Cognitive-Behavioral Therapy Core Competencies

Instructors:Dr. Reo Leslie, LMFT, LPC, CAC III

OREvelyn Leslie, MA, CAC III, RPT-S

What do the instructors bring to this topic? Dr. Reo Leslie, LMFT, LPC, CAC III has 32

years of post-masters experience in counseling, teaching, training, and supervision.

Mrs. Evelyn Leslie, M.A. CAC III, RPT-S, DAACS has 15 years of post-masters experience in counseling, teaching, training, and supervision.

Upon completion of this class, students will be able to: Define CBT and describe the basic theory behind it. Describe the use of CBT for managing thoughts, de-

escalating cravings and triggers, and handling relapse Describe how the use of CBT helps clients increase their

capacity to change thoughts, attitudes, behaviors and core beliefs.

Recognize that thoughts, feelings, and behaviors are interconnected

Recognize that lasting change occurs outside of therapy

Course Goals

Goals cont. Convey to clients that core beliefs and maladaptive

behaviors are learned and can be unlearned, and/or replaced with adaptive, pro-social behaviors

Complete a cognitive case conceptualization that includes strenghts, deficits, and client needs and a treatment plan that addresses goals for changes in the client’s cognition and behavior

Know how to use a thought record with a client to help change cognition and behavior

Day One- Review of CBT Theory and Practice Basic Concepts in CBT Efficacy of CBT in Colorado Theoretical Foundations of CBT Structure of CBT Sessions Review of Day One Pre-Test

Day Two- Application and Skill Demonstration of CBT Cultural Competency Assessment Using CBT Treatment Planning With CBT Utilizing a Specific CBT Model- BECCI Feedback to Students Review of Day Two Class Final Exam

Knowledge: Research in support of CBT for substance use disorders

and other problems- The modality is research-based and evidence-based according to Colorado studies ( Division of Criminal Justice, Department of Corrections, State Court Administrator, etc.) and National studies (SAMSHA, National Institute for Corrections, etc.)

Definition of CBT In relation to substance use disorders, “CBT attempts to help

clients RECOGNIZE the situations in which they are most likely to use, AVOID these situations when appropriate, and COPE more effectively with a range of problems and problematic behaviors associated with substance use.” (Carol. 1998, p. 1)

Theoretical Foundations for CBT

Cognitive Theory “a system of psychotherapy that attempts to

reduce excessive reactions and self-defeating behaviors by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions” (Beck et al. 1991, p. 10)

Disturbance in behaviors, emotions and thoughts can be modified or changed by changing and altering cognitive processes

Change your thoughts and your behavior will follow

Theoretical Foundations (cont) Cognitive elements and structures

Automatic thoughts Rules, values and attitudes Core belief structures Value Clarification

Behavioral Theory Social Learning Theory

Modeling Operant conditioning Classical conditioning

Intrapersonal skills Interpersonal skills

Essential/Active Clinical Ingredients of CBT

Collaborative, empathic relationship between therapist and client Functional Analysis Cognitive Reconstruction Coping Skill Development Training in;

Recognizing and coping with craving Managing thoughts Problem solving Planning for emergencies Recognizing seemingly irrelevant decisions Refusal skills Self monitoring of situations, thoughts, and behaviors

Examination of client’s cognitive processes related to substance use and/or current problem

Identification and debriefing of past and future high-risk situations Encouragement and review of extra-sessions implementation of skills Practice of skills within sessions

Basic Principles of CBT for Addiction Counseling CBT is a research-based, evidence-based, value-driven,

goal driven, psychoeducational, and collaborative therapeutic process

The psychotherapist and client decide together on appropriate treatment goals and work toward these goals as the basis of addiction counseling

CBT may be used for individual, group, couple, or family therapy with addiction and other clients

Research shows CBT must be followed, not only verbalized, in order to be effective with addiction clients

Clinical Assumptions of CBT

Anti-social behavior that is learned can be unlearned and replaced with new learned pro-social behavior

Human beings are social creatures and can be changed by changing social environments and thought processes

Psychotherapists facilitate change in clients by helping the client understand the systemic relationship between situations, thoughts, emotions, behaviors, and consequences

What are things I need to understand as a CBT therapist? Modeling Session Structure Directive Approach Classical Conditioning Operant Conditioning Functioning Analysis Cognitive Restructuring Coping Skill Development

Structure and Format of CBT Initial session of CBT-

Develop rapport Setting the session agenda Reviewing client history Educating the client about their disorder Educating client about psychotherapy and CBT Normalizing client issues Instilling hope Establishing client treatment goals Correcting (if necessary) client’s therapy goals Assigning homework Summarizing Bridging 20/20/20 Rule- Structured follow up in each subsequent session

