Re-issue Thought Log “What is different?” “What situations would your ‘old’ thinking and feelings return?”
  29. 29. A Mindfulness Meditation
  30. 30. Mindfulness and CBT Becoming MoreAware 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
  31. 31. CR with Mindfulness1. Observe thoughts 5. Construct -non-striving alternative2. Identify thinking thoughts patterns -Letting go -patience3. Identify cognitive 6. Complete distortions cognitive schema -Non-judging/accepting 7. Behavioral mind Experiments4. Challenge cognitive -Trust/patience distortions -Fresh mind 8. Validate -non- striving/patience
  32. 32. CBT/Mindfulness in craving states Cravings - normal in recovery Time limited Individualized and descriptive Identify cues and triggers Urge Surfing- A Marlatt (2002) Recall negative consequences
  33. 33. BibliographyBeck, A., Wright, F., Newman, C. Liese, B. (1993). Cognitive Therapy of Substance Abuse. New York: The Guilford Press, Inc.Beck, Judith. (1995). Cognitive Therapy: Basics and Beyond. New York: The Guilford Press.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.Marlatt, G. A. (2002). Buddhist philosophy and the treatment of addictive behavior. Cognitive and Behavioral Practice, 9, 44–49.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.