#10 The ABCs of CBT: Psychosocial Interventions 101

September 8, 2022 | By Carolyn Chan

with Dr. Carla Marienfeld

Integrate motivational interviewing into your busy practice, and learn the basic principles of cognitive behavioral therapy. This episode highlights common psychosocial interventions for individuals with substance use disorders. After this episode, you will feel empowered to connect patients to these evidence-based resources. We’re joined by Dr. Carla Marienfeld, MD from UCSD, @DrMarienfled who gives us practical ways to counsel patients on these interventions, as well as bring them into the busy clinic setting.

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Credits

• Producer: Kenneth Morford, MD
• Show Notes and Infographic: Hannah Daneshvar, MD, MPH
• Hosts: Carolyn Chan, MD, Kenneth Morford MD, Paul Williams MD
• Reviewer: Natalie Stahl MD MPH
• Showrunner and Cover Art: Carolyn Chan, MD
• Technical Production: Castos
• Guest: Dr. Carla Marienfeld

Production Partner: ACAAM

CME Partner: VCU Health CE

Show Segments

• Introductions: 0:30
• Guest One liner: 3:15
• Case from Kashlak: 4:50
• Motivational Interviewing: 5:25
• The PACE Mnemonic: 8:10
• OARS – micro-skills of MI: 9:30
• Psychosocial interventions: 17:15
• Cognitive Behavioral Therapy: 19:20
• Adapting CBT for Busy Office Visits: 22:20
• Community Programs (Mutual support groups): 25:00
• CRAFT, ACT, and Contingency Management: 26:34
• ASAM four levels of care and referral management: 33:15
• 12 Step Programs 45:45
• Take Home Points: 51:10

The ABCs of CBT: Psychosocial Interventions Pearls

1. Motivational interviewing (MI) is a communication style that promotes healthier behaviors by helping individuals address and resolve ambivalence about change.
2. The core micro-skills of MI include open-ended questions, affirmations, reflections, and summary statements; use the mnemonic “OARS” as a guide!
3. Cognitive Behavioral Therapy (CBT) focuses on the connection between thoughts and behavior and can help patients with SUD recognize triggers and cues for substance use and strategize ways to anticipate, avoid, or cope with them. Some CBT techniques (such as “Catch it, Check it, Change it”) can be explained to patients in less than 5 minutes, 
4. Contingency management is a psychosocial intervention focusing on positive reinforcement. Preferred behaviors such as negative urine drug tests may be rewarded with raffle drawings. It’s shown to be efficacious in the treatment of stimulant use disorder.
5. The ASAM criteria can help determine the appropriate level of care based on a patient’s substance use severity and biopsychosocial needs. Ideally, individuals will engage in long-term treatment and move between levels of care as needed (ASAM).
6. There are a wide variety of community programs (also known as mutual support groups) that offer free, peer-led support for people with substance use disorders. While AA (Alcoholics Anonymous) is the most familiar and widespread example, particularly in the era of online meeting availability there are a wide variety of programs with diverse ideologies and programs that patients can try.
7. Psychology Today can be a resource for finding therapy services for patients with substance use disorders.

Motivational Interviewing

Motivational interviewing (MI) is an evidence-based approach that uses a facilitated conversation to move people towards positive behavior change (Miller, 2012). It is best understood as a communication style for addressing and resolving ambivalence about change (SAMHSA, 2019). MI aims to evoke a person’s own values, motivations, and reasons for change as the foundation for promoting healthier behaviors. It has been shown to improve outcomes for a range of physiological and psychological conditions (Rubak, 2005), especially substance use disorders (Smedslund, 2011; Lindson-Hawley, 2015), and can be applied to other behaviors including medication adherence (Palacio, 2016). 

The spirit that one should bring to MI can be captured by the mnemonic PACE: (Haque, 2019)

P – Partnership (“my job is to do what I can to help you be successful”)

A – Acceptance (non-judgment, meeting the person where they’re at)

C – Compassion (do no harm, wanting the best for the person)

E – Evocation (evoke/elicit what is important to a person and changes they want to make)

Key micro-skills that form the core of MI conversations can be summarized with the mnemonic OARS: (Haque, 2019)

O – Open-ended questions: to ensure the patient is doing most of the talking

A – Affirmations: offer positive observations of patient strengths, acknowledge their efforts

R – Reflections:  the “bread and butter” of MI – use a simple or complex reflection to demonstrate empathy, interest, and understanding of a patient’s perspective. 

S – Summaries: “mega-reflection” – summarize the “change talk” you’ve heard and the steps the patient is taking towards behavior change, and move towards planning the next steps

When it’s time for a clinician to advise or share information with a patient, they can use the “Ask-Tell-Ask” approach to ensure information is offered in a way patients can hear and use it.

Ask: assess patient’s knowledge about options (“what do you know about ___________?”)

Tell: use their answer to choose key bullet points you want to share with them

Ask: get feedback on what you shared, or use teach-back to ensure they’ve understood

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is a therapy modality initially used to treat depression and anxiety, then expanded for the treatment of substance use disorders with a focus on relapse prevention (Larimer et al, 1999). CBT is focused on the connection between thought and behavior. While individuals may not be able to directly change how they feel about something, they do have the ability to change their thinking patterns, which can influence their feelings and ultimately their behavior. With respect to substance use disorder, CBT helps patients recognize triggers and cues for substance use and strategize ways to anticipate, avoid, and cope with them. CBT also focuses on the development of coping skills to manage cravings, emotions, and anxiety in a healthy way.

