M25 CBT in Addiction Counselling 2020 Edition

• ACCSA - Addiction Counselor Certifications South Africa Pty (Ltd)
• Module 25 - Cognitive Behavioural Therapy Workshop
• Compiled by tRn - Michael J. Theron - Clinical Psychologist - ICAADC

Cognitive Behavioural Therapy Workshop Contents

• Section 1
  • Introduction & Background
  • Efficacy of CBT for SUDs
  • Individual and Group Treatments
  • Motivational Interventions
  • Contingency Management
  • Relapse Prevention and other treatments
  • Couples and Family Treatments
  • Combination Treatment Strategies
  • Relative Efficacy across Treatments
  • Effectiveness of CBT for SUDs
  • Clinical Elements of CBD for SUDs
  • Case Conceptualization and Functional Analysis
  • Cognitive and Motivational Strategies
  • Skills Training
  • Clinical Challenges
  • Notes to the Counsellor
  • Methods
• Section 2
  • Why CBT?
  • Functional Analysis
  • Skills Training
  • Critical Tasks
  • Improve interpersonal functioning and enhance social supports
  • Therapist Role
  • A CBT Based Approach Workshop
  • The CBT Poem
  • The Importance of Negative Thoughts
  • How does Cognitive Behavioural Therapy Work?
    • Learning coping skills
    • Changing behaviours and beliefs
    • Solving life problems
  • Isn’t It Events (Or Other People) That Bother Me?
  • Why Do People Respond in Different Ways to The Same Event?
  • Thoughts and Actions
  • Understanding Emotions and Feelings
  • Body Feelings Are Associated with Different Emotions
  • Understanding Thoughts
  • The Upsides and Downside of Thinking
  • Thoughts vs. Facts
  • Thoughts Affect How You Feel
• Accuracy of Our Thoughts: Unhelpful Thinking Styles
  • What Can I Do About My Thinking?
    • Catching Your Thoughts
    • Challenging Your Thoughts
    • Helpful Questions for Challenging Your Thinking
• Section 3
  • The ABC Model/Analysis
  • How to Uncover Your Unhelpful Thoughts
  • Thought Diary
  • Module Summary
  • Unhelpful Thinking Styles Summary
  • Unhelpful Thinking Styles
  • Module Summary and Challenging Our Unhelpful Thoughts
  • Thought Diary 2
  • D for Detective Work and Disputation and Thought Diary 2
  • Module Summary
  • E for the End Result
  • Thought Diary 3
  • D for Detective Work and Disputation
  • E for the End Result
  • Thought Diary 4
  • D for Detective Work and Disputation
  • E for the End Result
  • F for Following Through
  • Thought Cards
  • Turning Your Thoughts into Actions
  • Reviewing the ABCs and DEFs
    • Step 1
    • Step 2
    • Step 3
    • Step 4
  • Module Summary
  • Core Beliefs
  • Identifying Themes from Thoughts Diaries
  • Identifying a Core Belief
  • Thought Diary Example
  • Challenging your Core Beliefs
  • Behavioural Experiments
  • Core Beliefs Worksheet
  • Following Through
  • Module Summary
  • Maintaining Your Gains and Staying Well
• Section 4
  • The CBT Workbook
• Section 5
  • Next Steps
  • Further Useful Reading
  • References

