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C i i B h i Th f S bCognitive Behavior Therapy for Substance Use Disorders

Barbara S. McCrady, PhDDistinguished Professor of Psychology and Director of the Center on

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

Distinguished Professor of Psychology, and Director of the Center on Alcoholism, Substance Abuse, and Addictions (CASAA) at the University of New Mexico

American Indian & Alaska Native Behavioral Health Webinar Series

This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT).

For more information on the ATTC Network, visit: attcnetwork.orgTo find your regional center, visit: attcnetwork.org/findregcenter.asp

For more information on the National American Indian & Alaska Native ATTC, visit: attcnetwork.org/americanindian, or call 319-335-5564

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Upcoming webinars from the National American Indian & Alaska Native ATTC

Overview of Fetal Alcohol Spectrum Disorders:What we are Learning about Diagnosis and Intervention

presented by: Wendy O. Kalberg, MA, LED

An Introduction to Motivational Interviewing with Native American Adaptationspresented by: Kamilla Venner, PhD, Athabascan

Clinical Evaluation: Assessmentpresented by: Denise Casillas, MA, QMHP, Cheyenne River Sioux

Tribe

Clinical Evaluation: Treatment Planningpresented by: Denise Casillas, MA QMHP, Cheyenne River Sioux Tribe

For more information about our webinar series, contact Kate Thrams at kate-thrams@uiowa.edu or 319-335-5362

Webinar Follow-Up

CEHs are available upon request for $10 per session.

Continuing Education Hours (CEH)

• This session has been approved for 1.0 CEH’s by:• NAADAC: The National American Indian & Alaska Native ATTC is a NAADAC (The Association for Addiction Professionals)

certified educational provider, and this webinar has been pre-approved for 1.0 CEH.

• To obtain CEHs for this session, submit a CEH Request Form and payment to the National AI & AN ATTC. A request form is available for download in the “Files” pod in the webinar screen. If you choose to download a file, a new tab will be opened in your browser, and you will have to click on the webinar window to return to view the webinar.

• Participants are responsible for submitting state specific requests under the guidelines of their individual statestate.

Presentation handouts:• A handout of this slideshow presentation is also available by download.

If you are unable to download the documents from the webinar, please contact Kate Thrams at kate-thrams@uiowa.edu or 319-335-5362

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Webinar Follow-Up

This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse

Evaluation: SAMHSA’s GPRA

Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT).

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Immediately following this webinar, you will be redirected to a customer satisfaction survey. Please take a few i t t i f db k thi bi Y ki ti th t d t t tminutes to give us your feedback on this webinar. . You can skip any questions that you do not want to answer,

and your participation in this survey is voluntary. Through the use of a coding system, your responses will be kept confidential and it will not be possible to link your responses to you.

We appreciate your response and look forward to hearing from you.

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Th bi t d ti i t

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Disclaimer

Th N ti l A i I di & Al k N ti Addi ti T h l T f

Please note:

• The National American Indian & Alaska Native Addiction Technology Transfer Center is supported by a grant from SAMHSA

• The content of this publication does not necessarily reflect the views or policies of SAMHSA or the Department of Health and Human Services (HHS).

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Today’s Speaker

Barbara S. McCrady, PhD, is a Distinguished Professor of Psychology and the Director of The Center on Alcoholism, Substance Abuse, and Addictions (CASAA) at the University of New Mexico. Prior to coming to UNM in 2007, she was the Chair of the Department of Psychology and Clinical Director of the Center of Alcohol Studies at Rutgers UniversityPsychology and Clinical Director of the Center of Alcohol Studies at Rutgers University. Dr. McCrady has focused her career on the development and testing of effective treatments for persons with substance use disorders. She created one of the first substance abuse treatment programs based on cognitive-behavioral therapy principles and tested the effectiveness and cost-effectiveness of this treatment model. She has developed an original, conjoint treatment model for substance abusers and their spouses, and has conducted programmatic research on this treatment model. Dr. McCrady also has been active in bringing scientific attention to Alcoholics Anonymous, and has conducted controlled research evaluating alternative treatment models for women withconducted controlled research evaluating alternative treatment models for women with alcohol and other substance use disorders, with a special focus on women in poverty. Her work has been funded by the NIH since 1979. Dr. McCrady has published more than 240 scientific articles, chapters, and books, and has lectured widely on her work in the United States, Canada, and Europe.

