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CEP Workshop Series 2013

Module 6: Management 2
Fraser Todd and Michelle Fowler
Workshop Introduction
Workshop Agenda
Mihi and Introductions
Housekeeping & Workshop overview
Introductory Mindfulness Exercise
Level 1 Interventions - Diagnoses
Psychological Interventions
Drugs and Medication
Action Planning
Exercise 1: Mindfulness Introduction
Review of Treatment Planning
Review of Treatment Planning
Parm reducuon
hases and sLages of LreaLmenL
SLrucLurlng 1reaLmenL
WlLhdrawal managemenL
Level 1 lnLervenuons - ulagnoses
Level 2 lnLervenuons - SympLoms and key facLors
(aeuologlcal, Lrans-dlagnosuc, ampllers)
From Formulation to Treatment Planning
Steps for Developing a Treatment Plan:
1he Cplnlon
PlsLory and MSL
lormulauon SLaLemenL
Coal ldenucauon and Semng
Coal lannlng
1reaLmenL lannlng
roblems and SLrengLhs
Aeuologlcal formulauon
& 4x4 Crld
SLep 1:
SLep 2:
SLep 3:
SLep 4:
rlorluslng goals
Speclc lnLervenuons
10 polnL LreaLmenL sLrucLure
Rachel Formulation Statement:
)*+'%&#,-+-./ #'0 1&-22%&3(
lrom whaL you have Lold me lL appears LhaL you may have some geneuc predlsposluon Lo subsLance use dlsorder and soclal anxleLy. Cn Lop of Lhls you also had Lraumauc experlences whlle you were growlng up such as abandonmenL and sexual abuse. 1hls appears Lo have led Lo experlences of
lL appears your alcohol use
ulsLresslng emouons feellngs you have been experlenclng for a long ume\
faclng . you have been experlenclng
your dlsLress and emouons wlLhouL worsenlng Lhe sympLoms of depresslon wlLhouL worsenlng Lhe sympLoms of depresslon as well as prevenung you from achlevlng your llfe goals.
Powever, l also hear LhaL you are mouvaLed Lo make some changes by comlng here and Laklng Lhese sLeps, whlch lsn'L easy. ?ou are ln good physlcal healLh and you were able Lo be absunenL whlle you were pregnanL whlch demonsLraLes belng a good mum and meeung Lhe needs of your daughLer and Lhe connecuons wlLh your famlly ls lmporLanL Lo you. l heard you Lalk abouL havlng hope ln your fuLure, whlch ls greaL! 1hls wlll help you sLay focused on your sLudles and fuLure recovery.
Early and Middle Phase Treatment Goals:
7#86%+ 9:#+ 5%;'2 <:& %#&+/ #'0 =:>-'2 .: =-00+% .&%#.=%'. ?6#3%3
8lsk and safeLy - self, oLhers, chlld, ACu relaLed harms
lmprove mood
Manage wlLhdrawal - alcohol, cannabls, nlcoune
Coplng skllls - anger, emouonal regulauon
sycho-educauon regardlng lllnesses
Lducauon - Lncourage and supporL soclal work sLudles
SupporL neLworks
1Su - address rumlnauon, lnLruslve memorles, hyper-arousal
SplrlLual - ldenuLy,
lnLegraLe key sLraLegles lnLo follow-up/Lherapy sesslons
Motivational Framework for Session Structuring:
1ake opporLunlues Lo reecL
& summarlse
Change Lalk
Well-belng Lalk
3b 4
8elnforce commlLmenL Lalk SeL Agenda
SplrlL of mouvauonal lnLervlewlng
In the next episode
Management Structure
Structured Follow-up Session Planning Template:
W-.60&#@#+ 4#'#2%=%'.
MaLua 8akl. 2011. !"#$%&'() +,%-./&0&1 2&'&3)4)'%5 6",.)1,')$ 78/ 4).,(&1 &'.
'"/$,'3 9/&(::8')/$ ,' 9/,4&/; -)&1%-< $9)(,&1,$% &..,(:8'$< ("$%8.,&1 &'. 3)')/&1
-8$9,%&1 $)='3$> MaLua 8akl, WelllngLon.
MaLua 8akl. 2011. !"#$%&'() +,%-./&0&15 2&'&3)4)'% 3",.)1,')$ 78/ &..,(:8'
&'. &11,). $)/?,()$> MaLua 8akl, WelllngLon.