Section 1 Introduction & Background

• Substance use disorders (SUDs) are heterogeneous conditions characterized by recurrent maladaptive use of a psychoactive substance associated with significant distress and disability.
• These disorders are highly common, with lifetime rates of substance abuse or dependence estimated at over 30% for alcohol and over 10% for other drugs, and past year point prevalence rates of 8.5% for alcohol and 2% for other drugs.
• As understanding of the nature of substance use patterns has improved, a greater specificity of both psychosocial and pharmacologic treatments has followed, with evidence for the efficacy and cost effectiveness of these approaches.
• This section will provide an overview of the evidence for and clinical application of cognitive behavioural therapy (CBT) for substance use disorders. For the purposes of this article, we will broadly define CBT to include both behavioural and cognitive behavioural interventions.
• Given the scope of the literature, this review will focus on the treatment of alcohol and drug use disorders not including nicotine. For review of the literature on CBT for smoking cessation see Vidrine et al (2006).
• Substance use is defined as taking any illicit psychoactive substance or improper use of any prescribed or over the counter medication.
• Substance use disorders as used here will refer to substance abuse and substance dependence.
• Symptoms of substance abuse reflect the external consequences of problematic use such as failure to fulfil role obligations, legal problems, physically hazardous use, and interpersonal difficulty resulting from use.
• Symptoms of substance dependence reflect more internal consequences of use such as physical withdrawal upon discontinuation of a substance and difficulty with cutting down or controlling use of a substance.

Efficacy of CBT for SUDs

• Evidence from numerous large-scale trials and quantitative reviews supports the efficacy of CBT for alcohol and drug use disorders.
  • Meta-analytic review of CBT for drug abuse and dependence:
    • Included 34 randomized controlled trials with 2,340 patients treated.
    • Found an overall effect size in the moderate range (d = 0.45), with effect sizes ranging from small (d = 0.24) to large (d depending on the substance targeted.
    • Larger treatment effect sizes were found for treatment of cannabis, followed by treatments for cocaine, opioids, and, with the smallest effect sizes, poly-substance dependence.
    • Of individual treatment types, there was some evidence for greater effect sizes for contingency management approaches relative to relapse prevention or other cognitive behavioural treatments.
    • Advantages were computed relative to control conditions, most frequently general drug counselling or treatment-as- usual.
  • Similar results for both alcohol and illicit drugs were reported in a meta-analytic review of CBT trials by Magill and Ray (2009).
  • Evidence also supports the durability of treatment effects over time.
    • Rawson and colleagues (2002) reported that 60% of patients in the CBT condition provided clean toxicology screens at 52-week follow-up.

CBT Interventions

• CBT for substance use disorders includes several distinct interventions, either combined or used in isolation, many of which can be administered in both individual and group formats.
• Specific behavioural and cognitive-behavioural interventions administered to individuals are reviewed, followed by a review of family-based treatments.
• The evaluation of CBT for SUDs in special populations such as those diagnosed with other Axis I disorders (i.e., dual diagnosis), pregnant women, and incarcerated individuals is beyond the scope of the current review, and thus the descriptions provided focus on SUD treatment specifically.

Individual and Group Treatments

• CBT for SUDs encompasses a variety of interventions that emphasize different targets.
• Below we review individual and group treatments including motivational interventions, contingency management strategies, and Relapse Prevention and related interventions with a focus on functional analysis.

Motivational Interventions (MI)

• At the outset of considering treatment, motivation for treatment and the likelihood of treatment adherence needs to be considered.
• To address motivational barriers to change motivational enhancement techniques have been created and tested.
• Motivational Interviewing (MI) is an approach based on targeting ambivalence toward behaviour change relative to drug and alcohol use, with subsequent application to motivation and adherence to a wide variety of other disorders and behaviours, including increasing adherence to CBT for anxiety disorders.
• Treatments based on the MI model are utilized as both stand-alone interventions and in combination with other treatment strategies for SUDs.
• A meta-analytic review of interventions based on MI found effect sizes across studies in the small to moderate range for alcohol and the moderate range for drug use when compared to a placebo or no-treatment control group, and similar efficacy to active treatment comparisons.
• Most typically, MI is offered in an individual format (although group formats are also utilized) often consisting of a relatively brief treatment episode. Greater efficacy may be achieved when a higher dose of treatment is used.

