Leader’s Guide Cognitive Behavioural & Relapse Prevention .

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Leader’s GuideCognitive Behavioural & RelapsePrevention StrategiesTreatnet Training Volume B, Module 3: Updated 18 September 20071Instructions1. Introduce yourself.2. Explain the purpose of this series of trainings sponsored by the United NationsOffice on Drugs and Crime: “The capacity building programme mission is totransfer technology and knowledge on substance abuse intervention to serviceproviders in the participating local areas. Service providers include managers,physicians and psychiatrists, counsellors, psychologists, social workers, peereducators, outreach workers, and other professionals working in the substanceabuse field.”3. Thank participants for their interest in this series of trainings before starting yourpresentation.1

Training goals1.Increase knowledge of cognitive behaviouraltherapy (CBT) and relapse prevention (RP)strategies and resources.2.Increase skills using CBT and RP strategiesand resources.3.Increase application of CBT and RPstrategies for substance abuse treatment2Instructions1. Read the training goals to your audience.2. Explain that it is very important for participants in this training module to not onlygather new knowledge but also to practise the skills covered in this module andapply them to their work with addicted clients.3. Explain your training and follow-up plans. Stress that after this training, you willbe available to answer questions and provide feedback and advice regardingtheir demonstrations of the new skills through the role-plays.2

Module 3: WorkshopsWorkshop 1: Basic Concepts of CBT and RPWorkshop 2: Cognitive Behavioural StrategiesWorkshop 3: Methods for Using CognitiveBehavioural Strategies3Instructions1.Read the slide to your audience.2.Explain that this training module will take approximately 6-7 hours.3

Workshop 1: Basic Concepts ofCBT and RP4Instructions1. Introduce Workshop 1, “Basic Concepts of CBT and RP.”2. Explain that one of the most important ingredients of psychosocial treatment forsubstance use disorders is teaching people how to stop or reduce theirsubstance use and how to avoid relapsing and returning to dangerous levels ofuse.3. Explain that one set of techniques that has been shown to be highly effective forthis purpose is based on principles of cognitive behavioural therapy (CBT).4

Pre-assessmentPlease respond to the pre-assessmentquestions in your workbook.(Your responses are strictly confidential.)10 minutes5Instructions1. Ask participants to complete the 5 pre-assessment questions. They have 10minutes to complete these questions.2. Explain that both the pre-training and post-training assessments are conductedto insure that the training is appropriate for your particular audience, to measurethe effectiveness of the training, and to provide opportunities for improving it.3. The assessments may create tension among audience members. To reducesuch tension, explain that both assessments are confidential and that they donot need to provide any personal information.5

IcebreakerIf you had to move to an uninhabited island,what 3 things would you take with you andwhy? (food and water are provided)6Instructions1. This activity is optional, although recommended.2. Ask your audience the question on the slide.NotesIcebreakers are meant to create interaction among participants. Feel free to replacethe icebreaker with another one if it would be more appropriate for youraudience.6

Training objectivesAt the end of this workshop, you will:1.Understand that substance use is a learned behaviour that canbe modified according to principles of conditioning and learning2.Understand key principles of classical and operant conditioningand modelling3.Understand how these principles apply to the treatmentsdelivered in cognitive behavioural therapy and relapseprevention training4.Understand the basic approaches used in cognitive behaviouraltherapy and how they apply to reducing drug use and preventingrelapse5.Understand how to conduct a functional analysis and knowabout the 5 Ws of a client’s drug use7Instructions1. Read the training objectives to your audience.2. Explain that these objectives should be achieved as a team.3. Encourage participants to ask you questions as needed.7

What are Cognitive Behavioural Therapy(CBT) and Relapse Prevention (RP)?8InstructionsRead the slide to your audience.8

What is CBT and how is it used inaddiction treatment?zCBT is a form of “talk therapy” that is used toteach, encourage, and support individualsabout how to reduce / stop their harmful druguse.zCBT provides skills that are valuable inassisting people in gaining initial abstinencefrom drugs (or in reducing their drug use).zCBT also provides skills to help people sustainabstinence (relapse prevention)9Instructions1. Read the slide to your audience.2. Explain that the cognitive-behavioural paradigm works under the assumptionthat substance abuse is a learned maladaptative behaviour rather than causedby an underlying pathology. Under this assumption, therapy for substance abusetakes the form of an educational-learning process in which the clinician becomesa coach and the client has an active learning role throughout the process. Thegoal is for the individual with an addiction is to re-learn alternative behaviours tosubstance abuse while the clinician teaches, coaches, and reinforces his or herpositive behaviour.3. Explain that CBT attempts to help clients recognise, avoid, and cope. That is,RECOGNISE the situations in which they are most likely to use drugs, AVOIDthese situations when appropriate, and COPE more effectively with the range ofproblems and problematic behaviours associated with substance abuse.9

