Training on MSc in Cognitive Psychotherapy Course at Trinity College, Dublin 24th October 2013

1. Cognitive Behaviour Therapy for Addiction :
Motivation and CHANGE
MSc in CBT Dublin, October 24th 2013
Frank Ryan

2. Overview of workshop
Welcome and introductions
Goals of workshop
Scientific perspectives on addiction
Role of cognition in addiction
Applications & competencies: Time for CHANGE
Introducing “4 Ms”
Motivation & engagement
Managing impulses and craving
Mood management
Mindful recovery

3. Time for CHANGE
Change
Habits
And
Negative
Generation of
Emotion
(Ryan, 2006; 2013)

4. The Four Ms
Motivate (and engage)
Manage impulses to use
Mood management
Mindful recovery

5. Addiction is commonly co-morbid
75% had one or more co-occurring mental health condition
8% had a psychotic disorder,
40% had minor depression,
26% had severe depression,
37% had a personality disorder and
19% severe anxiety
(Weaver et al 2002)

6. 4 Ms
Motivation and
engagement
Maintain
Change
(relapse
prevention)
Manage
impulsivity
Manage
Negative
emotions

7. Healthcare costs (in billions Euro)of emotional and addictive disorders in 30
European countries (27 EU Plus N, CH and Iceland) Gustavsson et al 2011
80
70
60
50
40
30
20
10
0
Depression
Addiction
Anxiety disorders

8. Five things about addiction
ADDICTION IS COMPULSIVE HABIT
COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF
CONSCIOUSNESS
ADDICTION IS ABOUT 50% HERITABLE
MOST PEOPLE WITH ADDICTIONS WHO PRESENT FOR HELP HAVE
OTHER PSYCHIATRIC PROBLEMS AS WELL
ADDICTION IS A CHRONIC RELAPSING DISORDER

9. Five More things…
“COME BACK WHEN YOU’RE MOTIVATED” IS NO LONGER AN
ACCEPTABLE THERAPEUTIC RESPONSE!
DIFFERENT PSYCHOTHERAPIES APPEAR TO PRODUCE SIMILAR
TREATMENT OUTCOMES
THE MORE INDIVIDUALIZED AND BROAD-BASED THE TREATMENT
A
PERSON WITH ADDICTION RECEIVES, THE BETTER THE
OUTCOME
MIRACLE CURES RARELY HAPPEN
CHANGE TAKES TIME

10. Low Intensity
Interventions
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
High Intensity
Interventions
Programmed cognitive behaviour therapy
sessions such as Relapse Prevention Skills
Training either on one to one or group basis.
Mindfulness based cognitive therapy
Behavioural Couples Therapy

11. Emotions Matter
When we experience negative emotions
drugs are more rewarding, as they are
reinforced both positively and
negatively.

12. But not the full story...
Psychodynamic
tradition viewed drug
addiction as: “a
replacement for a
defect in the
psychological
structure”. Kohut (1971,p 46),

13. The question of motivation……
In groups of three, discuss what drives
or motivates drug use or compulsive
gambling,.
Use examples from your own work if
possible.

14. Cognitive therapy
Addiction motivated by
need to cope with or
suppress the
consequences
maladaptive core
beliefs such as „I am
helpless‟ or „I am
unlovable‟ (Beck et al. 1993, p. 52)

15. Cognitive behaviour therapy
“Relapse Prevention
Skills Training” model
(Marlatt & Gordon,1985;
Marlatt & Witkiewitz,
2005 ) tackled addiction
using functional
behavioural analysis
(antecedents,
behaviour,
consequences) and
induction of alternative
coping skills.

16. Focus of CBT in Substance Misuse
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!”

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

18. • Formation of dysfunctional schemas e.g "I
am not as good as other people".
Early adverse learning
experiences
• Formation of substance related beliefs e.g.
"I feel better about myself when I use
cocaine or alcohol; people seem to like me
more".
Exposure to euphoric
orhedonic effects of
drugs such as alcohol
and cocaine
Critical Incident: Failed
job interview
• Schema about personal inadequacies is
activated and triggers automatic thoughts "I
am stupid", negative affect and substance
related beliefs e.g. "I can't handle this
without a drink; I'll feel better if I have some
cocaine"

19. Current case
Maria: 30 yr-old female
Single, but lives with ex-partner
Experiences depressive and angry emotions
that trigger episodes of excessive drinking> impulsive
suicidal behaviour and intent.
Shows high level of insight and motivation
but still engages in problem behaviour 3-4
times per month
Vulnerability factors include parental abandonment and
Rigid parenting style; recently disclosed sexual
violence.