Contingency Management (CM)

• As treatment is initiated, a primary challenge is countering the robust reinforcing effects of the drug.
• Contingency management (CM) approaches are grounded in operant learning theory and involve the administration of a non-drug reinforcer (e.g., vouchers for goods) following demonstration of abstinence from substances.
• Many clinical trials have supported the efficacy of CM for various substances such as alcohol, cocaine, and opioids.
• Meta-analytic reviews indicate that effect sizes for the efficacy of CM across studies are in the moderate range, with greater efficacy for some substances (opioids, cocaine) relative to others (tobacco, polydrug use).
• To allow for greater cost efficacy of CM approaches, researchers have investigated the role of lottery-type strategies for distribution of reinforcers.
  • For example, the punchbowl method rewards negative screens for drug use with the opportunity to draw a prize from a “punchbowl.” Most prizes have low monetary value (e.g., $1), but the inclusion of rarer large prizes (e.g., $50) both saves money while offering a successful inducement for abstinence.
• CM procedures may use either stable or escalating reinforcement schedules, in which reinforcer value increases as duration of abstinence increases.
• In addition to contingencies linked to negative drug screens (e.g., from swab or urine toxicology screens), adaptive behaviours ranging from attendance at prenatal visits to medication adherence have been successfully modified with CM approaches.
• A relative limitation of CM is the availability of funds for providing the reinforcers in clinical settings.
• The establishment of job-based reinforcements have been introduced as alternatives to aid the clinical adoption of these methods.
• Also, contingency management strategies have also been incorporated into couple's interactions (utilizing the reinforcers available to the couple) to aid the reduction of drug use (see below).

Relapse Prevention (RP) and Other Treatments

• Another well-researched cognitive-behavioural approach to drug abuse has emphasized a functional analysis of cues for drug use and the systematic training of alternative responses to these cues.
• This approach, termed Relapse Prevention (RP) focuses on the identification and prevention of high-risk situations (e.g., favourite bars, friends who also use) in which a patient may be more likely to engage in substance use.
• Techniques of RP include challenging the patient's expectation of perceived positive effects of use and providing psychoeducation to help the patient make a more informed choice in the threatening situation.
• A meta-analysis reviewing the efficacy of RP across 26 studies examining alcohol and drug use disorders as well as smoking found a relatively small effect (r=.14) for RP reducing substance use but a large effect (r=.48) for improvement in overall psychosocial adjustment.
• Similar CBT strategies have also been developed that in addition to attending to the functional cues for drug use may include a broader range of psychoeducation, cognitive reappraisal, skills training, and other behavioural strategies.
• Individual CBT packages vary in the degree to which each of these components is used.
• For example, a cognitive behavioural intervention for cocaine dependence developed by Carroll and colleagues (1994) includes components of functional analysis, behavioural strategies to avoid triggers, and building problem-solving, drug refusal and coping skills.
• Evidence for the efficacy of CBT for SUDs is supported in meta-analytic reviews, with effect size estimations in the low moderate range using heterogeneous comparison conditions and large effect sizes compared to no-treatment control groups.

Couples and Family Treatments

• Although substance abuse treatment often occurs in an individual or group format, the disorder itself has strong ties to the patient's social environment.
• Accordingly, several promising treatments have been developed, which utilize the support of the partner, family, and community to aid the patient in achieving abstinence.

Community Reinforcement Approach (CRA)

• Like CM, focuses on altering contingencies within the environment (e.g., inclusion of favourable non-alcohol related activities in the patient's daily schedule) to make sober behaviour more rewarding than substance use.
• The efficacy of the CRA approach for alcohol dependence has been supported through several meta-analyses with utility also demonstrated in drug dependent populations, such as cocaine and opioid dependent patients.

Behavioural Couples Therapy (BCT)

• Another treatment which utilizes the support of a significant other.
• In this treatment it is assumed that there is reciprocal relationship between relationship functioning and substance abuse, whereby substance use can have a detrimental effect on the relationship and this relationship distress can lead to increased substance use.
• Therefore, the focus of this treatment involves improving a partner's coping with substance-related situations as well as improving overall relationship functioning.
• Interventions commonly include psychoeducation, training in withdrawal of relationship contact contingent on drug use, and the application of reinforcement (e.g., enhanced recognition of positive qualities and behaviours) contingent on drug free days and including the scheduling of mutually pleasurable non-drug activities to decrease opportunities for drug use and to reward abstinence.
• A recent meta-analysis has shown considerable support for the use of BCT over individually based counselling treatments (not including CBT) in alcohol use disorders such that those in the BCT condition demonstrated reduced frequency of use, and consequences of use as well as greater relationship satisfaction at follow-up.
• In addition, a meta-analysis conducted by Stanton & Shadish (1997) found that BCT was associated with strong treatment retention, perhaps due to successful incorporation of the patient's home environment and desired support system in treatment.

