implementing cognitive behavioral therapy strategies for ......implementing cognitive behavioral...

Implementing Cognitive Behavioral Therapy Strategies for the

Treatment of Anxiety and Depression

Dr. Hal Baumchen, PsyD, LP, LADC

Dr. Hal Baumchen

• President and Clinical Director of NorthStar Regional Co-Occurring Disorder Treatment Program (Chanhassen, MN)

• Founder of Northland Counseling Services (Chanhassen, MN)

• Author of Destinations and Journeys, two Co-Occurring Disorder Treatment Manuals, the Destinations Companion Workbook, the Journeys Companion Workbook, and Reflections – Insight for the Journey and two manuals for mental health treatment

• Author and founder of Journey to Recovery

Roadmap

• Co-Occurring Disorders (COD)

• Challenges of COD

• Best ways to manage challenges

• Specific CBT Interventions for Anxiety and Depression

Introduction

A framework to hang your knowledge of COD and a foundation upon which to build treatment.

It’s not what you know, it’s what you can teach that truly makes a difference.

Defining Co-Occurring

Disorders

Co-occurring disorders

refer to an individual

having one or more

substance abuse disorders

and one or more mental

health disorders.

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

Identifying Co-Occurring Disorders

The Addicted Life

The co-occurring disorder begins to run your and ruin your life

People with Co-Occurring Disorders

show increased risk of homelessness, as high as 30%, and are highly vulnerable to housing instability.

Source: Substance Abuse Treatment for Persons With Co-occurring Disorders Treatment Improvement Protocol 42 (TIP42)

People with Co-Occurring Disorders

are 20 times more likely to be hospitalized and use emergency services.

Source: Substance Abuse Treatment for Persons With Co-occurring Disorders Treatment Improvement Protocol 42 (TIP42)

People with Co-Occurring Disorders

have an average lifespan of 45.1 years, compared to 76 years for the general population.

Source: Substance Abuse Treatment for Persons With Co-occurring Disorders Treatment Improvement Protocol 42 (TIP42)

NIDA estimates 45% of offenders in state prisons and local jails have a mental health problem and comorbid substance use disorder.

It is estimated that 7.7 million adults have co-occurring mental and substance use disorders. This doesn’t mean that one caused the other and it can be difficult to determine which came first.

Source: Han, et al. Prevalence, Treatment, and Unmet Treatment Needs of US Adults with Mental Health and Substance Use Disorders. 2017.

Of the 20.3 million adults with substance use disorders, 37.9% also had mental illnesses.

Source: Han, et al. Prevalence, Treatment, and Unmet Treatment Needs of US Adults with Mental Health and Substance Use Disorders. 2017.

Among the 42.1 million adults with mental illness, 18.2% also had substance use disorders.

Source: Han, et al. Prevalence, Treatment, and Unmet Treatment Needs of US Adults with Mental Health and Substance Use Disorders. 2017.

Challenges of Co-occurring Disorders

Understanding the Progression

Some people have mental health problems and start abusing drugs and alcohol as a way to self-medicate.

Understanding the Progression

Others use alcohol and drugs long enough to develop mental illness symptoms or make existing mental illness symptoms worse.

Recognizing Mental Health Issues

Illness that frequently co-occur with substance use disorders include:

Attention Deficit Hyperactivity Disorder (ADHD)

Bipolar disorder

Conduct disorders

Personality disorders

Anxiety disorders

Depression

Thought disorders (including schizophrenia, hallucinations, and delusions)

Paranoia

Post-Traumatic Stress Disorder (PTSD)

The Three Axes of COD

Psychiatric – including medical issues

The Three Axes of COD

Psychiatric – including medical issues

Psychological – including cognitive processing difficulties

The Three Axes of COD

Psychiatric – including medical issues

Psychological – including cognitive processing difficulties

Substance Use – including physical addiction and withdrawal

Cognitive Processing Difficulties in Co-Occurring Disorders

Cognitive processing is more difficult because of:

Withdrawal Effects

Detoxification Complications

Cognitive processing is more difficult because of:

Sleep Problems

Sleep Deprivation

Cognitive processing is more difficult because of:

Chemical Imbalance

Cognitive processing is more difficult because of:

Anxiety

Depression

Cognitive processing is more difficult because of:

Trauma

Cognitive processing is more difficult because of:

Thought Disorder

Cognitive processing is more difficult because of:

Brain Injury

Cognitive processing is more difficult because of:

Learning Disabilities

ADHD

Cognitive processing is more difficult because of:

Nutritional Deficiencies

These syndromes, symptoms, and effects lead to significant cognitive impairments.

Treatment interventions must be sensitive to those impairments

Best Ways to Manage the Challenges of Co-Occurring Disorders

Effective Resources

Effective Resources

Engaging and Effective

Our secret to working with the complexities of co-occurring disorders was not to make the interventions more complex, but rather make the interventions simpler and more effective.

Reinforce and Extend Your Therapeutic Influence

• Handouts

• Assignments

• Psychoeducation Materials

• Group Worksheets

• Structured Therapy Tools

• Skill-building Information

Designed With a Purpose

Treatment for Co-Occurring Anxiety and Depression

Making a Difference

• Sequential Treatments

• Parallel Treatment

• Fully Integrated Treatment

Being different makes a difference.

Treatment for Co-Occurring Disorders has Two Major Goals:

1. Reduce Symptoms

2. Prevent Relapse

Anxiety Symptoms

Anxiety Symptoms

Constant worry about an event, often out of proportion to its actual significance

Feeling restless, tense, or on edge

Being easily fatigued or worn out

Muscle tension or headaches

Having difficulty staying focused or concentrating

Anxiety Symptoms

Being indecisive and distressed when making decisions

Feeling irritable Trouble relaxing or sitting still Trembling or shaking Significant muscle tension Sleep disturbance

Managing Worry

Managing Worry

The Worrier’s Checklist Assumes things will turn out bad Looks for what could go wrong Is afraid things will get worse Is distracted from the present by concern for the future Rehearses unfavorable and negative scenarios Is often filled with mental anguish, upset Is overly concerned with things that aren’t right

Managing Worry

The Worrier’s Checklist Worries about what others will think Is inconsolable in regard to his or her concern Is preoccupied with safety or health Watches with twisted anticipation for even small

signs of trouble Rehearses potential failures, rejections, comments or

disapproval from others

Inaccurate Thoughts

Inaccurate Thoughts

Anxious people often imagine that other people are judging them critically, unfairly, and harshly. Unrealistic and inaccurate beliefs about themselves, others, and the world are common for them and these inaccurate views create distortions that can leave people seeing themselves as inadequate, incompetent, undesirable, not fitting in with others, and anxious. These insecurities and anxious thoughts must be identified and replaced with healthy and true statements.

Inaccurate Thoughts

When people look at me, they are examining what I do

If I am criticized, it means that I’m wrong

If I make a mistake, it means I’m stupid

If I don’t agree with people, they won’t like me

I have to be nice to everyone to be a good person

If someone is hurt or offended by what I do, it means I am a bad person

If I show emotion, it means I am weak

If they see I am anxious, people will think there is something wrong with me

Inaccurate Thoughts

The opinions other people have about me are very important

I’m afraid I look or sound silly to other people

I can tell people will evaluate me negatively

I might offend someone, so I have to be very careful about what I say

Approval from others is very important to me

Being anxious is a sign of weakness

When people see me behave like this, they will speak badly of me to others

Using Positive Thoughts

Using Positive Thoughts

It is unlikely others have noticed my anxiety

It is more noticeable to me than them

If they were to think anything about my behavior, they would probably just think I am shy