1he process and Lhe acuLe sympLoms, physlcal and psychologlcal, LhaL can
accompany Lhe cessauon or reducuon of use of any subsLance LhaL has been used
regularly over a prolonged perlod of ume.
WlLhdrawal occurs ln subsLance-dependenL people who sLop or conslderably
reduce Lhelr drug use.
1he dlagnosls of dependence ls generally requlred Lo undersLand and manage drug
Maladapuve auern of use wlLh aL leasL Lhree of Lhe
followlng occurrlng wlLhln a 12 monLh perlod:
1. 1olerance
2. WlLhdrawal
3. use ls oen more Lhan lnLended (quanuLy, ume)
4. unsuccessful auempLs Lo cuL down or conLrol use
3. Much ume spenL ln use relaLed acuvlLy
6. lmporLanL acuvlues glven up or reduced
7. Conunued use desplLe knowledge of assoclaLed problems
DSMIV Criteria for Dependence
1he purpose of 'wlLhdrawal managemenL' ls Lo ensure Lhe safeLy of Lhe person,
and oLhers, as Lhey sLop or reduce subsLance use, and where posslble Lo address
wlLhdrawal sympLoms Lo allevlaLe acuLe dlsLress.
Withdrawal Management
ApproprlaLe wlLhdrawal managemenL plannlng depends on an accuraLe assessmenL of
Lhe person's:
pauerns of subsLance use, whaL, how much, how oen and lasL use
wlLhdrawal rlsks, rlsks Lo self and oLhers, hlsLory of wlLhdrawal
co-exlsung problems, menLal and physlcal healLh
supporL sysLems, famlly, whanau and frlends
mouvauon, goals and reslllence
semng safeLy
exLernal sources of sLress
Factors Affecting Planning
Crganlse a safe envlronmenL
Crganlse supporLs
LducaLe of ways of deallng wlLh cravlngs
1lps Lo lmprove sleep
8elaxauon Lechnlques
Management of Withdrawal
Coplng wlLh mood swlngs, sLrange LhoughLs and aches and palns
Laung properly
ConcenLraung only on Lhe lmmedlaLe fuLure
ldenufylng hlgh rlsk slLuauons
CbLalnlng counselllng
Management of Withdrawal
Perbal and mlneral supplemenLs
naLural melaLonln
Management of Withdrawal
Wlde range of semngs, from Lhe person's own home Lo general pracuce,
general hosplLals, pollce cells and prlsons.
CommunlLy home based wlLhdrawal managemenL:
Soclal or resplLe servlce based wlLhdrawal managemenL:
Soclal wlLhdrawal managemenL beds:
lnpauenL medlcal wlLhdrawal managemenL:
Withdrawa Management: Settings
lnLenslLy of use
1ype of use
uose, frequency and durauon of use
Mode of admlnlsLrauon
CLher subsLance use
Co-exlsung menLal healLh problems
Co-exlsung physlcal healLh problems l.e hyperLenslon, dlabeLes
A hlsLory of hlgh rlsk or wlLhdrawal relaLed selzures
A hlsLory or apparenL wlLhdrawal relaLed compllcauons such as dehydrauon
8lsks Lo Lhe lndlvldual or communlLy
LnvlronmenL and psychosoclal supporLs.
