This document summarizes a workshop on applying cognitive behavioural therapy to addiction. It discusses motivational interviewing and the "four M's" approach of motivating change, managing impulses and craving, managing emotions, and maintaining lifestyle changes. It outlines techniques like identifying triggers, coping skills, and relapse prevention. It also notes the role of impaired cognitive control in addiction and the need to address automatic tendencies and cognitive biases through treatments like contingency management and mindfulness.

1. Motivation and change: Cognitive behaviour therapy applied to addiction Workshop presented at the European Association of Behavioural & Cognitive Therapies Dubrovnik 17th September 2009 Frank Ryan C PsycholAFBPsS Clinical Psychologist Honorary Research Fellow CNWL NHS Mental Health Trust Birkbeck College

2. Overview of workshop Welcome and introductions Goals of workshop (discussion and identification of clinical issues) Scientific perspectives on addiction Applications & competencies: Time for CHANGE Introducing “4 M’s” Motivation & engagement Managing impulses and craving Managing emotions Maintaining change (relapse prevention skils) f.ryan@psychology.bbk.ac.uk

3. Time for CHANGE Change Habits And Negative Generation of Emotion (Ryan, 2006) f.ryan@psychology.bbk.ac.uk

4. Low intensity interventions High intensity interventions Substance specific Giving accurate information about addiction, detoxification and relapse to service user & family Brief motivational interventions Contingency management Identifying triggers and cues Coping skills for impulse control Facilitating engagement in AA/NA/CA/GA Programmed cognitive behaviour therapy sessions such as Relapse Prevention Skills Training either on one to one or group basis. Behavioural Couples Therapy Co-morbid specific Guided self-help (books, and cCBT on CD ROMS and Web.e.g Beating the Blues and www.livinglifetothefull.com CBT for other ICD10 disorders: Anxiety Depression Anger PTSD What’s in the tool-kit? Range of psychological inputs and core competencies based on stepped care.

5. EABCT 2009:New Perspectives (1) Treatment outcomes are often poor in addiction Treatment specific effects not demonstrated (e.g. Project Match). This suggests key variables are not being addressed specifically. Recent findings implicate impaired cognitive control as a factor in the persistence of addiction. This needs to be assimilated into CBT

6. EABCT 2009:New Perspectives (2) Compulsive nature of substance misuse and addiction implicates cognitive control Result is distinctive “cognitive signature” and behavioural dysregulation Remediation needs to overcome automatic tendencies that are often implicit

7. f.ryan@psychology.bbk.ac.uk Outcomes Overview Effect sizes for addictive disorders are diverse: Alcohol(r=.27) 36-63% gain Cocaine(r=-.03) ?? Tobacco(r=.09) 45-55% gain Relapse Prevention Skills Training does not consistently confer superior outcomes across addictive spectrum compared to control interventions but substantially larger effect sizes have been found for: Psychosocial gains (r=.48 i.e. 25%-75%) compared to substance use reduction (r=.14). Irwin et al(1999)

8. f.ryan@psychology.bbk.ac.uk Why Drugs are Addictive Drugs of abuse such as alcohol, amphetamine cocaine act as primary reinforcers. This operates directly or indirectly through reward circuit in the brain. Some people find this hard to resist.

9. Two Pathways to emotion (& craving) Information about emotionally salient stimuli and stimuli associated with drug availability reaches the amygdala directly from the thalamus (low road) and also via the cortex (high road).This is why sometimes we feel urges or emotions fear without knowing why. Stimuli are monitored continuously but “amygdala alerts” do not necessarily generate conscious awareness.

