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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
Feedback Form
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Conclusion
Any questions?