Factors Affecting Severity of Withdrawal
Lxacerbauon of co-exlsung menLal healLh or physlcal problems
Low mood and sulcldallLy
AnxleLy and panlc auacks
lrrlLablllLy and anger
ulsLurbed sleep and lnsomnla
uehydrauon due Lo vomlung and or dlarrhoea
LlevaLed blood pressure
ueluslons and psychosls
8raln damage
General Risks of Stopping Substances
Which Substances are Most Risky
'WlLhdrawal syndrome' 7 -10 days (dependlng on subsLance)
WorsL days beLween 2-4
AglLauon , lrrlLablllLy
Moodlness, mood swlngs or feellng low
AnxleLy and worrles
8esLlessness and lnablllLy Lo sleep
ulmculLy concenLraung and dgeuness
1lredness and low ln energy
Cravlng (hanglng ouL) and sLrong urges Lo use
SLrange dreams and/or nlghLmares
Withdrawal Symptoms
"6/3-8#+ 5/=?.:=3
Sweaung, goosebumps, feellng hoL or cold
Cold or u llke sympLoms
Loss of appeuLe, feellng slck, sLomach cramps, vomlung
Aches and palns
leellng shakey and shlvery
lncreased hearL raLe
Withdrawal Symptoms
A speclc alcohol use hlsLory also lncludes:
Lype and sLrengLh ( alcohol per volume) currenLly uslng
ume of lasL drlnk
average number of sLandard drlnks (S1u's) a day over ume
any drlnklng soon aer waklng
needlng Lo conLrol shakes by uslng alcohol
pasL hlsLory of selzures
pasL hlsLory of halluclnauons
co-exlsung physlcal healLh problems
Alcohol Withdrawal
eople who are physlcally dependenL upon alcohol are llkely Lo
experlence wlLhdrawal sympLoms 6-24hours aer Lhe lasL drlnk ls
AWS ls usually uncompllcaLed resolvlng ln 3days
AWS however ls deLermlned by cllenLs drlnklng pauern, frequency,
durauon and quanuLy
Alcohol Withdrawal Syndrome
Alcohol Withdrawal
Alcohol Withdrawal
Alcohol Withdrawal Complications
occur ln 23 of people wlLh severe alcohol dependence
generally more common ln Lhe rsL 48 hours buL can occur up Lo day
usually vlsual and Lacule and are occaslonally audlLory
can occur whlle Lhe person ls sull orlenLaLed wlLhouL dellrlum
occur ln 13 of people wlLh severe alcohol dependence
rlsk lncreases Lo 70 lf person has had a prevlous wlLhdrawal
generally occur wlLhln Lhe rsL 48 hrs
'grand mal' Lype of selzure
usually one or few ln number
uellrlum Lremens ls Lhe mosL severe form of alcohol wlLhdrawal syndrome
and ls a medlcal emergency.
ln people who are severely dependenL dellrlum Lremens Lyplcally occurs
aer Lwo Lo ve days of unLreaLed severe wlLhdrawal syndrome.
Delerium Tremens (DTs)
leaLures lnclude:
llucLuauons ln blood pressure or pulse
ulsLurbance ln uld balance/elecLrolyLes/hyperLhermla
Cross Lremor
aranold ldeauon
Confuslon and dlsorlenLauon
LxLreme aglLauon or resLlessness
Delirium Tremens (DTs)
lorm of braln ln[ury resulung from lack of Lhlamlne (81) declency ln
chronlc alcohol dependenL pauenLs
Can lead Lo permanenL braln damage and memory loss lf noL LreaLed
Wernickes Encephalopathy
nysLagmus, wlLh or wlLhouL blurred vlslon
erlpheral neuropaLhy (can be presenL ln up Lo 80 of people wlLh
Wernlcke's encephalopaLhy)
Symptoms of Wernickes Encephalopathy
1hlamlne should be prescrlbed and oered as an oral medlcauon Lo people aL
hlgh rlsk of developlng Wernlcke's encephalopaLhy:
Lhe malnourlshed or aL rlsk of malnourlshmenL
Lhose wlLh decompensaLed llver dlsease
ln acuLe alcohol wlLhdrawal
before and durlng planned alcohol wlLhdrawal
Preventative Measures for WE
1he Cllnlcal lnsuLuLe WlLhdrawal AssessmenL for Alcohol 8evlsed ClWA-
10 lLem scale used ln assesslng severlLy of wlLhdrawal
Pelps Lo gulde LreaLmenL
lmp Lo help lndlcaLe when wlLhdrawal ls conunulng desplLe LreaLmenL
1he scale ls usually done 1-4 umes per day.
Monitoring the Withdrawal State
1hlamlne 100mg dally up Lo Lhree umes a day for people wlLhdrawlng
from alcohol
ulazepam reduclng reglme dependlng on severlLy of wlLhdrawal. lor
mlld Lo moderaLe wlLhdrawal reglme ls usually over 3-7 days
Medication Management
A speclc cannabls use hlsLory lncludes:
quanuLy of use, amounL consumed, Lype of cannabls and poLency
durauon, pauern and frequency of use
mode of admlnlsLrauon (smoked or eaLen, mlxed wlLh Lobacco)
ume and amounL of lasL use
pasL hlsLory of aggresslon and vlolence
Cannabis Withdrawal
rovlde a menu of lnLervenuon opuons. 1hls may lnclude:
1he cholce of sudden cessauon, wlLh or wlLhouL sympLomauc medlcauon
A supporLed gradual reducuon uslng psycho-soclal lnLervenuons.