20. New Perspectives
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

21. Vulnerability factors in addiction

22. Implications for psychotherapy

23. 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.
f.ryan@imperial.ac.uk

24. 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 approach (appetitive)urges
or avoidant (fear ) without
knowing why. Stimuli are
monitored continuously but
“amygdala alerts” do not
necessarily generate conscious
awareness.

25. Overview of scope and aims of CBT in Substance Misuse
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)

26. Cognitive control is impaired before during and after
substance misuse
Pre-existing –dispositional deficits
Acute effects of intoxication
Withdrawal effects
Carry-over effects
Associated risk factors due to injuries or
self-neglect

27. Executive control is impaired
Up to six 6 years in after seeking treatment alcohol dependent people who are
largely abstinent show deficits in executive control despite appearing to
function normally in many settings
Detoxified alcoholic men with an average of over 26 weeks abstinence and with
otherwise good psychosocial functioning can nonetheless register loss of grey
matter in neural structures involved in higher cognitive function: Morphological
changes were highest in the DLPFC (up to 20%) but were noted also in the
temporal cortex, insula, thalamus, and cerebellum. (Chanraud et al, 2007).
Volumetric reductions in grey matter, in the region of 5%-11%, have been observed
with long term abstinent heroin and cocaine addicted people Franklin et al,
2002; Yuan et al 2008.
f.ryan@imperial.ac.uk

28. Key Concepts from psychology
Reflective system and impulsive system govern
behaviour – Reflective impulsive model (RIM) (Strack
and Deutsch, 2004)
Reward learning is enduring and resistant to
devaluation or extinction i.e. becomes stimulus
driven rather than outcome driven
(Yin & Knowlton, 2006)

29. Motivational dynamics: conflict between impulse and
control

30. Attention, Motivated !
“people become consciously aware of
an act only after they unconsciously
decide to engage in it. In addition, at
least some volitional behaviour does
not require any conscious
awareness at all: Goals and
motivation can be unconsciously
primed.”
Motivated attention is the driving force
of addiction.
The key variable is motivated
attention
Attention triggers action even
in the absence of
awareness.

31. Dual processing; fast and slow.
Cognitive
appraisal
Level of
processing
Controlled
processing
(slow)
Activation of
addiction related
beliefs. e.g "I will
have more fun if I
use cocaine"
Cue detected
Automatic processing
(fast)
Conditioned cue
reactivity :
somatovisceral
arousal and
approach tendency

32. Prelude to passion:Limbic activation by
“unseen” sexual and drug cues. Childress et al 2008

33. Neural response at 33ms exposure specific
to drug and sexual cues.

34. 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.

35. Accordingly....
Result is distinctive “cognitive signature” and
behavioural dysregulation.
Remediation needs to overcome automatic
tendencies that are often implicit.
The neural networks subserving drug seeking
and taking endure (excessive “wanting”) long
after the pleasure or liking is gone.
Exposure, the most potent weapon in CBT is
ineffective, or at least inconsistent.

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

37. Cycle of pre-occupation
Attribution of incentive
salience
Attentional bias
Contents of
Working memory
Attentional bias
f.ryan@imperial.ac.uk

38. Any Questions?

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

40. 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 predicts outcome.
Field, Mogg & Bradley, 2006 Attention to drug-related cues
in Wiers, R.W., & Stacey, A.W Handbook of implicit
cognition and addiction.(Eds)
Sage. London.
f.ryan@imperial.ac.uk

41. But “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

42. Assessment and engagement
Begin with current concerns
Explore personal history
Elicit history of substance misuse:
Functional analysis (ABC)is helpful
Work towards formulation

43. Formulation

44. Building resilience

45. Conclusion:
You know most of it already! (but please stay until
end of workshop just to make sure)
From a CBT perspective,
there are no entirely novel
mechanisms or
compensatory strategies
involved in the acquisition,
maintenance or regulation of
addictive behaviour.

46. The first M: Motivation and how to foster it

47. 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”.

48. 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

49. 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”

50. 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….”

