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COGNITIVE BEHAVIOURAL TECHNIQUES

Cognitive behavioural therapy (CBT) has been identified as one of the most effective ways of treating cooccurring depression and substance use difficulties 1, 2. A number of simple CBT-based strategies are useful in managing clients with these symptoms, including: Cognitive restructuring. Pleasure and mastery events scheduling. Goal setting. Problem solving.

Cognitive restructuring
Cognitive restructuring is a useful method for controlling symptoms of depression (and anxiety) and is based on the premise that what causes these feelings is not the situation itself but, rather, the interpretation of the situation 3. The idea is that our behaviours and feelings are the result of automatic thoughts which are related to our core (deeply held) beliefs. Therefore, feelings and behaviours of anxiety, depression, relapse etc. are the result of negative thoughts and beliefs that can be modified. A simple process of recognition and modification of these thoughts and beliefs can be conducted with clients using the A E model depicted below.

A. Antecedent Event that triggers


automatic thoughts

B. Beliefs about event


Automatic thoughts

C. Consequences feelings/behaviours that


result from thoughts

D. Disputing automatic thoughts look for evidence to


support/disprove these thoughts

E. Alternative explanation Rational alternatives to the automatic thought

In this model there is an initial event (the antecedent) which leads to automatic thoughts (beliefs about the event). These thoughts have resulting feelings and behaviours (consequences). Because these thoughts are automatic and often negative, they are rarely based on any real-world evidence it is therefore necessary to look for evidence either supporting or disproving evidence (dispute automatic thoughts). Finally, developing rational alternative explanations to automatic thoughts can result in a new interpretation of the antecedent (alternative explanation). This process allows the client to stop and evaluate the thought process and realise how he/she comes to feel that way. A client worksheet is included in the client handout section of this website to walk clients through the thought recognition and modification process. Some common negative automatic thoughts and beliefs which can be challenged by using cognitive restructuring exercises include: All or none (black and white) thinking If I fail partly, it means I am a total failure. Mental filter Interpreting events based on what has happened in the past. I cant trust men, they only let you down. Overgeneralisation Expecting that just because something has failed once that it always will. I tried to give up once before and relapsed. I will never be able to give up. Catastrophising Exaggerating the impact of events imagining the worst case scenario. I had an argument with my friend, now they hate me and are never going to want to see me again. Mistaking feelings for facts People are often confused between feelings and facts. I feel no good, so therefore I am no good. Should statements Thinking in terms of shoulds, oughts and musts. This kind of thinking can result in feelings of guilt, shame and failure.

I must always be on time. Personalising People frequently blame themselves for any unpleasant event and take too much responsibility for the feelings and behaviours of others. Its all my fault that my boyfriend is angry, I must have done something wrong. Discounting positive experiences People often discount positive things that happen. I stayed clean because I didnt run into any of my using mates. (Adapted from Beck 4 and Jarvis et al. 5) A client information sheet on common negative thoughts is provided in the client handout section of this website. Along with a client information sheet on cognitive restructuring.

Structured problem solving


Structured problem solving is also a useful means to manage the symptoms of anxiety/depression as these symptoms are often the result of an inability (or perceived inability) to deal effectively with problems 6. Some simple steps suggested by Carroll 7 and Mynors-Wallis 8 can be a useful guide in assisting the client: Identify the problem (try to break it down) and define it. Step back from the problem and try to view it as an objective challenge. Brainstorm possible solutions (realistic and unrealistic). Think about each solution in practical terms, and evaluate the pros and cons. Decide on the best solution (and a second, back-up solution). Put the solution into action. Evaluate how effective it was and whether it can be improved.

A problem-solving worksheet for clients is included in the client handout section of this website.