OUTPATIENT COGNITIVE BEHAVIOR THERAPY FOR ALCOHOL AND OTHER SUBSTANCE USE DISORDERS

Barbara S. McCrady, Ph.D.Center on Alcoholism, Substance Abuse, and AddictionsUniversity of New Mexicobmccrady@unm.edu

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Objectives of the webinar

Overview the CBT model for conceptualizing drinking and drug use.

Integrate unique aspects of CBT with American Indian/Alaskan Native (AI/AN) clients into the presentation.

Illustrate the use of functional analysis for case conceptualization and treatment planning.

Provide CBT treatment tools.

Good CBT manuals

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Some introductory comments

Cognitive behavior therapy (CBT):P id f k li l h l d d bl Provides one framework to conceptualize alcohol and drug problems

Provides a set of techniques to help people change

The content of treatment is individualized and adapted to the individual’s needs and cultural context

Is provided in the context of a welcoming and client-centered therapeutic relationshiprelationship

Basic assumptions of the CBT model for AUDs and other SUDs

Basic Assumptions Historical factors may be important to understanding how or why someone Historical factors may be important to understanding how or why someone

developed a drinking problem However, changing drinking/drug use can best be accomplished by examining a

person’s current situation, including how historical factors affect the person in the present

Drinking/drug use occurs in the context of multiple systems Factors that maintain current drinking/drug use may be related to the individual Factors that maintain current drinking/drug use may be related to the individual,

the family, or other social systems

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The organizing model – functional analysis as a line

Trigger Negative

consequencesThoughts & Feelings Behavior Positive

consequencesconsequences

The organizing model –functional analysis as a circle

TriggerTrigger

Thoughts & Feelings

Negative Consequences

ActionsPositive Consequences

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Basic assumptions of the CBT model - 2

Triggers Triggers Events and situations that occur before drinking and increase an individual’s

desire to drink

Triggers may be related to the individual, family, or other social systems

Basic assumptions of the CBT model - 3

Thoughts, feelings, and physiology Understanding internal reactions to triggers may help a client understand his or her useg gg y p

Internal reactions may be physical, such as withdrawal symptoms, or urges or cravings

Internal reactions may be emotional, such as depression, anxiety, or happiness

Internal reactions may be self-evaluative, such as negative self-statements, low efficacy expectations

Internal reactions may focus on expectations about the positive effects of alcohol/drugs

Some research suggests that AI/AN clients find the focus on thoughts & feelings less h l f l h h f CBThelpful than other aspects of CBT

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Basic assumptions of the CBT model - 4

Consequences D i ki /d i d t b i t i d b it Drinking/drug use is assumed to be maintained by its consequences

Consequences may be physical, cognitive, affective, or environmental

Some positive consequences come from reactions to drinking/drug use by the social network

Positive consequences are more immediate than negative consequences

Negative consequences are what drive changeNega ve co seque ces a e w a d ve c a ge

Examples of a linear functional analysis for “Daniel”

Ashamed Still not ready Mom nagsme to get a job

Ride my bike by theliquor store

Haven’t had

Drink

Drink

Shakingf d ll h

Shaking goes Still addicted

I’ll justget a 4-packI like the guyswho hang there

AngryNot ready to work

I can ignore her

yto workMom madBrother critical

Tastes goodNo withdrawalGood to hang out

Wasting my lifeNot hangingout with positive people

Drink

Drink

Haven t hada drink for 4 hours

Home alonewith nothingto do

Afraid will havea seizureWant to drink

awayKnow I won’t have a seizure

Mom angryAshamed

DepressedBored

Forget myproblems

Still depressedLetting everyonedown

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Example of a circular functional analysis for “Daniel”

Ride my bike by the liquor storeq

I’ll just get a 4-pack; I like the guys who hang there

Wasting my life; Not

hanging out with positive

people

Drink

Tastes good; No withdrawal; Good to hang

out

Getting started

Begin to establish rapport

D d d d h li ’ Do a good assessment to understand the client’s: Concerns

Life context – work, family, community

Develop a CBT conceptualization of what’s maintaining the drinking or drug problem Share your conceptualization with the client, inviting his or her perspective (e.g.,

“Here’s how I’m thinking about your drinking…how do you think about it?”)