What is relapse prevention (RP)?Broadly conceived, RP is a cognitive-behaviouraltreatment (CBT) with a focus on the maintenance stageof addictive behaviour change that has two main goals:zTo prevent the occurrence of initial lapses after acommitment to change has been made andzTo prevent any lapse that does occur fromescalating into a full-blow relapseBecause of the common elements of RP and CBT, wewill refer to all of the material in this training moduleas CBT10Instructions1. Read the slide to your audience.2. Explain that relapse prevention is a cognitive-behavioural treatment that includes a largeeducational component (Marlatt & Donovan, 2005). Relapse prevention aims to increase theclient’s awareness of high-risk situations and increase coping skills, self-efficacy, and control ofinternal and external variables that may make them more vulnerable to relapse. Relapseprevention (RP) combines cognitive and behavioural techniques such as thought-stopping, copingskills, alternative activities, etc.Additional InformationRelapse prevention is a generic term that refers to a wide range of therapeutic techniques to preventlapses and relapse of addictive behaviours. The term “relapse” was initially employed in themedical context to refer to those people who re-experience a disease stage. Currently, this term isbeing used for a variety of behaviours including returning to regular substance abuse (Marlatt &Donovan; 2005).People who make behavioural changes (e.g., smoking cessation, increasing regular exercise, etc.)tend to relapse to previous behavioural repertoires over time (Polivy & Herman, 2002). Similarly, ithas been demonstrated that few individuals are able to completely succeed in substance abuseabstinence for the long-term on the first attempt (Addy & Ritter, 2000). Sobriety and relapse areboth part of an interactive, complex process in the treatment context. Relapse prevention skillscan be improved over time in a lapse/relapse learning curve in which increasing practise ofcoping skills will decrease the probability of relapse. The main goal of RP is maintaining sobrietyover time and preventing the occurrence of lapses and their escalation into a full relapse episode.It is difficult to determine whether a lapse may end up in relapse. It ultimately depends on how theclient responds to high-risk situations.10

Foundation of CBT:Social Learning TheoryCognitive behavioural therapy (CBT)zProvides critical concepts of addiction and howto not use drugszEmphasises the development of new skillszInvolves the mastery of skills through practise11Instructions1. Read the slide to your audience.2. Explain that under the cognitive-behavioural paradigm, thoughts, feelings, andbehaviours are separate areas of human behaviour and cognitive processingthat become associated through learning. For instance, alcohol use is abehaviour that might be linked to thoughts, feelings, and even other behavioursby personal experience and observation. When these associations becomestronger over time, they may act as triggers without any substances necessarilybeing present at the time.3. Provide some examples. For instance, thinking that a cigarette will help me torelax may become a trigger to smoke. Even behaviours may become triggers fordrug use.11

Why is CBT useful? (1)zCBT is a counseling-teaching approach wellsuited to the resource capabilities of mostclinical programszCBT has been extensively evaluated inrigorous clinical trials and has solid empiricalsupportzCBT is structured, goal-oriented, andfocused on the immediate problems faced bysubstance abusers entering treatment whoare struggling to control their use12Instructions1. Read the slide to your audience.2. Explain that cognitive-behavioural therapy employs learning principles within ahighly structured intervention with clearly defined goals that focus on theindividual’s current problems. The learning principles are based on classicalconditioning and operant conditioning that might occur through observation anddirect experience.12

Why is CBT useful? (2)zCBT is a flexible, individualized approachthat can be adapted to a wide range ofclients as well as a variety of settings(inpatient, outpatient) and formats (group,individual)zCBT is compatible with a range of othertreatments the client may receive, such aspharmacotherapy13Instructions1. Read the slide to your audience.13