Goal setting
Goal setting is a useful strategy to help clients with both AOD treatment as well as depression/anxiety symptom management. For example, one goal might be to spend more time partaking in rewarding activities each week. Goal setting can keep therapy on track and also enables progress to be measured over time. It allows the client to experience feelings of control and success, which may counter common feelings of

hopelessness and worthlessness. Goal setting also ensures that therapy remains client-focused which increases motivation and helps the therapist ascertain what the clients central concerns are. However, it is important that the focus is on the process of goal pursuit rather than outcome and expectations of achievement; it is important that happiness is not conditional upon goal achievement or else failure may exacerbate depressive symptoms 9. According to Marsh et al. 10 goals should be:

geared towards the clients level of motivation and concern (clients stage of change see Chapter 6 of these Guidelines); negotiated between client and AOD worker; specific and achievable it is important that the client begins to gain a sense of mastery by achieving his or her goals; based on process rather than outcome; short term break down overall goals into shorter-term ones in order to increase motivation and feelings of success; and described in positive rather than negative terms for example, the goal to decrease feelings of apprehension and worry at parties is expressed in negative terms. The same goal, expressed in positive terms is I will try to relax and enjoy myself at parties.

A goal setting worksheet is provided in the client handout section of this website.

Pleasure and mastery events scheduling


Individuals with depressive symptoms often stop engaging in behaviours that give them a sense of pleasure and achievement. This can lead to a cycle in which they become very inactive, leading to more negative feelings and lower mood and energy, which then leads to even less engagement in activities, and so on 10, 11. Pleasure and mastery events scheduling is a behavioural technique to help clients engage in activities that give them a sense of pleasure and achievement in a structured way. It can be very difficult for clients to simply resume previous levels of activity, so this strategy enables clients to use a weekly timetable in which they can schedule particular activities. It is important for clients to start with activities that are simple and achievable. Clients might be encouraged to think of just one activity they can do for achievement and one for pleasure each day. Each week more activities can be added to form a list. A worksheet is provided in the client handout section of this website for clients to complete; it also includes a list of possible starting points. Clients may also need to be reminded of the fact that they deserve to feel good and that motivation generally follows activity rather than the reverse and, thus, the key is initiation of such activity. The gradual pattern of experiencing the emotional and physical benefits of pleasure and achievement can break the negative thought cycle.

REFERENCES
1. 2. Lee N, Jenner L, Kay-Lambkin F, Hall K, Dann F, Roeg S, et al. PsyCheck: Responding to mental health issues within alcohol and drug treatment. Canberra: Commonwealth of Australia; 2007. Baker A, Lee NK, Claire M, Lewin TJ, Grant T, Pohlman S, et al. Brief cognitive behavioural interventions for regular amphetamine users: A step in the right direction. Addiction. 2005; 100(3):367-78. McMullin RE. Taking out your mental trash: A consumer's guide to cognitive restructuring therapy. New York: W. W. Norton & Company; 2005. Beck J. Cognitive therapy: Basics and beyond. New York: The Guildford Press; 1995. Jarvis T, Tebbutt J, Mattick R. Treatment approaches for alcohol and drug dependence. Chichester: John Wiley & Sons; 1995. Gellis ZD, Kenaley B. Problem solving therapy for depression in adults: A systematic review. Research on Social Work Practice. 2008; 18:117-31. Carroll KM. A cognitive-behavioral approach: Treating cocaine addiction. Rockville: U.S. Department of Health and Human Services, National Institute on Drug Abuse; 1998. Mynors-Wallis L. Problem solving treatment for anxiety and depression: A practical guide. Oxford: Oxford University Press; 2005. Street H. Exploring relationships between goal setting, goal pursuit and depression. Australian Psychologist. 2002; 37(2):95-103. Marsh A, Dale A, Willis L. A counsellor's guide to working with alcohol and drug users. 2nd ed. Perth: Drug and Alcohol Office, Western Australia; 2007. Cotterell N. Cognitive therapy of depression during addiction recovery. In: Kantor JS, ed. Clinical depression during addiction recovery: Process, diagnosis and treatment. New York: Marcel Dekker; 1996.

3. 4. 5. 6. 7. 8. 9. 10. 11.

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