Develop a treatment plan that is deliberate in including the client’s family and community

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Developing a CB treatment plan

Always: Use m ltiple so rces of information Use multiple sources of information

Interviews Questionnaires Self-recording cards Family input

Develop a sobriety plan Develop a sobriety plan Enhance motivation

Developing a CB treatment plan - 2

Depending on the client, focus on: Changing triggers Changing thoughts and feelings Changing behavior – alcohol/related Changing behavior – general coping skills Changing consequences Changing the social environment

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Treatment Planning Sheet for “Daniel”

Sobriety Plan y__Challenge: Drinking every day; has had seizures in the past when stopping __

__Possible solution: Inpatient detox______________________________________

___________________________________________________________________

Changing High Risk Situations__Challenges: Mother upset; no car; doesn’t know nondrinkers; no job; hangs out

at home a lot________________________________________________________________________________________________________________

__Possible solutions: Learn how to talk to mom; have mom come to therapy; find a

low-stress job and save money for a car or own apartment; find ways to meet__

nondrinkers through interests (e.g. sculpting, music)________________________

___________________________________________________________________

Treatment Planning Sheet for “Daniel” (cont.)

Changing Cognitions

__Challenges: Sees self as a person who is letting down his family and community; wants to drink – afraid of seizures; “I’m a hopeless alcoholic, just like my_______

father”_______________________________________________________________

__Possible solutions: Think about what would help him feel he’s a positive part of__

community and family; identify positive values and goals; think about father’s____

positive qualities to emulate; think about positive people in community wants to be

like

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Treatment Planning Sheet for Daniel (cont.)

Changing BehaviorChanging Behavior

__Challenges: limited job skills, doesn’t know how to talk_________

with mom and brother when they say upsetting things; lack of____

positive and meaningful ways to spend time___________________

___Possible solutions: once have some sobriety, look at job training__

programs; get basic job in the meantime; learn communication skills

– involve family in treatment; consider personally and culturally___

meaningful ways to be involved with community _______________

Treatment Planning Sheet for Daniel (cont.)

Changing Social Environments

Ch ll li i h d fi d h f l ll d i k __Challenges: lives with mom and finds that stressful; all drinkers____

among the men he knows and hangs out with; shy and feels________

uncomfortable with going to AA meetings alone__________________

___Possible solutions: involve mom in treatment; work towards having_

money to live in own place or with other family/kin; look for________

nondrinkers in the community; find someone to go with to AA meetings;

learn about AI/AN meetings and types of meetings with more learn about AI/AN meetings and types of meetings with more________

comfortable formats______________________________________

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Enhancing Motivation

Motivational interviewing style

Feedback

Decisional balance

Feedback from family, friends, community

Feedback

Information needed: Number standard drinks consumed per day

Hours over which consumed alcohol

Gender

Weight

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Session 1 – Feedback - 2

Standard Drinks:Standard Drinks:

Beverage Type Size Standard Drinks

Beer 12 oz. 116 oz. 1.3

Wine 5 oz. 11 fifth 5

Hard Liquor 1.5 oz. Shot 1Hard Liquor 1.5 oz. Shot 11 pint 91 fifth 17

100 120 140 160 180 200 220 2400 .00 .00 .00 .00 .00 .00 .00 .001 .04 .03 .03 .02 .02 .02 .02 .022 .08 .06 .05 .05 .04 .04 .03 .033 .11 .09 .08 .07 .06 .06 .05 .05