Important concepts in CBT (1)In the early stages of CBT treatment, strategiesstress behavioural change. Strategies include:zplanning time to engage in non-drug relatedbehaviourzavoiding or leaving a drug-use situation.14Instructions1. Read the slide to your audience.2. Explain that in cognitive behavioural therapy the emphasis is not on beingstrong, but in teaching clients to be wise and make good decisions.14

Important concepts in CBT (2)CBT attempts to help clients:zFollow a planned schedule of low-risk activitieszRecognise drug use (high-risk) situations and avoidthese situationszCope more effectively with a range of problems andproblematic behaviours associated with using15Instructions1. Read the slide to your audience.15

Important concepts in CBT (3)As CBT treatment continues into later phasesof recovery, more emphasis is given to the“cognitive” part of CBT. This includes:zzzzTeaching clients knowledge about addictionTeaching clients about conditioning, triggers, andcravingTeaching clients cognitive skills (“thoughtstopping” and “urge surfing”)Focusing on relapse prevention16Instructions1. Read the slide to your audience.16

Foundations of CBTThe learning and conditioning principlesinvolved in CBT are:zClassical conditioningzOperant conditioningzModelling17Instructions1. Read the slide to your audience.17

Classical conditioning: ConceptsConditioned Stimulus (CS) does not produce aphysiological response, but once we have stronglyassociated it with an Unconditioned Stimulus (UCS)(e.g., food) it ends up producing the samephysiological response (i.e., salivation). 18Instructions1. Read the slide to your audience.2. Explain to your audience the graphic: Conditioned stimuli (CS) are those stimulithat by their nature do not produce a physiological response in our bodies (e.g.,a bell) but that once we strongly associated them with an unconditioned stimulus(UCS; food, in this case) after repeated exposures, they end up producing thesame physiological response (salivation) in absence of the UCS (food).3. Ask participants for examples of stimuli associated with drug use. For instance,tobacco users may have strong associations between a cigarette and smokingfriends, types of food or drinks (e.g., coffee), and places (e.g., pubs or bars).18

Classical conditioning: AddictionzRepeated pairings of particular events,emotional states, or cues with substance usecan produce craving for that substancezOver time, drug or alcohol use is paired withcues such as money, paraphernalia, particularplaces, people, time of day, emotionszEventually, exposure to cues alone producesdrug or alcohol cravings or urges that are oftenfollowed by substance abuse19Instructions1. Read the slide to your audience.2. Explain that classical conditioning is a learning process that has three maincomponents: A conditioned stimulus (CS), unconditioned stimulus (UCS), and aconditioned response (CR).3. Explain to participants that over time, a repeated stimulus (a bell ringing) pairedwith another event (the presentation of food) can elicit a reliable response (dogsalivation). The same can be said of the addicted person. Certain stimuli orcues, for example, money, boredom, or anxiety, that are associated with use ofa drug can, over time, trigger cravings for that drug.19

Classical conditioning: Applicationto CBT techniques (1)zzUnderstand and identify “triggers”(conditioned cues)Understand how and why “drug craving”occurs20Instructions1. Read the slide to your audience.2. Explain that clinicians should then work with clients to develop a comprehensivelist of the client’s triggers (conditioned stimuli). Some clients becomeoverwhelmed when asked to identify cues (one person reported that evenbreathing was associated with their drug use). Again, it may be most helpful toconcentrate on identifying the craving and cues that have been most problematicin recent weeks. This list should be started during the session; the practiseexercise for this session should include self-monitoring of craving, so clients canbegin to identify new, more subtle cues as they arise.(Adapted from Carroll, 2002)20

Classical conditioning: Application toCBT techniques (2)zzLearn strategies to avoid exposure totriggersCope with craving to reduce / eliminateconditioned craving over time21Instructions1. Read the slide to your audience.2. Explain that classical conditioning theories can be applied in two importantareas: (1) in learning strategies and skills to avoid being exposed to triggers(friends, locations, money, etc.) and (2) in coping with craving to reduce oreliminate conditioned craving over time.3. Provide some examples of strategies that can be learned, such as avoidingcertain places or people, avoiding having cash, etc.4. Provide examples of how to cope with cravings, such as exercising, relaxationtechniques, calling a non-substance user friend, etc.5. Ask participants for more examples.21