10. Implications of recent cognitive neuroscience findings Addiction is maintained by enduring changes in priorities and deficits in information processing. Therapies that infiltrate and modify this, i.e. increase cognitive control, are more likely to be effective. There is therefore a potential role for “neurocognitive rehabilitation” using the prototype described here Conversely, changes in attentional and mnemonic functioning, especially implicit processes, will index and predict therapeutic gain. f.ryan@psychology.bbk.ac.uk

11. Cognitive biases are linked to craving Cognitive biases are associated with increased craving. Increased craving leads to increased cognitive bias. Increased cognitive bias leads to increased craving Bias tends towards maintenance rather than engagement: this has implications for treatment. (Field, Mogg & Bradley, 2006 Attention to drug-related cues in addiction: Component processes in Wiers, W.W., & Stacey, A.W Handbook of implicit cognition and addiction.(Eds) Sage. London. f.ryan@psychology.bbk.ac.uk

12. Work in progress….. Working Memory Top down Processes (goals and coping strategies) Bottom up Processes “Reward Radar” f.ryan@psychology.bbk.ac.uk

13. Cycle of pre-occupation Attentional bias Contents of Working memory Attentional bias Attribution of incentive salience f.ryan@psychology.bbk.ac.uk

14. Exciting findings in the lab, but what about applications in the real world? “Great Empires have been overturned. The whole map of Europe has been changed... But as the deluge subsides and the waters fall short, we see the dreary steeples of Fermanagh and Tyrone emerging once again.” Sir Winston Churchill, c. 1919 f.ryan@psychology.bbk.ac.uk

15. New findings need to be integrated into comprehensive treatment approaches “Givens” such as engagement, formulation, and acquiring coping strategies cannot be discounted; CBT is a pragmatic and evolving framework that should be able to accommodate new procedures and concepts. f.ryan@psychology.bbk.ac.uk

16. Reward radar is always on! Emphasis on reversal of implicit cognitive biases. Focus on enhancing cognitive control (STM and attention ) mechanisms via goal maintenance Prioritises impulse control strategies f.ryan@psychology.bbk.ac.uk

17. Themes applied Importance of goal maintenance Rehearsal+ repetition+ reinforcement = Reversal. Importance of identifying alternative goals and pursuing these in a systematic manner.

18. f.ryan@psychology.bbk.ac.uk Substance Misuse Impairment of health and social functioning Impairment of occupational functioning Continued use in face of these negative consequences - loss of control over intake Best viewed as a continuum with escalating use generating increasingly stereotypical responses and more consequential harm Commonly associated with co-morbidity, including suicide

19. f.ryan@psychology.bbk.ac.uk Scope and aims of CBT in Substance Misuse (1) Engaging and motivating individuals into therapeutic programmes Placing substance misuse in a personal context for the individual (formulating). Facilitating the acquisition of skills to cope with impulses driving drug seeking and taking Enhancing affect regulation Relapse prevention and follow-up (maintenance strategies)

20. Scope and aims of CBT in Substance Misuse (2) Motivation, Motivation, Motivation! Conceptualising, formulating and treatment planning Identify high risk stimuli: internal and external Correct maladaptive beliefs about substances e.g “people would ridicule me if I did not drink at the party” Identify the involvement of early maladaptive schemas e.g. defectiveness or unloveability as contexts for misuse Negative automatic thoughts: “Who cares if I drink?” Coping with craving: e.g. “delay and distraction” Rationalisations “ permission giving beliefs” e.g. “I deserve one…” Circumscribing lapses/slips: One swallow doesn’t make a summer!”

21. f.ryan@psychology.bbk.ac.uk The Four Ms Motivate (and engage) Manage impulses to use Manage your mood Maintain lifestyle change

22. Or, just do two things! Facilitate impulse control Facilitate affective regulation

23. Tried & Tested:Summary of useful CBT techniques f.ryan@psychology.bbk.ac.uk Recognising or “capturing” automatic thoughts Goal setting Reality testing/behavioural experiments Cognitive rehearsal Identifying underlying beliefs and assumptions Coping skills (e.g. relaxation therapy; “distancing”) Problem solving skills Relapse prevention skills: identifying high risk situations and rehearsing how to cope with them

