CBT for Concurrent Disorders

Shari A. McKee, Ph.D., C.Psych.

Sarah Durant, B.A., ACMay 26, 2014

Georgianwood Program for Concurrent Disorders

Waypoint Centre for Mental Health Care

Georgianwood

3-month residential program

Fully integrated mental illness and addiction

treatment

2 streams:

Skills Stream: for clients with major mental illness

CBT Stream: for clients with concurrent anxiety

disorders or depression

Offer CBT, skills training, Seeking Safety, self-help

groups, anger management, psychoeducation,

family education, vocational counseling, etc.

Integrated Treatment for

Concurrent Disorders

Concurrent disorders =mental illness + substance use

Integrated treatment = substance abuse treatment

+

mental illness treatment

- At the same time

- By the same team

Why do CBT with CDs?

CBT targets thoughts & behaviours to improve

mood and is an empirically supported treatment

Is a best-practice recommendation for working with

clients with concurrent disorders (Mueser, Noordsy, Drake & Fox,

2003)

CBT is manualized - can find a CBT manual for

almost any problem (e.g., psychosis, substance use,

depression)

However, few specific manuals for CBT for CDs

CBT is Empirically Supported as

a Treatment for:

OCD

PTSD

Depression

Substance abuse

Eating disorders

Personality disorders

Schizophrenia

Chronic painetcJ. Beck, 1995

Long-term Effects of Cognitive Therapy,

Medications, and Placebo

Patient responders that completed CT were significantly less likely to relapse than responders that terminated medications.

The CT group was no more likely to relapse than the patients continuing on medications.

0

20

40

60

80

100

0 6 12 18 24

CT

Meds.

Plac.

Hollon et al., 2005

Archives of General Psychiatry

Months following acute

treatment

% Surv

ival

Goals of CBT

1. To provide symptom relief

2. To facilitate remission of the mental health

symptoms

3. To help resolve the most pressing problems

4. To give tools to help avoid relapse

Georgianwoods CBT Group

2 co-therapists (ideally)

60-minute session once a week

60-minute homework group once a week

Each session is recorded & rated for fidelity

Group has included clients with bipolar disorder, depression, schizophrenia, anxiety disorders, & schizoaffective disorder all with concurrent substance use disorders

Georgianwoods Pre & Post

Depression & Anxiety Scores (n=153)

Depression:

BDI pre score average = 29 (severe)

BDI post score average = 11 (minimal)

Anxiety:

BAI pre score average = 23 (moderate)

BAI post score average = 9 (mild)

Measuring Outcomes

Want to measure outcomes for many reasons:

To know whether patients are benefitting

To know whether therapists are effective at getting

information across

To justify ongoing administrative support for the group

To continually improve the quality of the group

Example of Outcomes to Measure

Understanding of the content (multiple choice quiz)

Symptoms (anxiety, depression, psychosis screeners)

Attendance

Engagement in the group (rating form for therapists)

Pre-post skills test

PRN use etc

Manuals

Mind over Mood manualGreenberger & Padesky (1995)

Intended as self-help guide very user friendly

Can buy on Amazon, Chapters, etc

We subsidize cost of manual ($10)

We created a 12-session facilitators guide

Great for mood and anxiety symptoms

Hazelden CBT for CDs Manual McGovern, Drake, Merrens, Mueser & Brunette, 2008; 2014

Available through the Hazelden website

Cost: $120 plus shipping

15-session manual with handouts & fact sheets

Was created specifically for patients with CDs

Authors are some of the big names in the field

of CDs (Drake, Mueser, McGovern etc)

Rating Mood

Clients come a few minutes early to group to fill out mood ratings

Can use anxiety & depression screeners from Mind over Mood

Group leaders should examine clients responses to items #10, 11 & 12 of the depression screener (suicide-related)

Or can use emotion thermometers if clients struggle with reading/comprehension

Emotion Thermometers

Issues that can Interfere with CBT

Post-acute withdrawal

Medications (sedating)