Combination Treatment Strategies

• There has been the hope that combination treatment strategies (e.g., CBT plus pharmacotherapy) will lead to especially enhanced drug treatment outcomes.
• However, much like the results for mood and anxiety disorders, this approach has frequently met with equivocal outcomes.
• For example, some studies have supported the combination of naltrexone and CBT for alcohol dependence.
• In contrast, the COMBINE study evaluated combinations of naltrexone, Acamprosate, and behavioural interventions for alcohol dependence in 1383 patients and found that naltrexone, behavioural interventions, and their combination resulted in the best drinking outcomes; however, combination treatment did not exhibit additive efficacy relative to monotherapy.
• The addition of behavioural strategies, such as CM has been shown to enhance the efficacy of opioid agonist therapies, such as methadone (e.g., Rawson et al., 2002).
• Other strategies have demonstrated success, such as the addition of disulfiram to CBT (Carroll et al., 2004) and citalopram to CBT or CM for cocaine dependence.
• The combination of psychosocial approaches has also yielded mixed results.
• For example, the combination of CBT and CM yielded the highest effect sizes (in the large range) relative to other interventions alone in a meta-analysis of treatments for drug dependence, but only two studies contributed to these effect sizes, leaving confidence in this approach limited.
• In contrast, several studies have not demonstrated behavioural therapies, such as cue exposure and CBT and CM and CBT.
• At this time, more studies of the combination of efficacious monotherapies are needed to determine the strongest treatment strategies for alcohol and drug use disorders.

Relative Efficacy across Treatments

• Studies evaluating the relative efficacy of different cognitive-behavioural approaches for SUDs have yielded equivocal results regarding the relative benefits of these approaches for drug use outcomes.
• For example, in a comparison of BCT to individual CBT for alcohol dependence, similar efficacy was noted with some cost advantages of individual CBT relative to BCT.
• In a study comparing CM to CBT for stimulant dependence, CM demonstrated better acute efficacy; however, at follow-up, efficacy was similar for both treatments.
• Similar results have been found comparing CM and CBT for opioid dependent patients in methadone maintenance treatment.
• In the Project MATCH trial of the treatment of alcohol dependence, three evidence-based psychosocial treatment strategies (including CBT and an MI-based treatment) evidenced similar overall outcomes across treatment conditions at post-treatment and 3-year follow-up.
• Moreover, attempts to match patients to treatments based on baseline characteristics has yet to yield a clear sense of the front-line treatments based on the individual.
• However, results of effect size analysis across treatment trials provide support for the most robust treatment effects for contingency management for drug use and combined psychosocial treatments (e.g., CBT + cue exposure) for alcohol use.