24. Conclusion:You know most of it already! (but please stay until end of workshop just to make sure) From a cognitive social learning perspective, there are no entirely novel mechanisms or compensatory strategies involved in the acquisition, maintenance or regulation of addictive behaviour. f.ryan@psychology.bbk.ac.uk

25. f.ryan@psychology.bbk.ac.uk Treatment barriers:The possible effects of repeated setbacks Scenario 1: Client blames themselves: “I’m lacking will power and I’m useless anyway…” Scenario 2: Therapist blames client ( sometimes with their full agreement/collusion : “ You are not motivated or committed, come back when you’re ready (i.e. stop wasting my time!) Scenario 3: Therapist blames themselves: “I’m no good at this, my clients never seem to improve” Scenario 4: Client blames therapist : “ You don’t understand me or my problems and the treatment is useless”.

26. f.ryan@psychology.bbk.ac.uk Motivational Interviewing 1 Opening strategy: ask about lifestyle, stresses and problem behaviour A typical day The good things and the less good things about the current drug use Current concerns

27. Motivational interviewing 2 Elicit self-motivational statements: e.g.” Its sounds like your partner is worried about your drinking, but I was wondering how you feel about it?” Listen with accurate empathy: “It sounds like you want to quit but when you tried treatment before you went back to using cocaine”

28. Motivational interviewing 3 Roll with resistance: “you’re not sure you want to make a commitment to quit today” Point out discrepancies: “ You’re not sure your drinking is a big problem, but people who care about you seem to be concerned” Clarify free choice: “In the end, its down to you to make the decision….”

29. Brief motivational encounters…. Establish rapport through empathy Focus on raising the issue (i.e. substance misuse) Build commitment Agree goal Use self-monitoring and reinforcing feedback f.ryan@psychology.bbk.ac.uk

30. Assessing readiness and building commitment to change Importance Readiness Confidence Ask: How important/ready/confident are you on a scale of 0-10? Then “Why not lower/higher …? ” Identify and challenge negative thoughts about change Encourage re-attribution of past failures (prevent the cultivation of internal, global and general attributions of impulsivity) Express accurate empathy

31. Dealing with ambivalence Identify an issue or situation about which you are ambivalent about taking steps to change. In pairs: One to explore the pros and cons of changing f.ryan@psychology.bbk.ac.uk

32. Structuring sessions: the “20 20 20” rule 20 minutes: Review substance misuse, give motivational feedback, note current concerns 20 minutes: Introduce session topic (e.g. coping with craving) & relate to current concerns 20 minutes: assign homework /practice exercise for coming week & anticipate high risk situations

33. f.ryan@psychology.bbk.ac.uk Session by session monitoring: COMET Continuous Outcome Monitoring During Engagement In Treatment

34. f.ryan@psychology.bbk.ac.uk Outcome Monitoring Percentage days abstinent (PDA) e.g. Client reports alcohol use on 4/7 days (3/7)X100= 43% approximately=PDA This can be applied to various time intervals such as change since baseline. Feedback to clients can be provided in a motivational context.

35. Contingency management Identify target behaviour e.g. supplementary drug use; testing or treatment for hepatitis C. Emphasise collaborative dimension. Reinforce frequently and according to pre-ordained schedule. Maintain for up to twelve weeks f.ryan@psychology.bbk.ac.uk

36. Just say no! When offered drugs: Say no first Make direct eye contact Don’t be afraid to ask the person to stop offering Don’t leave the door open to future offers (e.g. I don’t feel like it today) Be assertive, not aggressive

37. f.ryan@psychology.bbk.ac.uk Manage impulses (urges) and craving: the “Reward Radar” never switches off! Stimulus Control Implementation intentions Be aware of and attempt to correct cognitive biases Identify alternative rewards Self monitoring Distance /de- centre / mindfulness meditation Challenge expectancies and implicit cognitions via behavioural experiments Support self-efficacy Goal specificity