4 .15 .12 .11 .09 .08 .08 .07 .065 .19 .16 .13 .12 .11 .09 .09 .086 .23 .19 .16 .14 .13 .11 .10 .097 .26 .22 .19 .16 .15 .13 .12 .11

8 .30 .25 .21 .19 .17 .15 .14 .139 34 28 24 21 19 17 15 14

Sample Behavioral Effects

Only completely safe limitImpairment begins

Approximate Blood Alcohol PercentageMen

Body Weight in Pounds

Driving skills significantly affected;

Information processing altered

Legally intoxicated; Criminal penalties;

Reaction time slowed; Loss of balance;

Drinks

9 .34 .28 .24 .21 .19 .17 .15 .1410 .38 .31 .27 .23 .21 .19 .17 .16

One drink is 1.5 oz. shot of hard liquor, 12 oz. of beer, or 5 oz. of table wine.

Impaired movement; Slurred speech

90 100 120 140 160 180 200 220 240

0 .00 .00 .00 .00 .00 .00 .00 .00 .00

1 .05 .05 .04 .03 .03 .03 .02 .02 .02

2 .10 .09 .08 .07 .06 .05 .05 .04 .04

3 .15 .14 .11 .10 .09 .08 .07 .06 .06

4 .20 .18 .15 .13 .11 .10 .09 .08 .085 .25 .23 .19 .16 .14 .13 .11 .10 .09

6 .30 .27 .23 .19 .17 .15 .14 .12 .11

Women

Approximate Blood Alcohol Percentage

Body Weight in Pounds

Only completely safe limit

Sample Behavioral Effects

Drinks

Driving skills significantly affected;

Information processing altered

Legally intoxicated;

Impairment begins

7 .35 .32 .27 .23 .20 .18 .16 .14 .13

8 .40 .36 .30 .26 .23 .20 .18 .17 .15

9 .45 .41 .34 .29 .26 .23 .20 .19 .17

10 .51 .45 .38 .32 .28 .25 .23 .21 .19

One drink is 1.5 oz. shot of hard liquor, 12 oz. of beer or 5 oz. of table wine.

g y ;Criminal penalties;

Reaction time slowed; Loss of balance;

Impaired movement; Slurred speech

Subtract .015 for each hour that you take to consume the number of drinks listed in the table. For example, if you are a 160 pound woman and have two drinks in two hours, your BAC would be .06 - (2 x .015) = .03

NOTE: Blood Alcohol Level (BAL) charts do not take into consideration a wide range of additional variables that contribute to the determination of BAL's achieved and the behavioral effects experienced at a given BAL. These additional variables include: age, water-to-body-mass ratio, ethanl metabolism, tolerance level, drugs or medications taken amount and type of food in the stomach during consumption speed of consumption, and general physical condition. Thus, BAL charts only provide extremely rough estimates and should never be used alone to determine any individual's safe level of drinking.

Adapted from BAC Charts produced by the National Clearinghouse for Alcohol and Drug Information.

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Feedback sheet

1. Based on the information you gave during the assessment, I calculated the number of “standard drinks” y g g ,you consumed in a typical week, during the last month:

Total number of standard drinks per week _____ Average number of standard drinks per day _____

2. I also estimated your highest and average blood alcohol level (BAL) in the past month. Your BAL is based on how many standard drinks you consume, the length of time over which you drink that much, whether you are a man or a woman, and how much you weight. So,

Y i d k BAL i k Your estimated peak BAL in an average week was _____ Your estimated average BAL in an average week was_____

This is a measure of how intoxicated you typically become. In New Mexico, the legal intoxication limit is 80 mg % or higher.