20/20/20 Rule- Structured Follow Up to the Initial Session First 20 Minutes- Assess substance abuse,

craving, and risk situations since the last session Second 20 Minutes- Introduce the session topic,

discuss the concepts, and relate discussion to current issues

Third 20 Minutes- Explore client response to the topic, assign homework for the next session, and anticipate tasks and risks ahead for the week

What does the State of Colorado think of CBT? Specific CBT programs have been used and evaluated

in psychotherapy with drug-related criminal offenders: Aggression Replacement Training (ART) Moral Reconation Therapy (MRT) Reasoning and Rehabilitation (R and R) Thinking for a Change (T4C) Criminal Conduct and Substance Abuse Treatment

Strategies for Self Improvement and Change (SSC)

How is CBT used in Colorado for treatment of our clients? Probation Recidivism Reduction Assessment Treatment Planning Treatment Delivery Reducing Therapeutic Resistance in the Addiction

Counseling Process Matching the level of care to the client’s motivational

stage of change

Knowledge:

The structure and format of sessions 20/20/20 rule following the structured initial session

CBT is compatible with; Pharmacotherapy for drug/alcohol use and/or co-occurring

mental health disorders Self-help groups such as AA and the other 12-step programs Family and couple therapy Vocational counseling, parenting skills, etc. Psychoeducational approaches Motivational Interviewing and Motivational Enhancement

Therapy

CBT- The Clinical Approach for Our Client Population Office of Research and Statistics Data, State of Colorado,

Division of Criminal Justice (2006) Males- 39% have a history of mental illness; 79% have drug and

alcohol problems, 23% have current mental health problems Females- 53% have a history of mental illness; 91% have drug

and alcohol problems, 36% have current mental health problems

Mentally ill clients in jail have an average stay that is four times longer (120 days vs. 32 days) than the average incarcerated person

Knowledge: Interventions not part of CBT

Excessive self-disclosure by the therapist Use of confrontational style/confrontation of denial

approach Requiring the patient to attend self-help groups Extended discussion of 12-step recover, higher

power, “Big Book” philosophy Use of disease model language or slogans Extensive exploration of interpersonal aspects of

substance abuse Extensive discussion or interpretation of underlying

conflicts or motives Provision of direct reinforcement for abstinence

(vouchers, tokens)

Knowledge:

Similar approachesCognitive therapyCommunity Reinforcement ApproachMotivational enhancement therapy Family Psychoeducation

Dissimilar approachesTwelve-step facilitation Interpersonal psychotherapy Confrontational approaches

Skills: Initiate a collaborative working relationship with

clients Perform a functional analysis

Deficiencies and obstaclesSkills and strengthsDeterminants of Use or problem behavior

Social Environmental Emotional Cognitive Physical Situational Systemic or Cultural

Skills: Write treatment plan goals targeting both behaviors

and cognitive structures identified through assessment and functional analysis

Ability to teach self assessment and coping skills Ability to facilitate skill practice Assign extra-session implementation of skills and

offer appraisal as appropriate based on functional analysis and client willingness

Ability to lead clients in guided discovery Ability to keep session focused on CBT related

treatment goals Ability to match client interventions to appropriate

stage of change

Attitudes: People can and do change thoughts, feelings,

behaviors and beliefs Change is a process, not an event CBT addresses a comprehensive range of client

difficulties Thoughts, feelings and behaviors are interconnected Lasting change occurs outside of therapy Maladaptive and anti-social behaviors are learned

and can be unlearned, and/or replaced with adaptive, pro-social behaviors

If you can learn, you and unlearn, and learn something else

Key Concepts of CBT for Clients

Classical conditioning- Understanding stimulus and response in triggering craving and response to triggers

Operant conditioning- Reward and punishment in relationship to antisocial behavior or pro-social behavior.

Both are essential in treatment of addictive and compulsive behavior

CBT Outcome Studies From: Academy of Cognitive Therapy – For Professionals: CBT Outcome Studies Web Address: www.academyofct.org Cognitive Behavioral Therapy (CBT) has been demonstrated in hundreds of studies

to be an effective treatment for a variety of disorders and problems for adults, older adults, children and adolescents.