Operant conditioning: Addiction (1)Drug use is a behaviour that is reinforcedby the positive reinforcement that occursfrom the pharmacologic properties of thedrug.22Instructions1. Read the slide to your audience.2. Explain that drug use can also be seen as behaviour that is reinforced by itsconsequences. Drugs may be used because they change the way a personfeels (powerful, energetic, euphoric, stimulated, less depressed), the way theythink (I can only get through this if I am high), or the way they behave (lessinhibited, more confident)3. Ask participants for more examples.22

Operant conditioning: Addiction (2)Once a person is addicted, drug use isreinforced by the negative reinforcementof removing or avoiding painfulwithdrawal symptoms.23Instructions1. Read the slide to your audience.2. Ask participants for examples of how withdrawal symptoms can be negativereinforcements for continuing drug use.NotesPlease be aware that the confidentiality of clients needs to be maintained. Ask forgeneral examples and not for particular cases.23

Operant conditions (1)Positive reinforcement strengthens a particularbehaviour (e.g., pleasurable effects from thepharmacology of the drug; peer acceptance)24Instructions1. Read the slide to your audience.2. Ask participants for examples of positive reinforcements that can strengthen abehaviour.3. Explain that positive reinforcement occurs when a particular behaviour increasesin occurrence by the consequence of experiencing or observing a positivecondition. For example, if I eat when hungry, the consequence will be to feelsatisfied; therefore, I will probably repeat this behaviour again in the future.24

Operant conditions (2)Punishment is a negative condition thatdecreases the occurrence of a particularbehaviour (e.g., If you sell drugs, you will go tojail. If you take too large a dose of drugs, youcan overdose.)25Instructions1. Read the slide to your audience.2. Ask for other examples.3. Explain to your audience that punishment refers to a negative condition thatdecreases the occurrence of a particular behaviour. For example, if I put myhand in a hot stove, the consequence will be that I will burn my hand (pain – anegative consequence); therefore, I will probably avoid repeating this behaviouragain.25

Operant conditions (3)Negative reinforcement occurs when a particularbehaviour gets stronger by avoiding or stopping anegative condition (e.g., If you are having unpleasantwithdrawal symptoms, you can reduce them by takingdrugs.).26Instructions1. Read the slide to your audience.2. Ask your audience for some other examples.3. Explain that negative reinforcement occurs when a particular behaviour increasesin occurrence by avoiding or stopping a negative consequence. For example, arat in a cage receives a mild electrical shock on its feet (negative consequence),the rat discovers that pressing a bar stops the shocks; as a consequence, thebehaviour of pressing the bar is strengthened.26

Operant conditioning: Application toCBT techniqueszFunctional Analysis – identify high-risksituations and determine reinforcerszExamine long- and short-termconsequences of drug use to reinforceresolve to be abstinentzSchedule time and receive praisezDevelop meaningful alternativereinforcers to drug use27Instructions1. Read the slide to your audience.2. Explain that you will be discussing each one of these techniques in the upcomingslides.27

Modelling: DefinitionModelling: To imitate someone or to follow theexample of someone. In behaviouralpsychology terms, modelling is a process inwhich one person observes the behaviour ofanother person and subsequently copies thebehaviour.28Instructions1. Read the slide to your audience.2. Explain that under a cognitive behavioural approach, substance abuse is alearned behaviour that developed through complex interplays of modelledbehavior, classical conditioning, or operant conditioning. The same principlescan be used to help the client stop substance use (adapted from Carroll, 2002,pp. 18-24).3. Explain that modelling is a technique that will help clients learn new behavioursand coping skills through observing other people’s behaviours. If you employtechniques such as role-playing, observing videos, or observing good modelsacting in an adaptive way, your client can learn new behaviours. Either inindividual or group settings, your conduct (or the model’s conduct) will beobserved by the client and, ideally, copied by them. For instance, the client willlearn to respond in new way by watching you apply techniques to avoid or dealwith high-risk situations (e.g., refusing drugs from a friend).4. Ask your audience for other examples.28

Basis of substance use disorders:ModellingWhen applied to drug addiction, modelling is amajor factor in the initiation of drug use. Forexample, young children experiment withcigarettes almost entirely because they aremodelling adult behaviour.During adolescence, modelling is oft

Increase knowledge of cognitive behavioural therapy (CBT) and relapse prevention (RP) strategies and resources. 2. Increase skills using CBT and RP strategies and resources. 3. Increase application of CBT and RP strategies for substance abuse treatment Instructions 1. Read the training goals to your audience. 2.

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