Comprehenslve assessmenL, LreaLmenL plannlng and supporuve counselllng
ln Lhe communlLy are Lhe maln sLraLegles
Measurement of Cannabis Withdrawal
A pasL hlsLory of vlolence and aggresslon may lndlcaLe a rlsk of aggresslve
behavlour whlch could place oLher people aL rlsk
underlylng menLal healLh lssues may be unmasked durlng wlLhdrawal
SulcldallLy and self ln[ury may be a rlsk facLor for people wlLh a co-exlsung
mood or psychouc dlsorder
Risks Associated with Cannabis Withdrawal
Cannabis Withdrawal
Cannabis Withdrawal
eople wlLh severe wlLhdrawal sympLoms and or co-exlsung problems may
requlre approprlaLe medlcauon
Common Lo use low dose Cueuaplne or lf more severe reduclng dlazepam
Medication Management
A speclc A1S use hlsLory lncludes:
names and Lypes of A1S used
rouLe of use and documenLauon of ln[ecung slLes
average frequency and quanuLy of use, ln mllllgrams, over ume
ume of lasL use
conLexL of use
perlods of absunence
currenL or recenL psychosls sympLoms
lnlual reasons for sLarung Lo use A1S
ATS Withdrawal Assessment
A1S wlLhdrawal ls noL physlcally dangerous and mosL people wlll compleLe
wlLhdrawal wlLh mlld Lo moderaLe sympLoms
a pasL hlsLory of vlolence and aggresslon may lndlcaLe a rlsk of aggresslve
behavlour whlch could place oLher people aL rlsk
underlylng menLal healLh lssues may emerge durlng wlLhdrawal
seroLonln LoxlclLy may occur due Lo elevaLed seroLonln levels, especlally lf
Lhe person ls also prescrlbed an SS8l
Risks Associated with ATS Withdrawal
lollowlng Lhe 'crash' wlLhdrawal beglns
MosL sympLoms peak beLween days Lwo and Len
Some sympLoms can perslsL for several monLhs, especlally sleep and
mood problems.
ATS Withdrawal
laugue and exhausuon
Lmouonal lablallLy (lrrlLable, aglLaLed, depressed)
Cverwhelmlng deslre Lo sleep or sleeplng dlmculues
ATS Withdrawal
uu8lnC nLx1 WLLk
SLrong cravlngs or urges Lo use
ulsrupLed sleeplng pauerns
Mood swlngs
Peadaches, aches and palns
lncreased appeuLe
lrrlLablllLy, paranola, anxleLy
ATS Withdrawal
ATS Withdrawal
Address healLh lssues LhaL could be causlng paln
MonlLor mood sLaLes and sulcldal ldeauon closely
rovlde dleLary advlce abouL Lhe need for susLalned healLhy eaung and
muluvlLamln use followlng llkely poor nuLrluon whlle uslng A1S
lnvolve menLal healLh servlces lf anxleLy, depresslon or psychosls emerge
as problems posL deLoxlcauon
Management of Withdrawal
eople wlLh severe wlLhdrawal sympLoms and or co-exlsung problems
may requlre approprlaLe medlcauon
Common Lo use Cueuaplne or lf more severe reduclng dlazepam reglme.
Medication Management
Exercise 2: Rachel: Withdrawal
ln small groups:
nomlnaLe a scrlbe and someone Lo feedback
8evlew Lhe case of 8achel lf you need Lo
1. WhaL sympLoms of wlLhdrawal do you Lhlnk 8achel wlll experlence?
2. Cver whaL ume perlod?
3. uescrlbe ln deLall Lhe speclc sLeps you wlll Lake Lo manage her wlLhdrawal sympLoms
Level 1 Interventions: Diagnoses
Level 1 Interventions: Diagnoses
Level 1 1reaLmenL = applylng generlc lnLervenuons Lo dlagnoses
useful ln sLepped care approach, common basls of LreaLmenL lnLegrauon
lor Lhose wlLh severe menLal lllness:
o 1/3
do well aer 12 monLhs of LreaLmenL
o 1/3
do poorly lnlually buL are dolng well aer 10 years of LreaLmenL
o 1/3
are dolng poorly aer 10 years of LreaLmenL
1herefore a sLepped Level 1 approach ls reasonable lnlually
Level 1 Interventions: Diagnoses
Major Depression & Alcohol:
SympLoms of ma[or depresslon (MuL) presenL ln Lhe ma[orlLy of heavy drlnkers
ln mosL, depresslon resolves wlLhln 2-4 weeks of absunence
Any perslsung depresslve sympLoms lncrease Lhe raLe of relapse & vlce versa
SS8l's lncrease Lhe rlsk of relapse due Lo lncreased lmpulslvlLy (Lherefore drlnklng
when experlenclng cravlngs) especlally ln males wlLh exLernallslng behavlour.
nalLrexone reduces SS8l-lnduced lmpulslvlLy
SS8l's + nalLrexone = beuer ouLcomes for boLh alcohol and depresslon
Level 1 Interventions: Diagnoses
Major Depression & Alcohol:
1&%#.=%'. 7%8:==%'0#D:'3
Where depresslon appears Lo be prlmary, LreaL boLh depresslon and alcohol early
Where lL ls unclear lf depresslon ls prlmary, deLox and monlLor for 2-4 weeks
ln males wlLh exLernallslng problems, comblne anudepressanL + nalLrexone
Sull conslder SS8l + nalLrexone ln oLhers wlLh prlmary/perslsung depresslon + alc
Alm for compleLe remlsslon of depresslve sympLoms
Conslder an ob[ecuve raung scale measure e.g. 8ul Lo complemenL cllnlcal
Level 1 Interventions: Diagnoses
Major Depression & Cannabis:
1he co-occurrence of depresslon and cannabls ls malnly due Lo common
underlylng facLors (dlsrupuve behavlour ln chlldhood) raLher Lhan any dlrecL eecL
SS8l's may lnLeracL wlLh cannabls such LhaL cannabls ls less en[oymenL
1hose wlLh cannabls dependence engage less well ln LreaLmenL of depresslon
1here ls no evldence LhaL cannabls use lmpacLs on Lhe LreaLmenL for depresslon.
1here ls no rauonale for wlLhdrawlng cannabls before Lreaung depresslon
Level 1 Interventions: Diagnoses
Major Depression & Cannabis:
1&%#.=%'. 7%8:==%'0#D:'3
WlLh respecL Lo Lhe relauonshlp beLween cannabls and depresslon ln any parucular
person, llsLen Lo Lhe person and work wlLh Lhelr reporLs of Lhe lnLeracuon
lf an SS8l ls Lo be prescrlbed work hard Lo engage. Some wlll reduce cannabls, oLhers
wlll sLop Lhe SS8l
uo noL delay LreaLmenL for depresslon unul cannabls use has sLopped.
lf Lhere ls comorbld alcohol use, nalLrexone may be used buL may lead Lo lncreased
cannabls use.
Conslder Lhe lnLeracuon beLween cannabls and oLher problems oen comorbld wlLh
depresslon, such as anxleLy sympLoms
Level 1 Interventions: Diagnoses
Bipolar Disorder & Alcohol:
Alcohol used mosL commonly ln Lhe depressed phase
Llnked more Lo coplng Lhan pleasure
Sodlum valproaLe may be more eecuve Lhan oLher mood sLablllsers
1&%#.=%'. 7%8:==%'0#D:'3
1reaL blpolar dlsorder asseruvely, mood sLablllser, C81, sLablllsauon of soclal rhyLhms
Conslder Sodlum valproaLe as rsL llne mood sLabllser
Conslder nalLrexone, monlLor llver funcuon as nalLrexone, alcohol and
Sodlum valproaLe may all lmpalr llver funcuon
Level 1 Interventions: Diagnoses
Bipolar Disorder & Cannabis:
Cannabls used malnly durlng perlods of elevauon
used for hedonlc or pleasurable aspecLs
Cannabls assoclaLed wlLh elevaLed mood and psychouc sympLoms
1he lmpacL of cannabls on blpolar sympLoms may be qulLe varlable
from person Lo person
1&%#.=%'. 7%8:==%'0#D:'3
As for alcohol, LreaL blpolar dlsorder asseruvely
Absunence from cannabls may be qulLe easlly achleved
Level 1 Interventions: Diagnoses
PTSD & Alcohol:
Alcohol use drlven by hyperarousal
vlclous cycle of lnLruslve memorles, hyperarousal and rumlnauon
1&%#.=%'. 7%8:==%'0#D:'3
use mlndfulness and lmaglnal desenslusauon early
Conslder rlsperldone, beLa-blockers or prazosln for hyperarousal
ulsulphlram (anLabuse) may reduce anxleLy and hyperarousal
Level 1 Interventions: Diagnoses
PTSD & Cannabis:
Plgh raLes of cannabls use ln people wlLh 1Su, drlven by lnLruslve memorles?