While CBT can be delivered in a structured, manualized approach by a trained health professional, it can also be applied in a busy primary care office with just a few techniques. For example, clinicians can help patients identify triggers and explore coping skills that have worked for them in the past. Another tool to review with patients is “Catch it, check it, change it,” wherein an unhelpful or triggering thought or craving is identified (“catch it”), challenged (“check it”), and re-evaluated (“change it”). This framework helps patients recognize when they are at risk, take a pause, and then respond (rather than react) to the situation. 

Additional Psychosocial Interventions

In addition to CBT, individual therapy, couples therapy, and group therapy there are other options available to patients.

Contingency Management (CM): CM is based on operant conditioning where immediate rewards are provided to reinforce and promote positive behavior change. Rewards are determined based on goals identified collaboratively with patients, such as stopping or reducing substance use, addressing related health conditions, or showing up to medical appointments. CM is considered the gold standard for treating stimulant use disorders (Crescenzo, 2018). It can be practiced individually, in groups, and in both outpatient and inpatient settings. 

Acceptance and Commitment Therapy (ACT): ACT combines components of mindfulness and cognitive behavioral therapy to help patients learn to accept rather than avoid challenging situations in their lives.  ACT has six core processes: acceptance, cognitive defusion, being present, self as context, values, and committed action. It has been shown to be an effective treatment for individuals with substance use disorders (Osaji, 2020). 

Community Programs:  Also known as mutual help or mutual support groups, these programs are free and peer-run groups such as Alcoholics Anonymous (AA), SMART Recovery, and Refuge Recovery. The ease and flexibility of participation, group dynamics, and introduction to a peer cohort can support behavior change in patients with SUD. Programs have diverse ideologies and approaches; for example, 12-step programs such as AA are more strictly oriented towards abstinence, and SMART Recovery has a CBT approach. Most programs have online meeting options. You can use this list to learn more about options and find out which are accessible to your patients.

Community Reinforcement Approach and Family Therapy (CRAFT): CRAFT is a program based on the premise that substance use is a learned behavior, and that the loved ones of individuals with substance use disorder can be trained to use reinforcement techniques to make treatment engagement and abstinence more rewarding, and to diminish positive reinforcements of substance use (Archer, 2020).

Evaluating Levels of Care

Many patients, families, and community members assume addiction treatment to mean brief and intensive residential treatment (“rehab”). However, this level of treatment may not be necessary or effective for a given patient, and like all chronic illnesses, SUD often requires sustained treatment.

The American Society of Addiction Medicine (ASAM) criteria involve six dimensions to assess a patient’s substance use severity and biopsychosocial needs to determine the appropriate level of care (ASAM’s six dimensions):

• Dimension 1: Acute intoxication and/or withdrawal potential 
• Dimension 2: Biomedical conditions and complications
• Dimension 3: Emotional, behavioral, or cognitive conditions and complications
• Dimension 4: Readiness to Change
• Dimension 5: Relapse, Continued Use, or Continued Problem potential
• Dimension 6: Recovering/Living environment

ASAM Levels of Care:

• Level One: Outpatient services: Services might include seeing a clinician for medication or withdrawal management, seeing a therapist, or participating in community group therapy.
• Level Two: Intensive outpatient or partial-hospital programs: More intensive half-day or full-day programs (9-30 hours per week) that offer comprehensive therapeutic programs (i.e. with CBT, DBT, or trauma-focused therapy) and focus on coping skills.
• Level Three: Residential or inpatient treatment programs (“Rehab”): Residential programs offer patients time and space away from their home environment for treatment. These programs typically last 28 or 30 days. Ideally, if a patient completes a residential program, they step down into a lower level of care afterward such as an intensive outpatient program and ultimately participate in long-term outpatient care.
• Level Four: Intensive inpatient programs: These programs are intended for patients who have complicated withdrawal histories, severe intoxication, or acute medical and psychiatric comorbidities that require 24-hour medical monitoring and management in a hospital.

Identifying Community Resources

One universal hurdle faced by clinicians is knowing what resources exist in their area. In addition to the sponsorship model of addiction recovery, in which individuals in sustained recovery support peers, drug and alcohol counselors often offer services in the community. Licensed marriage and family counselors, social workers, and clinical psychologists can offer more structured assessment and therapy services. Psychology Today can be a useful tool to identify local providers based on geography, insurance, and preferred treatment focus (e.g. addiction) or modality (e.g. CBT).

Review: What can you do in five minutes as a busy PCP?

• Practice the OARS and the spirit of MI
• Explore coping skills with your patients
• Discuss community-based programs with your patients
• Assess the level of care that is appropriate for your patient

Need more time? Turn to your outpatient options and specialists who can discuss care options further with patients and help get them connected.

Take Home Points

1. Identify resources in your community and how these can help your patients on an individual level
2. Don’t try to do everything all at once. Make changes in your clinical practice by focusing on one skill at a time, such as applying the OARS, Ask-Tell-Ask, or Catch it, Check it, Change it.
3. Respect patient autonomy and focus on empowering and affirming them in making life changes.

Links

1. Motivational Interviewing for Clinical Practice – a primer for busy clinicians on how to integrate MI concepts into their clinical practice with sample dialogue to illustrate examples of these conversations.

Goal

Listeners will describe common psychosocial interventions used to treat individuals with substance use disorders.

Learning objectives

After listening to this episode, listeners will…

1. Define the ASAM levels of care for individuals with substance use disorders (SUDs)
2. Define and describe basic motivational interviewing techniques
3. Describe the common psychosocial interventions for the treatment of SUDs
4. Counsel a patient on participating in 12-step meetings (i.e. 12-step facilitation).

Disclosures

Dr. Carla Marienfeld reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Danesvhar H, Marienfeld C, Morford K, Stahl N, Williams P, Chan, CA. “10 The ABCs of CBT: Psychosocial Interventions 101”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/episode-list September 8th, 2022.