Effectiveness of CBT for SUDs

• Although empirical support for these interventions is promising, it is most often garnered through efficacy studies in which the treatment is carried out under optimal conditions.
• However, most SUD treatments occur in service provision settings under conditions that are far from optimal.
• A limited body of effectiveness research has been conducted examining these treatments without the stringent controls afforded by efficacy trials.
• Several studies examined the effectiveness of CM as a supplement to traditional drug counselling.
  • The studies initially provided relatively high rewards (as high as $1,000) for sustained abstinence from substance use, but recently, effectiveness studies have focused on providing low-cost CM as a more feasible addition to traditional counselling programs.
  • Petry and Martin (2002) examined the addition of CM to standard community-based treatment (methadone maintenance and monthly individual counselling) for cocaine and opioid dependent patients. CM in this study was delivered through a raffle format using a fixed ratio schedule in which drug-free urine samples afforded patients the opportunity to draw from a fish bowl for prizes valued between $1 and $100; patients in the CM condition achieved longer durations of abstinence through a 6-month follow up period relative to those who did not receive CM.
• The study of effectiveness of motivational enhancement strategies has yielded mixed results.
  • For example, in a large effectiveness trial of motivational enhancement therapy for Spanish-speaking patients seeking treatment for substance use, Carroll et al (2006) found small advantages for this treatment relative to TAU only among those in the sample seeking treatment for alcohol problems. This finding of an advantage for motivational enhancement in alcohol and not drug using samples was consistent with prior investigations.
  • Similarly, a study conducted by Gray, McCambridge, and Strang (2005) examined the effects of single-session MI delivered by youth workers for alcohol, nicotine, and cannabis use among young people. Upon 3-month follow-up those who received MI reported significantly fewer days of alcohol use than those who did not receive MI; however, significant differences were not found for cigarette or cannabis use indicating that the extent of benefit of MI is more modest than that identified by efficacy research studies. Results for the improvement of retention with motivational enhancement in effectiveness studies have been more promising, effectiveness research to better understand the application of CBT outside of controlled research settings.
• As implied above, CBT for substance use disorders varies according to the protocol used and— given the variability in the nature and effects of different psychoactive substances—substance targeted. However, across protocols several core elements emerge.
• Consistent across interventions is the use of learning-based approaches to target maladaptive behavioural patterns, motivational and cognitive barriers to change, and skills deficits.
• One of the core principles underlying CBT for SUDs is that substances of abuse serve as powerful reinforcers of behaviour.
• Over time, these positive (e.g., enhancing social experiences) and negative (e.g., reducing negative affect) reinforcing effects become associated with a wide variety of both internal and external stimuli.
• The core elements of CBT aim to mitigate the strongly reinforcing effects of substances of abuse by either increasing the contingency associated with non-use (e.g., vouchers for abstinence) or by building skills to facilitate reduction of use and maintenance of abstinence and facilitating opportunities for rewarding non-drug activities.
• Despite these commonalities, as the studies demonstrate, length of treatment can vary greatly even within the rubric of CBT for SUDs (e.g. single session MI, 12-session BCT, etc.). Research on duration and intensity of treatment is mixed with some correlational studies indicating a positive relationship between longer duration and positive outcome and others indicating no differential effects of treatment duration.