Even if they did think I was anxious, they would not think badly of me

Not everyone is looking at me

I’ll try to stay focused on the meal and our conversation

Not everyone constantly thinks about me, even though I think they do

Using Positive Thoughts

I can get through this

I’ve managed this kind of difficulty before

I’ve got good people around me

I am gaining strength and confidence

This is just an inconvenience of everyday life

This is distressing, but not dangerous

I don’t prefer this, but I can survive it

I can cope

I’m doing pretty well right now

Social Anxiety in Everyday Situations

Social Anxiety in Everyday Situations

Speaking in public

Eating or drinking in front of others

Writing or working in front of others

Reading aloud

Being the center of attention

Interacting with people

Giving a report

Asking questions in groups

Expressing disagreement with someone’s opinion

Social Anxiety in Everyday Situations

Making eye contact

Dating – including asking for the date, making phone calls, initiating intimacy

Talking in front of authority figures such as police, attorneys, bosses, teachers

Returning purchases to a store

Expressing your opinion

Making small talk

Using public toilets

Taking exams

Social Anxiety in Everyday Situations

Initiating conversations

Talking on the telephone

Taking part in a performance such as a play, athletic event, or concert

Going to a party, especially if you don’t know everyone

Interacting with strangers

Entering a room where people have already gathered or are seated

Going to work or school

Rethinking Avoidance

Rethinking Avoidance

Anxiety symptoms may be exaggerated and more extreme when someone is under a lot of stress or demands on them are high.

It is a huge temptation for many people to avoid whatever is causing anxiety.

It is necessary to retrain oneself to face their fears and to be able to control their attitude and physical responses enough to feel more relaxed and in control.

Depression Symptoms

Depression Symptoms

• Sad mood or crying spells

• Low energy

• Low motivation

• Guilt, remorse, regret

• Sleep problems

• Loss of interest in usual activities

• Loss of enjoyment

• Low sex drive

• Appetite changes

• Pessimism

• Trouble making decisions

• Low self-esteem

• Suicidal thoughts

• Difficulty concentrating

• Irritability

• Hopelessness

• Helplessness

• Fatigue

• Moving or speaking slowly

• Unexplained aches and pains

Depression Facts

Depression Facts

• Depression affects 121 million people worldwide (Reddy, 2010). • In 2014, an estimated 15.7 million Americans had at least one

major depressive episode in the last year. That represents 6.7% of the adult (age 18 and older) American population (NIMH, 2015).

• Two-thirds of people suffering from depression do not seek necessary treatment (WHO, 2001).

• 80% of all people with clinical depression who have received treatment significantly improve their lives (CDC, 2016).

Depression Facts

• The economic cost of depression is estimated at $210.5 billion a year, but the cost in human suffering cannot be estimated (Greenberg, 2015). It ranks in the top three workplace issues, behind family crisis and stress, in the United States (NNDC, 2016).

• Women experience depression about twice as often as men (Mayo, 2016).

• The rate of depression among veterans is five times higher than civilians (NNDC, 2016).

• By the year 2020, the World Health Organization (WHO) estimates depression will be the number two cause of “lost years of healthy life” worldwide (Reddy, 2010).

Depression Facts

• According to the U.S. Centers for Disease Control and Prevention (CDC), suicide was the tenth leading cause of death in the United States in 2014 (CDC, 2014).

• Major Depression is 1.5-3.0 times more common among first-degree biological relatives of those with the disorder than among the general population (Nemade, et al., 2007).

• 1 in 4 young adults will suffer an episode of depression before age 24 (Kessler, 593).

• Depression is the leading cause of disability in the United States among people 15-44 (NNDC, 2016).