Cannabls appears Lo reduce lnLruslve memorles
8educuon ln cannabls use may be assoclaLed wlLh lncreased 1Su sympLoms
1&%#.=%'. 7%8:==%'0#D:'3
As wlLh alcohol, use lmaglnal desenslusauon early
Conslder an SS8l for lnLruslve memorles
Brief Psychological Interventions
Brief Psychological Interventions
1argeL speclc problems aL Level 2: underlylng facLors from Lhe formulauon
May lnclude lnLervenuons for:
o lssues llkely Lo lmpeded engagemenL (especlally anxleLy and anger)
o Ampllers
o 1ransdlagnosuc facLors
8rlef C81 (bC81) can Lake 20 mlnuLes + over 1-4 sesslons
Cpumally need a good groundlng ln full lengLh C81
n8 C81 as eecuve as oLher psychoLheraples aL Lhe end of LreaLmenL, buL
lmprovemenLs conunue for a conslderable ume aerwards
Brief Psychological Interventions
Mouvauonal lnLervlewlng
Lmouon regulauon
Coplng skllls and dlsLress Lolerance
8elaxauon skllls
o rogresslve muscle relaxauon
o ueep breaLhlng
o Culded lmagery
8ehavloural acuvauon
Brief Psychological Interventions
Psychological Transdiagnostic Factors:
Self-esLeem and self-emcacy
Auenuon conLrol
negauve urgency
negauve emouonallLy
Cognluve and auenuonal blas
Lmouon regulauon
AvoldanL coplng sLyle
Basic CBT Model - ABC:
Acuvaung LvenL Eehavlour
Brief Psychological Interventions
Basic CBT Model:
Acuvaung LvenL Eehavlour
hyslcal sensauons
Brief Psychological Interventions
Basic CBT Model:
Acuvaung LvenL Eehavlour
AuLomauc 1houghLs lnLermedlaLe 8ellefs Core Schema
2&1&.&9:?) @-8"3-%$ A B)1,)7$5
hyslcal sensauons
Brief Psychological Interventions
Brief Psychological Interventions
Identifying Activating Events/Antecedents:
WhaL were you feellng before you dld LhaL? (aecL/emouon)
WhaL happens physlcally before Lhls happens? (physlcal)
Pow do you normally acL before Lhls happens? (behavlour)
WhaL LhoughLs go Lhrough your mlnd before Lhls happens? (Cognluve)
Where and when does lL usually happen? (conLexLual)
uoes Lhls happen wlLh everyone or [usL wlLh cerLaln people? (relauonal)
Brief Psychological Interventions
Identifying Maladaptive Thoughts:
Culded dlscovery (Socrauc quesuonlng)
ldenucauon of auLomauc LhoughLs LhaL occur ln a sesslon
8rlef explanauons/mlnl lessons
8eadlngs and oLher resources
1houghL records
AuLomauc LhoughL checkllsLs
CompuLer-asslsLed C81
Brief Psychological Interventions
Thoughts Record:
16:*26. 7%8:&0
LvenL AuLomauc 1houghLs
(8aLe degree of bellef
(8aLe lnLenslLy
Brief Psychological Interventions
Automatic Thoughts Checklist:
A*.:=#D8 16:*26.3 F6%8G+-3.