Clinical Elements of CBT for SUDs

• During assessment and early treatment sessions, case conceptualization requires consideration of the heterogeneity of substance use disorders.
• For example, the relative contribution of affective and social/environmental factors can vary widely across patients.
• A patient with co-occurring panic disorder and alcohol dependence may be experiencing cycles of withdrawal, alcohol use, and panic symptoms that serve as a barrier to both reduction of alcohol consumption and amelioration of panic symptoms.
• Alternatively, patients without co-occurring psychological disorders may face different barriers and skills deficits, such as difficulty refusing offers for substances or a perceived need for substances in social situations.
• Therefore, all these factors must be considered before embarking upon treatment.
• Consistent with general CBT models, treatment for SUDs benefits from the use of a regular structure, including agenda-setting, identification of goals, and the assignment and review of homework.
• This is particularly important for sub-groups for whom cognitive deficits, difficulty concentrating, or organizational and problem-solving skills deficits are present, as it can help such patients to more easily remember and apply treatment techniques outside of the treatment session.
• Functional analysis is an important component of treatment from the earliest stages.
• The identification of antecedents or triggers for use is critical to determining the appropriate situations and behaviours to target.
• For example, identifying high risk situations for use such as liquor stores or areas where drugs are commonly sold and encouraging the patient to avoid such situations (particularly in the early stages of recovery) can be used in this stage.
• Such stimulus control strategies may serve as an important precursor to building skills for resilience in these settings as it facilitates initial achievement of abstinence.
• These analyses will also help clarify for the clinician whether drugs are used as part of social repertoires, used to enhance positive activities, and/or are used to cope with difficult situations or emotions.
• Independent assessment of drug use motives can also aid this aspect of the functional analysis.
• For example, the use of the Revised Drinking Motives Questionnaire may provide important information about the nature of drinking motives and its association to triggers, such as mood disturbance.
• A more detailed explanation of the functional analysis is discussed further on in the module, along with a practical example.
• Once high-risk situations and events are identified (including people and places, as well as the internal cues such as changes in affect), CBT can be directed to altering the likelihood that these events are encountered (providing alternative non-drug activities, or activities with non-drug using individuals) as well as rehearsing non-drug alternatives to these cues.
• Motivational and cognitive interventions can be provided to enhance motivation for these alternative activities as behaviour, while also working to decrease cognitions that enhance the likelihood of drug use.
• In addition to the elements of motivational interviewing (i.e., assessment, dispassionate presentation of information, and elucidation and discussion of ambivalence about drug abstinence), broader cognitive strategies can target the cognitive distortions specific to substance abuse, including, rationalizing use (e.g., “I will just use this once,” “One drink won't hurt me,” “It has been a bad day; I deserve to use”) and giving up (e.g., “Why even try,” “I will always be an addict”).
• In such circumstances, eliciting evidence from the patient regarding the accuracy of these thoughts can help to identify alternative appraisals that may be more adaptive and better reflect the patient's experience.
• Similarly, providing psychoeducation on the nature of such thoughts and the role that they may play in recovery can help the patient to gain awareness about how such thinking patterns contribute to the maintenance of the disorder.
• As with other disorders, rehearsal of cognitive restructuring in the context of drug cues may enhance the availability of these skills outside the treatment setting.
• As part of cognitive restructuring, expectancies, or beliefs about the consequences of use, are another important target for intervention.
• It is not uncommon to find that patients maintain a belief that use of a particular substance will help some problematic aspect of their life or given situations.
• For example, a patient may believe that a family holiday would not be enjoyable without alcohol use.
• Like cognitive restructuring techniques, evaluating evidence for expectancies and designing behavioural experiments can be used to target this issue.
• In this instance the patient would be encouraged to refrain from drinking at the holiday party and assess the degree to which the event was enjoyable. In addition, the patient could evaluate evidence from past holidays to compare the consequences and benefits of alcohol use in these settings.
• Skills building can be broadly conceptualized as targeting interpersonal, emotion regulation, and organizational/problem-solving deficits.
• Clinical trials examining the addition of coping and communication skills training have demonstrated positive outcomes and are common components of CBT for substance abuse.
• The use of strategies should be based on case conceptualization, building from patient report and behavioural observation of such deficits.
• Interpersonal skills building exercises may target repairing relationship difficulties, increasing the ability to use social support, and effective communication.
• For patients with strong support from a family member or significant other, the use of this social support in treatment may benefit both goals for abstinence and relationship functioning.
• In addition, the ability to reject offers for substances can be a limitation and serves a challenge to recovery.
• Rehearsal in session of socially-acceptable responses to offers for alcohol or drugs provides the patient with a stronger skill set for applying these refusals outside of the session.
• Where relevant, this rehearsal can be supplemented by imaginal exposure or emotional induction to increase the degree to which the rehearsal is similar to the patient's high- risk situations for drug use.
• Emotion regulation skills can include distress tolerance and coping skills.
• Using problem-solving exercises and the development of a repertoire for emotion regulation, the patient can begin to both determine and utilize non-drug use alternatives to distress.
• Strategies for coping with negative affect, such as using social supports, engaging in pleasurable activities, and exercise can be introduced and rehearsed in the session.
• The development of pleasurable sober activities is of importance given the amount of time and energy that is often taken for substance use activities (i.e., obtaining, using, and feeling the effects of substances).
• When reducing substance use, patients can be left with a sense of absence where time was dedicated to use, which can serve as an impediment to abstinence.
• Thus, concurrently increasing pleasant and goal-directed activities while reducing use can be crucial for facilitating initial and maintained abstinence.
• Finally, goal-setting deficits can be targeted within the session as part of treatment.
• Guiding patients in setting treatment goals can serve as a first practice of this skill building.
• Also assisting patients in setting smaller goals in the service of longer term goals is an important exercise.
• The inability to delay long-term pleasure for short-term pleasure is a characteristic feature of substance use disorders, and thus the ability to set long-term goals may be compromised.
• Particularly for patients with more severe substance dependence, skills building may require shifting the patient's relevant skills and goals from that of an illicit lifestyle to that of a more normative lifestyle.
• Thus, the skills that may have been adaptive while actively using—interpersonal skills needed to obtain drugs and to connect with other substance users, the ability to manipulate those around you, to do things without being caught—may translate poorly to reconnecting with family and sober friends, obtaining and maintaining a job, and building healthy life activities.