38. Managing craving Recognise thinking about drugs e.g “life is boring without cocaine” or “I deserve a drink”. Include categories of testing personal control and permission giving beliefs. Avoid situations rich in drug cues e.g. parties where drugs are ubiquitous- setting alternative goals is often a good strategy Identify and rehearse coping strategies e.g. drink refusal skills; distraction; challenging your thoughts ; review negative consequences focus on benefits of restraint; talk to supportive friends or associates on programme

39. f.ryan@psychology.bbk.ac.uk Implementing intentions to change If situation X occurs I will perform behaviour Y e.g. “If I have money I will do my shopping before visiting the cocaine dealer” If I am offered alcohol to drink at the party I will say “no thanks, but I would love a mineral water”. Prestwich et al (2006)

40. f.ryan@psychology.bbk.ac.uk Manage affective dysregulation Conventional CBT techniques: correcting cognitive distortions; problem solving; exposure & behavioural experiments Pharmacotherapy

41. f.ryan@psychology.bbk.ac.uk Mindfulness Mindfulness disrupts automatic flow of cognitions < contrasts with ironic or paradoxical effects of effortful suppression> Mindful acceptance should influence outcomes by reducing intrusion

42. f.ryan@psychology.bbk.ac.uk Maintenance Relapse Prevention Skills Training: identify high risk situations and how to deal with them. Attend Twelve Step based groups such as AA/NA Use self-help materials Practice mindfulness meditation or other meta-cognitive techniques Remember that addiction casts a long shadow: appetitive responses are enduring and can be re-established by exposure to stress, small amounts of the drug of choice (possibly accidental?) and slight or ambiguous stimulation associated with drug.

43. f.ryan@psychology.bbk.ac.uk “Road to recovery… …is paved with good rehearsals.” Successful execution of any task requires both controlled and automatic processing- Treatment for addiction requires that automatic processes are recruited through practice, implementation intentions, cue exposure and stimulus control. Robust practice has been shown to increase automatic inhibition of competing goals (Palfai, p 416, Wiers & Stacey).

44. The Future:Neuro Cognitive Behaviour Therapy? Emphasis both on remediation of cognitive deficits and reversal of cognitive biases. Focus on goal maintenance and working memory mechanisms Prioritises impulse control strategies f.ryan@psychology.bbk.ac.uk

45. f.ryan@psychology.bbk.ac.uk Summary CBT can be usefully applied to the spectrum of substance misuse and commonly co-occurring problems. Particular attention must be given to enhancing therapeutic alliance: Continuous feedback is used to motivate the client to remain engaged in treatment despite the inherent treatment resistant nature of addiction. Impulse control and emotional control strategies should be addressed sequentially, but as part of a formulated treatment plan in a framework that accentuates cognitive control.

46. f.ryan@psychology.bbk.ac.uk References Newman, C. Substance Abuse in Contemporary Cognitive Therapy. Leahy, R.L Guilford Press New York, 2004 (pp-206-227) Irvin, J.E, Bowers, C.A, Dunn, M.E. & Wang, M.C.(1999) Efficacy of Relapse Prevention: A Meta-Analytic Review. J. of Consulting and Clinical Psychology. 67.563-570 Witkiewitz, K & Marlatt, G A. (2004) Relapse Prevention for Alcohol and Drug Problems. American Psychologist. 59. 224-235. Ryan, F. (2006) Appetite Lost and Found :Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUP. Routes to Recovery(2009) http://www.nta.nhs.uk/areas/workforce/routes_to_recovery.aspx

47. f.ryan@psychology.bbk.ac.uk Poetry, cognition and motivation “Two principles of human nature reign; Self-love, to urge, and reason to restrain; Nor this a good, nor this a bad we call, Each works its end, to move or govern all.” Alexander Pope An Essay on Man 1732