Feedback sheet - 2

3 You have experienced many negative consequences from drinking Here are some of 3. You have experienced many negative consequences from drinking. Here are some of the ones you said are most important to you:

___________________ _______________________

___________________ _______________________

___________________ _______________________

___________________ __________________________________________ _______________________

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Decisional Balance Sheet

P iti N tiPositive Negative____ Drinking/Drugs

Abstinence

Changing Triggers

Identifying high-risk situations

f Creating a list of triggers

Plans for dealing with situational triggers

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Identifying High Risk Situations

f Self-recording

Questionnaires

Anticipate high-risk situations each week

Client Monitoring Card:

Self-monitoring

Client Monitoring Card:

Urges Drinks/Drugs

TimeStrength(1-7) Trigger? Trigger?Time Type Amount

%Alcohol

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Creating a list of triggers

Environmental

Interpersonal

Emotional/thoughts

Physical

Planning to handle environmental triggers

A f Alternatives for handling environmental triggers: Avoid a situation

Leave a situation

Rearrange the environment

Behave differently in the environment

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Self-Management Planning Worksheet

Trigger Plan +/- Consequencesgg q

Changing internal reactions

Coping with cravings and urges

Changes thoughts about drinking

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Drinker coping with cravings and urges

TechniquesCh ll i h h Challenging thoughts

Thinking about negative consequences of drinking

Behavioral alternatives

Using meditative or spiritual approaches

Changing thoughts about drinking

Help the client learn to “think through” the drink

f f Review the decisional matrix to identify negative consequences of drinking and positive reasons to change

Write these on an index card and devise a plan for the drinker to review the card several times a day

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Learning new behaviors

Refusing drinks

Coping skills

Drink refusal

Learn to say “no” in a way that is comfortable for the client and respectful to the other personrespectful to the other person

Suggest an alternative Change the subject Feel good, not guilty, about refusing

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Coping skills

Mood management (e.g. anger, depression, anxiety)

Social interpersonal skills

Problem solving skills

Relationship enhancement

Job skills

Changing consequences

Finding alternative ways to experience positive consequences

Helping others to be more supportive and positive

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Developing alternatives

Positive Consequence AlternativePositive Consequence Alternative

Fills the time Think about what I value and enjoy; find ways to do things that fit with those values

Way to be with people Find positive ways to be part of community; find nondrinking groups, get involved with AA

Developing social networks to support sobriety

Modifying current social context Drink refusal skills

Nondrinking activities with social group

Informing family, friends, community of new status

Seeking new social networks – self-help groups Alcoholics Anonymous; Other 12-Step groups

Non 12-Step groups – SMART Recovery, Women for Sobriety

Seeking new social environments Shared leisure activities

Shared community interests

Shared religious interests

Shared intellectual interests

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General summary

CBT model is readily applicable to alcohol and other substance use CBT model is readily applicable to alcohol and other substance use disorders and for clients with different backgrounds, values, and cultures

The functional analysis provides the therapist and client with a common language to understand the client’s use

The functional analysis also provides a framework for selecting and y p gplanning interventions based on the unique pattern of variables maintaining the client’s drinking

Basic behavioral principles can guide the management of challenging client situations

Questions and discussion

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Questions and Discussion

Please type your questions or comments for the

presenter in the Q&A pod at this time…

Email Follow-up

Within the next 24 hours, you will receive an email from the National AI & AN ATTC which will include:

• Link to the recording of this webinar

We appreciate your participation in our survey, it should take you no more than 10 minutes to complete, and lets SAMHSA know:

• How many people attended our webinar

• How satisfied you are with our webinar

• How useful our webinars are to you

04/02/2014

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Upcoming webinars from the National American Indian & Alaska Native ATTC

Overview of Fetal Alcohol Spectrum Disorders:What we are Learning about Diagnosis and Intervention

presented by: Wendy O. Kalberg, MA, LED

An Introduction to Motivational Interviewing with Native American Adaptationspresented by: Kamilla Venner, PhD, Athabascan

Clinical Evaluation: Assessmentpresented by: Denise Casillas, MA, QMHP, Cheyenne River Sioux

For more information about our webinar series, contact Kate Thrams at kate-thrams@uiowa.edu or 319-335-5362

Tribe

Clinical Evaluation: Treatment Planningpresented by: Denise Casillas, MA QMHP, Cheyenne River Sioux Tribe

Th kThank youfor taking time out of your very important

work to ensure quality service through education in collaboration with the persons

you serve

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

you serve