! l should be dolng beuer ln llfe
! Pe/She doesn'L undersLand me
! l've leL hl/her down
! l [usL canL en[oy Lhlngs anymore
! Why am l so weak
! l always keep messlng Lhlngs up
! My llfe ls golng nowhere
! l can'L handle lL
! l'm falllng
! lLs Loo much for me
! l don'L have much of a fuLure
! 1hlngs are ouL of conLrol
! l feel llke glvlng up
! SomeLhlng bad ls sure Lo happen
! 1here musL be someLhlng wrong wlLh me
WrlghL !.P., Sudak, u.M. 1urklngLon, u. 1hase, M.
Plgh-?leld Cognluve 8ehavlor 1herapy for 8rlef Sesslons: An lllusLraLed Culde
Amerlcan sychlaLrlc ubllshlng
WashlngLon 2010
Brief Psychological Interventions
Common Cognitive Distortions:
1. All or noLhlng Lhlnklng
2. Cvergenerallzauon
3. MenLal lLerlng
4. ulsquallfylng Lhe posluve
3. !umplng Lo concluslons
6. Magnlcauon or mlnlmlsauon
7. Lmouonal reasonlng
8. Should sLaLemenLs
9. Labelllng
10. ersonallsauon
Exercise 3: Rachel Maladaptive Thoughts
ln small groups:
AppolnL someone Lo feedback Lo Lhe class
WhaL auLomauc LhoughLs, lnLermedlaLe LhoughLs,
core schema and cognluve dlsLoruons Lo you Lhlnk 8achel ls llkely Lo have?
Drugs and Medication
Drugs and Medication: Naltrexone
Cplold recepLor anLagonlsL
8locks relnforclng eecLs of alcohol, reduces cravlng dyscronLrol
under uullsed, one of Lhe mosL poLenL lnLervenuons for alcohol dependence
LlmlLed usefulness for oplold dependence
8locks analgeslc eecLs of oplolds (morphlne, codelne)
Drugs and Medication: Naltrexone
Side Effects:
nausea, vomlung, reduced appeuLe
neumonla (serlous)

Llver damage aL hlgh doses (serlous)
Sedauon ln a mlnorlLy
Drugs and Medication: Naltrexone
auenL should be oplaLe free for 7-10 days
30mg LableL
SLarL 30mg dally, may lncrease
Works wlLhln a few days, maxlmum eecL aer a few weeks

Long acung ln[ecuons avallable ln uS
Drugs and Medication: Naltrexone
Other Information:
oLenual eecLs on foeLus ln anlmal sLudles (avold aL leasL ln rsL LrlmesLer)
lound ln breasL mlle
Warn prevlous lv drug users on nalLrexone for oplold dependence of rlsk of
loss of Lolerance Lo oplolds and poLenual overdose
May be used wlLh SS8l's (+++), AnLabuse
Drugs and Medication
Potentially Fatal Interactions:
Lorazepam (auvan) + alcohol
o 8esplraLory and cardlac depresslon (lorazepam worse Lhan oLher
Amyl nlLraLe + slldenal (vlagra) or Ladalal (clalls)
o oLenually faLal hypoLenslon
LcsLasy + 8lLonavlr
LcsLasy + MACl's lncludlng Moclobemlde
AmpheLamlnes + MACl's lncludlng Moclobemlde
o Severe hyperLenslve crlsls
Structuring Treatment
lnLegraLe key sLraLegles lnLo follow-up/Lherapy sesslons
Motivational Framework for Session Structuring:
1ake opporLunlues Lo reecL
& summarlse
Change Lalk
Well-belng Lalk
3b 4
8elnforce commlLmenL Lalk SeL Agenda
SplrlL of mouvauonal lnLervlewlng
In the next episode
Exercise 4: Rachel: Maladaptive Thoughts
ln small groups:
AppolnL someone Lo feedback Lo Lhe class
uslng Lhe LemplaLe below g 44 of handbook, enLer Lhe speclc lnLervenuons
you would plan for 8achel across Lhe rsL 8 sesslons of LreaLmenL
Management Structure
Structured Follow-up Session Planning Template:
Action Plans
8efore Lhe nexL workshop, plck a cllenL you are due Lo see.
uurlng your nexL sesslon wlLh Lhem, ldenufy any auLomauc LhoughLs,
lnLermedlaLe bellefs, core schema and cognluve dlsLoruons Lhey have
relaLed Lo Lhelr key presenung problems.