Clinical Challenges

• There are many challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment.
• These include acute or chronic cognitive deficits, medical problems, social stressors, and lack of social resources.
• In addition, certain populations, such as pregnant women and incarcerated patients, may present challenges.
• In each of these circumstances, the use of functional analysis to arrive at strong case conceptualization and the flexible utilization of treatment components is important.
• For example, among individuals with low levels of literacy, the use of written homework forms may need to be replaced by alternative means of monitoring home practice (e.g., using simplified forms or having the patient call to leave a phone message regarding completion of an assignment).
• One challenge can be the shift in the social and environmental contexts associated with use relative to non-use lifestyles.
• For example, among individuals who have long histories of substance misuse, there are often significant life consequences, such as unemployment, family difficulties, reduced social networks, etc.
• In such groups, their fit to society is within the context of others with similar misuse problems.
• The illicit drug use culture, characterized at times by other illicit behaviours (e.g., drug dealing, theft, prostitution) and the valuation of skills (e.g., the ability to make a drug deal at 2:00AM), varies dramatically from a more mainstream culture.
• Thus, in treatment, the patient not only is being asked to transition to a culture in which he or she may have few skills and resources, but also to relinquish the parts of his or her life in which there is a sense of effectiveness and belonging.
• The sense of belonging to the substance use culture can increase ambivalence for change, particularly when measurable life changes occur at slow pace.
• In such cases, it is critical to establish alternatives for achieving a sense of belonging, including both social connection and effectiveness.
• Depending on the resources available to the patient, this may include joining some type of social group (e.g., a sports club), volunteer work, or other activity-based social opportunities.

Notes to the Counselor

• Research has established that CBT are valuable tools in assisting clients reach their treatment goals. Implementing CBT effectively, however, requires skills and preparation.
• Too often counsellors do not take the time necessary to prepare to guide clients through a learning process that can enhance their recovery, their relationships, and their sense of self efficacy.
• In this module we will review briefly several strategies and change methods shared by many CBT programs. We will begin with some general strategic recommendations.
• Pucci (2009) suggests that counsellors are more likely to be effective using CBT when they use these strategies:
  • Use A Coherent Systematic Approach
    • When a counsellor uses a systematic approach to CBTs they will have a therapeutic road map as a guide.
    • Using a systematic approach to CBT ensures there is a focus point to each session that builds on the client’s previous learning. Such approaches are typically published as manuals. Examples include Carroll (1998), Reilly & Shropshire (2002), and CSAT (2006).
  • Establish Accurate Empathy
    • When a counsellor establishes accurate empathy, the client begins to feel understood. Accurate empathy creates a therapeutic bond with the client who begins to feel the therapist truly understands what s/he is experiencing. If a counsellor offers an alternative unfamiliar way of thinking that is contrary to the client’s beliefs, the client may begin to feel misunderstood. Therefore, it is best to establish an empathic relationship prior to helping the client examine and change self- defeating beliefs and assumptions.
  • Recognize Irrational Thoughts
    • One aspect of CBT is helping the client see the relationship between thoughts or beliefs and behaviour. For example, most CBT approaches encourage the client to replace irrational beliefs about a situation (“This is awful, terrible, and horrible”) with a less severe, more rational statement (“This is unfortunate but it’s not the end of the world”). The counsellor’s ability to distinguish rational from irrational beliefs in the context of the client’s life and culture is one key to conducting effective CBT.
  • Assist in Creating Rational Replacement Thoughts
    • The counsellor needs to help the client develop new rational replacements for exaggerated or irrational thoughts. Old beliefs do not easily give way to new ones. It is important to be patient at this stage of CBT.
  • Focus on Client Assumptions
    • CBT directs clients to focus on the assumptions underlying their thoughts or beliefs. For example, a client may state that her friends don’t really appreciate her. A good therapeutic response might be, “Are you sure that there is evidence that they don’t appreciate you? Remember that there are several other possible explanations to explore. Consider that your friends might have been distracted and forgot to thank you at that moment. It could be very helpful for you to explore other possibilities. ” Alternatively, the counsellor could focus on the underlying assumption which may be contributing to the client’s distress, encouraging the client to say something like, “It would be nice, but not essential, for my friends to acknowledge my efforts. ” When the underlying assumption is corrected and made for rational, the client is not likely to feel quite so distressed.