ADULTS CBT has been clinically demonstrated through randomized controlled trials to be an

effective treatment for the following disorders and problems: Depression

Geriatric Depression Relapse Prevention

Anxiety Generalized Anxiety Disorder Panic Disorder Agoraphobia and Panic Disorder with Agoraphobia Social Anxiety / Social Phobia Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder (Trauma) Withdrawal from Anti-Anxiety Medications

CBT Outcomes (cont) ADULTS(cont)

Bipolar Disorder (in combination with medication) Eating Disorders

Binge-eating disorder Bulimia Anorexia

Body Dysmorphic Disorder (extreme dissatisfaction with body image) Substance Abuse

Cocaine abuse (CBT relapse prevention is effective) Opiate Dependence Smoking Cessation (Group CBT is effective, as well as CBT that has multiple

treatment components, in combination with relapse prevention) Marital discord Anger Borderline Personality Disorder Atypical sexual practices/sex offenders

CBT Outcomes (cont) Medically related disorders: Chronic pain (CBT, in combination with physical therapy, is effective for chronic pain

in many medical conditions) Chronic back pain Sickle cell disease pain (CBT that has multiple treatment components is effective) Physical complaints not explained by a medical condition (Somatoform disorders) Irritable-bowel syndrome Obesity (CBT is effective in combination with hypnosis) Rheumatic disease pain (CBT that has multiple treatment components is effective) Erectile dysfunction (CBT is effective for reducing sexual anxiety and improving

communication) Sleep disorders Geriatric sleep disorders Insomnia Vulvodynia (a chronic pain condition of the vulva) Chronic fatigue syndrome

CBT Outcomes (cont) INITIAL STUDIES

CBT has been clinically demonstrated to be an effective treatment in case series, same-investigator studies, or studies without a control group for the following problems and disorders (among adults unless otherwise noted):

Geriatric Anxiety Schizophrenia (in combination with medication) Dissociative Disorders Suicide attempts Substance/alcohol abuse Attention deficit disorder Caregiver distress Habit disorders

Medically related disorders: Migraine headaches Non-cardiac chest pain Cancer pain Pain relating to a disease that has no known cause (Idiopathic pain) Hypochondriasis, or the unsubstantiated belief that one has a serious medical

condition

CBT Outcomes (cont) Medically related disorders: (cont) Chronic pain (among children/adolescents) Hypertension (CBT is effective as an adjunctive treatment) Fibromyalgia Colitis Gulf War Syndrome Tinnitus

CHILDREN AND ADOLESCENTSCBT has been clinically demonstrated in randomized controlled trials to be an effective treatment for the following disorders and problems:

Depression (among adolescents and depressive symptoms among children) Anxiety disorders

Separation anxiety Avoidant disorder Overanxious disorder Obsessive-compulsive disorder Phobias Post-traumatic stress disorder

CBT Outcomes (cont) CHILDREN AND ADOLESCENTS (cont) Conduct disorder (oppositional defiant disorder) Distress due to medical procedures (mainly for cancer) Recurrent abdominal pain Physical complaints not explained by a medical condition (Somatoform disorders) COGNITIVE BEHAVIORAL THERAPY IS ALSO USED FOR: Stress Low self-esteem Relationship difficulties Group therapy Family therapy Work problems & procrastination Pre-menstrual syndrome Separation and Divorce Grief and loss Aging

Colorado Research Outcome Studies Downloadable from the Research and Article Websites

at The State of Colorado Division of Public Safety Key Resource: What Works: Effective Recidivism and

Risk-Focused Prevention Programs: A Compendium of Evidence-Based Options for Preventing New and Persistent Criminal Behavior, Prepared for the Colorado Division of Criminal Justice, RKC Group, Roger Przybyiski, February, 2008, Chapter 5, pp. 61-67

Review of Day One

CBT Basic Concepts Efficacy of CBT CBT Theory CBT Research Outcome Pre-Test

DAY TWO- CBT Application and Skill Demonstration Cultural Competency Assessment Using CBT Treatment Planning Using CBT Treatment Using CBT-BECCI Feedback to Students Review Final Exam

Cultural Competency

Research shows CBT works with a variety of addiction clients from diverse cultural backgrounds

Student discussion in small groups: How do you make allowances for CBT with culturally different clients?

What worked? What did not work?

Assessment Using CBT

Matching the Client’s Stage of Change and Motivational Level to Treatment Goals

Determining Dynamics of Integrated Treatment for Client (Skills and Pills)

Determining Degree of Required Cognitive Reconstruction, Functional Analysis, and Coping Skill Development

Determining the Severity of the Dysfunction Determining if Cognitive Impairment is a Clinical Factor

CBT Assessment and Treatment Tools (Review of Handouts with Students) Biopsychosocial Assessment What Do I Want From Treatment? Decision Balance Workshop Change Plan Support Plan The Cost of My Recent DUI Coping With Thoughts About Cocaine All Purpose Coping Plan Functional Analysis