Depression Self Evaluation 1. Low Energy 1 2 3 4 5 High energy

2. Difficulty sleeping or sleeping all the time 1 2 3 4 5 Uninterrupted sleeping patterns

3. No desire to be involved in activities 1 2 3 4 5 Very involved in activities

4. No desire for sex 1 2 3 4 5 Healthy sex drive

5. Aches and pains 1 2 3 4 5 Feel great

6. Loss of appetite 1 2 3 4 5 Enjoy eating

7. Sad 1 2 3 4 5 Joyful

8. Despairing and hopeless 1 2 3 4 5 Hopeful and confident

9. Irritable (low frustration tolerance) 1 2 3 4 5 Pleasant (high frustration tolerance)

10. Withdrawn 1 2 3 4 5 Involved

11. Mental anguish 1 2 3 4 5 Peace of mind

12. Low sense of self-worth 1 2 3 4 5 High sense of self-worth

13. Pessimistic (about the future) 1 2 3 4 5 Optimistic (about the future)

14. Negative (perceive most circumstances as

negative or even harmful) 1 2 3 4 5

Positive (perceive most circumstances as positive and

as opportunities for growth

15. Self-destructive (“I and others would be better

off if I weren’t here”) 1 2 3 4 5 Self-preserving (“Glad I’m here”)

Hopelessness and Helplessness

Hopelessness and Helplessness

• Feelings of inadequacy and self-doubt

• Reduced levels of motivation • Approaching new

circumstances with caution and mistrust

• Feeling stuck • Lower achievement and

productivity

• Feeling insecure • Inadequate problem solving • Believing change does not

matter • Inability to persevere under

stress

Seeing it Differently

• I can handle this • I’m making progress • I have good people around me • Although difficult, this situation is

not impossible • I can stand it, make do, and get

through it • I am capable of this challenge • Peace comes from the inside, not

from outer circumstances • I can choose my response and not be

reactive

• I see the difficulties I face as opportunities to grow

• This is distressing, but not dangerous • I have good ideas and plans for the

future • This situation is not a catastrophe • I am able to solve problems • I am not afraid to try new things • When things get tough, I know who I

can rely on

CBT Interventions for Co-Occurring Anxiety and Depression

Alcohol and Panic Disorder

Negative Thinking

Positive Thinking

CBT Intervention: Illustrate How CBT Works

• Thoughts and beliefs

• Strong feelings

• Corresponding actions

CBT Intervention: Illustrate How CBT Works

Then it turns out, there is no dog.

CBT Intervention: Illustrate How CBT Works

Anxiety, depression, and substance abuse are filled with thoughts that are not true.

CBT Intervention: Illustrate How CBT Works

If you want to change the way you feel or behave, you have to change the way you think.

Most people with chemical dependency problems want help

But those same people can become resistant to change

Rather than change they justify reasons to stay the same

Old thinking leads to the same old problems

CBT Intervention: Illustrate How CBT Works

To reduce symptoms and prevent relapse you must change the way you think.

CBT Intervention: Outline How Long-Lasting Change Occurs

1. Change is possible. Out of respect for yourself and others, you can change yourself.

Principles of Self-Change

CBT Intervention: Outline How Long-Lasting Change Occurs

2. The foundation of change is a change in your thinking.

Principles of Self-Change

CBT Intervention: Outline How Long-Lasting Change Occurs

3. Change is made possible through simple but systematic efforts, in a single direct, over time.

Principles of Self-Change

CBT Intervention: Outline How Long-Lasting Change Occurs

The goal of treatment is not how fast you can get out.

Principles of Self-Change

CBT Intervention: Outline How Long-Lasting Change Occurs

The goal of treatment is to get as strong as you can before you leave.

Principles of Self-Change

CBT Intervention: Teach Strategies to Change Your Thinking

CBT Intervention: Teach Character Goals

Ten Essential Traits

CBT Intervention: Teach Character Goals

Recovery is not the goal.

Recovery is not the goal. Recovery is the avenue to reach the goal

Managing Worry

Placeholders

Strategies to Build Hope

Focus on your strengths, not your weaknesses Make a commitment to someone for a future event Compliment someone else on their character

Hang out with positive people Confide in a sponsor or an accountability partner List three things for which you are grateful

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Conclusion

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info@journeytorecovery.com

952.777.8755

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