Implementing Evidence-Based Practices in Behavioral Therapy

COGNITIVE BEHAVIORAL THERAPY PRESENTED BY MARK DISSELKOEN MSW, LCSW, LADC

The ATTC Network 2

The ATTC Network Ten Regional Centers Central Rockies ATTC is now the Mountain Plains ATTC (UNR, UND)

University of Nevada, Reno

Disclaimer The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

Lets Define and Understand what an EBP is National Registry of Evidence Based Programs & Practices (NREPP) site http://nrepp.samhsa.gov/01_landing.aspx A new rating system was started on November 23, 2015 and is being applied to new proposed EPB s.

Continued: Existing programs on NREPP list prior to November 23, 2015 are now called legacy programs and will be reviewed under new rating system from 2015 through 2018. Existing programs on NREPP list prior to November 23, 2015 are now called legacy programs and will be reviewed under new rating system from 2015 through 2018. There are 3 outcomes related to the new rating system: Effective Promising Ineffective

Continued: Some EBP s on the list are very specific such as the Matrix Model which is based on a CBT theoretical framework other EBP s such as Motivational Interviewing is less structured related to a specific Model in comparison to Matrix which utilizes workbooks as part of treatment. It is critical to apply NIDA Principle 1: of the NIDA 13 Principles, that No single treatment is appropriate for all individuals. You need many tools in your tool box to implement client centered treatment rather than a one size fits all approach. This is called treatment matching.

The key to implementing EBP s with fidelity is: Writing descriptive policies on curriculum, implementation, and measurement (outcomes) Training key staff on these policies Supervision of staff in delivery of services Measurement and feedback Revise and update

How are EBPs measures related to fidelity? Through Supervision Clinical documentation Recording and observation Consent forms for recording and observation

WHAT IS COGNITIVE BEHAVIORAL THERAPY? Feeling and behavior are caused by a person s thoughts Not outside stimuli like people, situations and events May not be able to change circumstances May change how they think about themselves Equals change in how they feel and behave

COGNITIVE BEHAVIOR THERAPY in TREATMENT of a Person with a Substance Use Disorder Teach person to recognize situations in which they are most likely to use Avoid these circumstances if possible Cope with other problems/behaviors that may lead to use

OTHER COGNITIVE APPROACHES Rational Behavior Therapy (Dr. Albert Ellis) Irrational beliefs bring about bad feelings and unproductive activity in decision making We feel, choose, act according to our interpretations, our maps, of events Hold innate irrational beliefs (Anatomy of Emotions) consists of 3 parts: A real or imaginary future event An interpretation of events or beliefs about it, and; The resulting feeling or feelings

OTHER COGNITIVE APPROACHES cont. Rational Behavior Therapy ( Dr. Albert Ellis) cont. Patients are not aware of their beliefs and the beliefs influences. Clinicians make their patients: Aware of their functioning Point out to them the irrational belief(s) Correct such errors When this happens, feelings and actions often spontaneously change

OTHER COGINTIVE APPROACHES cont. Rational Emotive Therapy Theory People strive for happiness People are prone to adopting irrational beliefs and behaviors Lead to dogmatic musts, should, or ought's. Contrast with rational and flexible desires, wishes, preferences and wants How we manage this contrast impacts how we respond to circumstances positively or negatively Individuals have the power to change how they think, thus change how they feel (A) Activating Event, (B) Beliefs, (C) Consequences

Other Cognitive Approaches cont. Rational Emotive Therapy Approach Replace absolutist philosophies with flexible ones Accept that all human beings are fallible Acknowledgement of problem Identify underlying irrational thought(s) Challenge irrational thoughts Identify impediments to progress and overcome them Consolidate their gains and prevent relapse

GENERAL APPROACHES Components Functional Analysis Therapist and client work together Identify thoughts Feelings Circumstances Before and after they used Helps client determine risks likely to lead up to relapse Provides insight on why client uses Helps identify situations in which the person has coping difficulties

General Approaches- cont. Components Skill Training Determining if client is using as their main coping mechanism Goal is to get person to learn or relearn better coping skills Unlearn old habits Learn to develop healthier skills and habits Change the way they think about use Learn new ways to cope with situations and circumstances that lead to using

GENERAL APPROACHES- cont. How Long Does Cognitive Behavior Therapy Take? Typically short-term 12-16 sessions on average, but should be guided by individual need driven by ASAM Continued and Discharge Criteria

APPLICATION: Coping Skills Training Short term benefits of using becomes preferred way of coping Leads to psychological dependence Must use to cope, no choice Coping skills deficits are major obstacles Other ways to cope must be identified past, present, future Assessment includes identification of consequences of use as a coping mechanism Typical patterns of use

APPLICATION- cont. Coping Skills Training- Cont. Common Antecedent situations Mood states Thoughts Cravings Life problems Social Situational Emotional Cognitive Physiological

APPLICATION- cont. Coping Skills Training- Cont. Rank and order trigger situations, frequency, and occurrence and how serious the problem For each trigger, client should ask what expected gain is achieved by using in those situations Client may feel uncomfortable looking at use as benefit Explain that use is not unreasonable or abnormal Discuss here other ways of coping in those specific situations Practice skills in session In real life, homework

APPLICATION cont. Specific Skills Training: Intrapersonal Skills Managing thoughts and cravings for use: Challenging client Recalling unpleasant experiences Anticipate benefits Distracting oneself Delaying the decision Leaving the situation Seeking support

APPLICATION- cont. Specific Skills Training- cont. Intrapersonal Skills- cont. Anger Management Negative Thinking Pleasant activities Relaxation skills Decision making Problem solving Planning for emergencies

APPLICATION- cont. Specific Skills Training- cont. Interpersonal Skills Drink/drug refusal Refusing requests Handling criticism Intimate relationships Enhancing social support network General social skills Coping skills training with significant others Relapse prevention

Dialectical Behavior Therapy (DBT) CBT Theoretical Framework DBT skills training group is focused on enhancing clients' capabilities by teaching them behavioral skills. The group is run like a class where the group leader teaches the skills and assigns homework for clients to practice using the skills in their everyday lives. Groups meet on a weekly basis for approximately 2.5 hours and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only a subset of the skills have also been developed for particular populations and settings.

Continued: DBT individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy and runs concurrently with skills groups.

Continued: DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.

Continued: DBT therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work with people who often have severe, complex, difficult-to-treat disorders. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. Teams typically meet weekly and are composed of individual therapists and group leaders who share responsibility for each client's care.

Descriptive Information for DBT ReportNew.pdf

Thank You Questions/Feedback mdisselkoen@casat.org

Reference: Brief Interventions and Brief Therapies for Substance Abuse TIP 34 (2012) The Behavioral Health Recovery Management project is an initiative of Fayette Companies, Peoria, IL; Chestnut Health Systems, Bloomington, IL; and the University of Chicago Center for Psychiatric Rehabilitation.