Relevant Assessment and Treatment Domains for CBT Cultural Social Situational Environmental Cognitive Family Systems Emotional Physical

Treatment Planning with CBT

What are the individual counseling treatment goals? What are the group counseling treatment goals? What are the couple, marriage, and family therapy

goals? Is the client a substance abuser, mentally ill, in the

Criminal Justice System, or all three? Student discussion of CBT treatment planning issues

at the students’ context of clinical practice

Application and Skill Demonstration of a Specific CBT Model- BECCI

What does doing CBT based addiction actually look like? Behavior Change Counseling Index (BECCI) – Integrative

tool for evaluation of CBT, Motivation Enhancement Therapy, and Motivational Interviewing Counseling Skills with individuals, groups, couples, and families

Students will role play and demonstrate the ability to utilize CBT counseling skills with Addictive and Compulsive Behavior Clinical Issues

Counselor, Client, and Observer Rotation

Behavior Change Counseling Index (BECCI) Review D:\Documents and Settings\C\Local Settings\Temporary Internet Files\

Content.IE5\GHIJKLMN\BECCI Scale Feb 2003[1].doc © University of Wales College of Medicine 2002

For enquiries about BECCI, please contact Dr. Claire Lane LaneCA1@cf.ac.uk BECCI is an instrument designed for trainers to score practitioners’ use of behavior

change Counseling in consultations (either real or simulated). To use BECCI, circle a number

on the scale attached to each item to indicate the degree to which the patient/practitioner has carried out the action described.

As a guide while using the instrument, each number on the scale indicates that the action was carried out:

0. Not at all1. Minimally2. To some extent3. A good deal4. A great extent

For each item, identify a score based on the scale above.

BECCI Items The Items: 1. Practitioner invites the patient to talk about behavior change 2. Practitioner demonstrates sensitivity to talking about other issues 3. Practitioner encourages patient to talk about current behavior or status quo 4. Practitioner encourages patient to talk about change 5. Practitioner asks questions to elicit how patient thinks and feels about the topic 6. Practitioner uses empathic listening statements when the patient talks about the

topic 7. Practitioner uses summaries to bring together what the patient says about the

topic 8. Practitioner acknowledges challenges about behavior change that the patient

faces 9. When practitioner provides information, it is sensitive to patient concerns and

understanding 10. Practitioner actively conveys respect for patient choice about behavior change 11. Practitioner and patient exchange ideas about how the patient could change

current behavior

BECCI Scoring Practitioner BECCI Score: (based on

totals from item list) Practitioner speaks for (approximately): More than half the time About half the time Less than half the time Student/Observer/Instructor Review of

Roleplaying

REVIEW OF DAY TWO CBT and Cultural Competency CBT Assessment CBT Treatment Planning CBT Treatment CBT Skill Demonstration and Roleplaying-

BECCI Final Exam

Resources (Handout) Beck, A.,Wright, F., Newmand, C., & Liese, B.

Cognitive Therapy of Substance Abuse. New York: Guildford Press, 1993.

Beck, J.S. Cognitive Therapy: Basics and Beyond. New York: Guildford Press, 1995.

Carroll, K. M. NIDA Therapy Manuals for Drug Addiction: Manual 1: A Cognitive Behavioral Approach: Treating Cocaine Addiction. #98-4308.

Dobson, K. S. Editor. Handbook of Cognitive Behavioral Therapies: Second Edition. New York: Guildford Press, 2002.

Resources, cont. (Handout)

Leahy, R. L. Overcoming Resistance in Cognitive Therapy. New York: Guildford Press, 2003.

Leahy, R. L. Roadblocks in Cognitive Behavioral Therapy: Transforming Challenges in Opportunities for Change. New York: Guildford Press, 2003.

Miller, W. & Rollnick, S. Motivational Interviewing: Preparing People to Change Addiction Behaviors, 2nd Edition. New York: Guildford Press, 2002.

SAMHSA Treatment Protocols. Tip 8: Intensive Outpatient Treatment for Alcohol and Other Drug Abuse.

Resources cont. (Handout) SAMHSA Treatment Protocols. Tip 21: Combining

Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles in the Justice System.

SAMHSA Treatment Protocols. Tip 34: Brief Interventions and Brief Therapies for Substance Abuse.

SAMHSA Treatment Protocols. Tip 39” Substance Abuse Treatment and Family Therapy.

Straussner, S. L. Clinical Work with Substance Abuse Clients, 2nd Edition. New York: Guildford Press, 2004.

Wright, J.H., Basco, M.R. & Thase, M.E. Learning Cogivitve Behavioral Therapy: An Illustrated Guild. Washington DC: American Psychiatric Publishing, Inc., 2006.