Methods

• Leahy (2003) notes that some clinicians view CBT as too technique oriented, too mechanical, too structured, and too formula driven. But the purpose of the structured ingredients used in CBT combine to actively intervene by using specific strategies to move the client forward into self- efficacy.
• Counsellors are encouraged to master CBT methods that have proven to be effective before modifying the methods to suit personal preferences. Obtaining feedback from the client is also essential in CBT. It’s valuable for the counsellor and client to periodically summarize the methods they have used to determine which were useful, which were not, and why. For example, it can be beneficial to explore why weighing the evidence for a client’s automatic thought does not work all the time. Such examination may uncover more fundamental client beliefs or rules that can be explored. Awareness of what works for the client will help the counsellor understand which strategies are most likely to be successful as therapy proceeds.
• Methods for drawing out the client’s thoughts and assumptions are often less about modifying a thought and feeling and more about beginning an inquiry that leads to a deeper understanding of underlying beliefs and assumptions. Leahy describes the following methods to illustrate how CBT can be used to open a window into the client’s core issues.
  • Explain how thoughts can precipitate feelings
    • The counsellor focuses on how feelings are influenced by beliefs and assumptions. The client’s feelings are not disputed but rather the thoughts that elicit those feelings are called into question. Client homework or practice includes keeping track of feelings and how they are related to thoughts, beliefs, or assumptions.
    • Potential problems: Client may confuse thoughts with feelings and/or they may have difficulty identifying the thoughts associated with their feelings.
  • Distinguish thoughts from facts
    • Thoughts can prove to be either true or false. First, clients learn how to identify their thoughts; second, they are guided to examine the facts. Practice focuses on keeping track of any preceding events that led to a feeling or belief.
    • Potential problems: The client may respond to examining facts as invalidating and as critical of their feelings. It is important for the therapist to help the client recognize that examining situational facts does not automatically mean that they are incorrect.
  • Rate the degree of emotion and the strength of the related belief
    • Identifying how strongly a client feels about a belief helps the client understand the intensity of their emotions. Through homework focused on tracking thoughts, beliefs, and feelings over time the client explores how their emotional intensity might modify over time.
    • Potential problems: Client motivation to track thoughts and feelings may dissipate with time. It’s important to maintain consistent encouragement, coaching the client to continue following through with their assignments. It is only through consistent practice that clients begin to alter their perceptions and their behaviour.
  • Look for variations in a specific belief
    • Understanding the client’s beliefs across time and in different situations provides valuable information for both the counsellor and client. Changes and variations in beliefs can be linked to changes in the client’s feelings. Client homework, again, focuses on tracking.
    • Potential problems: Clients may be less inclined to track their negative thoughts during times when they are feeling better. Counsellor encouragement can let the client know that essential information can also be gained through tracking even when they’re not feeling negative.
  • Categorize the distortion in thinking
    • Thoughts can be true, false or they can have some degree of validity. Clients can monitor their thoughts and then categorize them to begin associating their negative feelings with irrational thoughts and cognitive distortions. Tracking homework will help reveal repetitive categories of thoughts for the client