Symptoms of mental illness (e.g., poor

concentration, apathy)

Cognitive impairment or illiteracy

Chaotic lifestyle distracted by life problems

Ongoing substance abuse

Tips for Doing Groups with People

with Serious Mental Illness

Use lots of visuals write on the board, handouts

Focus on a few key skills

Use strategic repetition

Have a clear structure to the group

Maintain group so that only one person is talking at

a time

Keep it short (one hour max) or else have breaks

Modifying CBT for CDs

Can adapt standard CBT skills to help clients

overcome problems related to both mental illness

and addiction

Always prompt clients for examples from both

areas:

E.g., if client focused on anxiety, ask for issues related

to substance use such as urges or cravings and relate

them back to the anxiety

20 Session Outline for

Hazelden CBT for CDs Manual

Session 1 Intro to the group

Session 2 Breathing retraining

Session 3 & 4 Primary symptoms of CDs

Session 5 & 6 Associated symptoms of CDs

Session 7 & 8 First 3 steps of CR

Session 9-13 Five steps of CR

Session 14-15 Wrap up

Intro to CBT for CDs Group

Introduces clients to main skills

Give an overview of CBT - structure

Instill hope and normalize their problems

Discuss goals

Create crisis plans if necessary

Hope & Goals

Want to instill hope

Discuss the effectiveness of CBT how it is an

empirically supported intervention for CDs

Normalize discuss the prevalence of co-morbid

disorders such as depression & substance abuse

Discuss their goals for therapy what do they

hope to get out of CBT? (make sure goals are

reasonable)

The Cognitive Model

Peoples feelings & actions are affected by how

they think about a situation:

Situation Thoughts Mood

Discuss Homework

Is typically part of CBT

Years of negative thinking is not likely to be

changed in just 45 minutes a week

Homework should build on the skill taught that

week but not be overwhelming

If not done, try to process what got in the way.

Need to be flexible.

Breathing Retraining

Gives clients an immediate skill they can start using

to cope with anxiety

Can discuss use of substances as a maladaptive way

of coping with anxiety

Breathing affects the way we feel & breathing

retraining can reduce physical tension & anxiety

Breathing Retraining contd

Often people mistakenly think that taking a

deep breath is helpful to calm down

What happens when you take deep, gulping

breaths?

May start to hyperventilate which increases

anxiety (fight or flight)

Overbreathing decrease the amount of CO2 in

the blood which means less blood to brain,

heart & extremities

Breathing Retraining contd

Overbreathing leads to symptoms of anxiety

Want to conserve CO2 through breathing

retraining

Best to breathe in through the nose

The exhalation is what aids relaxation

Want to exhale slowly

Can be helpful to use a relaxation cue word

such as Calm or Relax

Breathing Retraining Steps

1. Take normal breath in (by nose)

2. Exhale slowly

3. On exhaling, say C-a-a-a-a-a-a-a-a-a-l-m

4. Count to 4, and then take in the next breath

5. Practice this several times a day 10-15 breaths

at each practice

Exercise: Breathing Retraining

Lets try it as a group!

Primary Symptoms of CDs

This section includes psychoeducation for clients

about mental illness symptoms & links to

substance use

Go slowly & encourage active participation

Ask clients to describe their experiences with their

symptoms & how each symptom does or doesnt

apply to them

Primary Symptoms contd

If you make the education more personally

meaningful, it will be more memorable

Very important to continually link the symptoms to

substance use

Want to explain how substance use works how it

helps the client, hurts the client, & the sequence of

events that led to substance use

Fact Sheets

The manual comes with Fact Sheets about 10

common psychiatric diagnoses:

Schizophrenia, schizoaffective disorder, bipolar disorder,

major depression, dysthymia, PTSD, GAD, OCD, social

phobia, panic disorder

Should review charts prior to gr