51. 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

52. 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

53. 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

54. Tried & Tested:
Summary of useful CBT techniques
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.
f.ryan@imperial.ac.uk

55. Five facets of impulsivity
Negative urgency: the tendency to act rationally when experiencing negative
emotions e.g. “When I am upset, I often act without thinking and sometimes
reach for a drink”.
Lack of Perseverance: the tendency to give up on a task more easily, in effect a
lack of willpower. The manifestation of this personality trait could be endorsing
the item “I tend to give up easily” strongly discounting the statement “Once I
start something I'm determined to finish it”
Lack of Premeditation: the tendency to act without considering the consequences,
especially those in the medium to long-term, e.g. strongly disagreeing with a
statement such as “before deciding to do something I carefully weigh up the
“pros and cons”.
Sensation seeking: essentially the same as the FFM construct reflecting a
preference for novelty seeking, risk-taking and openness to new experience.
Positive urgency: this disposition refers to the tendency to act rashly when
experiencing positive affect feeling excited in response to positive life events
(see also Lynam, 2011)

56. Structuring the session
•
•
•
•
•
•
•
Update on developments since previous encounter, with particular emphasis on
any expression of addictive behaviour, negative mood states and current
concerns.
Setting the agenda, possibly asking the client to specify the priorities if the list of
concerns or problematic issues is extensive. Specifying the stage of CHANGE
(one of the 4Ms) of treatment e.g. managing impulses, managing mood
maintaining change
Reviewing any between session assignments homework
Introducing and then elaborating on the primary topic of the session e.g. coping
with impulses
Negotiating homework for coming week e.g. an implementation strategy or a
behavioural experiment
Summary and feedback
Schedule next appointment, reinforcing the importance of attendance even if
the therapeutic objectives are met by the homework is not accomplished.

57. In summary:
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
Overall, always apply social
reinforcement to “shape “
behaviour. A client who presents
for an appointment is always
welcomed warmly!

58. Session by session monitoring:
COMET
Continuous
Outcome
Monitoring
During
Engagement
In
Treatment

59. 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.

60. 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

61. 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!

62. 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

63. 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

64. 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)

65. The Third M:
Manage mood
Conventional CBT
techniques: correcting
cognitive distortions;
problem solving;
exposure & behavioural
experiments
Pharmacotherapy

66. Three vulnerabilities
-genetic loading contributing to neurobiological vulnerability;
-exposure to adversity in childhood and at early developmental stages;
-subsequent exposure to negative life events.
Assessment should explore these in detail.

67. Three sources of negative emotion
•
•
•
pre-existing negative affect due to dispositional traits and/or exposure
to adverse life events both historically and concomitant with recovery;
negative emotions stemming from the after effects of drug intoxication;
negative emotions arising from setbacks or lapses when self-control
fails.
Assessment should aim to distinguish between these.

68. Mindfulness
Mindfulness disrupts
automatic flow of cognitions
< contrasts with ironic or
paradoxical effects of effortful
suppression>
Mindful acceptance should
influence outcomes by
reducing intrusion

69. Sober breathing space
S top
O bserve
B reathe
E xpand
R espond (not react!)

70. Four components
Educate about emotions
Antecedent cognitive appraisals
° Probability errors
° Catastrophising
Prevention of emotional avoidance
° Behavioural avoidance e.g . avoiding eye contact
° Cognitive avoidance e.g. thought suppression ,
rumination
° Safety signals e.g. Carrying a bottle of water or a pill
Modification of emotionally driven behaviours
° Hypervigilance
° Health anxiety behaviours

71. Mindful Recovery
Relapse Prevention Skills Training: identify high risk situations and
how to deal with them.
Goal Maintenance (therapies that foster this are more effective)
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.

72. “Road to recovery……is paved with good rehearsals.”
Successful execution of any task
requires both controlled and
automatic processingTreatment for addiction
requires that automatic
processes are recruited
through
practice, implementation
intentions, programmed cue
exposure and stimulus
control.
Robust practice has been shown
to increase automatic
inhibition of competing goals
(Palfai, p 416, Wiers & Stacey 2006)

73. 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.

74. Summary
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.
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.
Addiction, once established, is an enduring condition because of
the powerful learning mechanisms it subverts. Help seekers and
their carers need to remain mindful of this in the years following
treatment.

75. References
Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R. and
Wanigaratne, S. (2010) Applied Cognitive and Behavioural
Approaches to the Treatment of Addiction: a Practical Treatment
Guide, Wiley-Blackwell, Chichester.
Miller, W.M. & Rollnick, S. (2013) Motivational Interviewing, Third Edition:
Helping People Change. Guilford Press, New York.
Ryan, F. Cognitive therapy for Addiction: Motivation and Change (2013).
Wiley Blackwell.