1. Cognitive Behavioral
Therapy and Mindfulness
in Addiction Treatment
Tony Pacione, LCSW, CSADC

2. Objectives
 Why CBT/Mindfulness for addictions?
 Define and ID automatic thoughts and core
beliefs in addictions
 Cognitive Restructuring: Identifying and
changing dysfunctional thought patterns
 Mindfulness in addiction treatment
 Integration of CBT and Mindfulness

3. What is CBT?
 Identify distorted or dysfunctional
thinking
 Influences mood and behavioral
 Common to all psychological
disturbances; including addiction
 “Collaborative empiricism”
 Identify, challenge and change thinking

4. What is the Mindfulness?
 “Moment to moment awareness
 On purpose
 In a particular way
 Without judgment”
 Clinical uses of Mindfulness
J Kabbot-Zinn 1990

5. Principles (skill set) of
Mindfulness
1. Non-judging 5. Non-striving
2. Patience 6. Acceptance
3. Fresh Mind 7. Letting Go
4. Trust
J. Kabat-Zinn 1990

6. CBT + Mindfulness
 CBT = (Identifying and modifying)
– perception
– beliefs and thoughts
– Cognitive appraisals
 Mindfulness =
– Fully present to the moment
– Less interested in thought content
– Observing the arising and ceasing of thought
 Both Assume: Thoughts / judgments are
NOT facts

7. Why CBT/Mindfulness
 Focused; limited resources
 Empirical support
 Clear goals, immediate impact, skill
development
 Compatible with Self-help; Other EBT,
and Pharmacotherapy
 Flexible and individualized

8. Improvement in “Mindfulness” QA study HRC
3.6
4
2.7
3
Ave Score 2
MAAS
1
0
Adm D/C
pre and post test 6 weeks (N =23)

9. Cognitive Schema: A Beck, 1993
Automatic Thoughts:
 “Mental” Reactions to situations
– Real; Imaginary/perceived; Anticipatory
 Not fully conscious or deliberate
 Instantaneous and immediate
 Emotional associations

10. Cognitive Schema
Conditional Beliefs:
 More general than automatic thoughts
– Boolean logic: “If… than; and/or”
 Assumptions: taken at face value, as
“truths;” rarely questioned
 Roles/expectations
 Attitudes/values

11. Cognitive Schema
Core Beliefs:
 More general than conditional beliefs
 Strongly held beliefs, underlying assumptions
about who I am
 Develop early in life and are reinforced as we
age
 Can become a ‘filter’ for interpreting life
experiences (“self-fulfilling prophecies”)
 Can be identified and changed
 Self Efficacy (A. Bandura)

12. Cognitive Schema: Core Beliefs
Two ‘varieties’ of dysfunctional core beliefs -
1. Un-lovable
 unworthy; irrelevant; needy
1. Incompetent
 defective; helpless; failure; “screw-up”
A. Beck 1993

13. Cognitive Schema (A. Beck)
Relevant Childhood and Developmental data (30
y/o male): Addicted mom, neglected by dad
Core Beliefs: I’m unlovable and irrelevant
Conditional Assumptions: If I please others than
I’ll be liked, and be important
Compensatory Strategy: Avoid displeasing
others at all costs
Situation: Co-worker asks me to stay late to help
Automatic Thoughts: I won’t be liked if I say “no”
Emotions: Fear and anxiety
Behavior: Stay late at work (anger your date)

14. Cognitive Restructuring
1. Observe 5. Construct
thoughts/emotions alternative
thoughts/beliefs
2. Identify thinking
patterns (ATs) 6. Complete
cognitive schema
3. Identify cognitive
distortions 7. Behavioral
Experiments
4. Challenge
cognitive
distortions 8. Validate Change
(#1)

15. Thought Record
(Steps 1-2) 49 y/o female alcoholic
Mood Rating or
Automatic and Craving
Situation/Event Thought Related Feeling (1-10)
“I will probably lose my
job if I’m off of
Recommended to take time off work for more than Fear
work for treatment a few days." Panic 10
“I feel trapped; I want
to help but the are
taking advantage Anger
Family members keep asking of me, but I can ‘t Guilt
me for money and support say no.” Depression 8
“He knows I’m
alcoholic now, and
Boss suggested I have a he’ll try to get rid of Fear
problem with alcohol me” Depression 9
Other patients don’t respond “No one is warming up
the way I want them to, to me; they think
when I approach them I’m a ‘bitch’!” Anxiety 7

16. Common Cognitive Distortions (Step 3)
 Dichotomous  ‘Catastrophizing’
thinking
 Emotional
 Overgeneralization reasoning
 Mental filters  Personalization
 Jumping to
conclusions
D Burns 1999

17. Thought Record
- Cognitive Distortions (Step 3) 49 y/o female
alcoholic
“I’ll lose my job if I take time off.” Overgeneralization and catastrophizing
“They all think I’m a ‘bitch’!” Personalizing
“I can’t say no to my family when jumping to conclusions
the ask for something.”
“My boss no longer respects me, Emotional reasoning
because he thinks I’m alcoholic; a
loser.”

19. Identifying Automatic Thoughts
(Steps 4-5)
 Affective shift in session
 Describe problematic situations
 Guided imagery
 Role-play
 Focus on high value ATs; intense affect

20. Challenging Automatic Thoughts
(Steps 4-5) Using I.C.E. to cool off ‘Hot’ thoughts
Thoughts/feelings NOT equal to Facts
 I – Identify the thought
 C – Challenge the thought
 E – Evaluate the thought
A. Pacione 2003

21. I.C.E.
(Steps 4-5)
Identify (and rate) the thought:
“I’ll lose my job if I take time off for treatment now.”
Truthfulness rating = 80%
Challenge the thought:
EVIDENCE FOR EVIDENCE AGAINST
•Iseen my boss get rid of someone •My boss also encouraged me to get
else before help
•My boss and his boss told me “we
support you”
•There’s been threats of lay offs
•I have others who depend on me •They told me “I'm a valuable
working employee”
• Boss has been watching me lately
• He knows I’m alcoholic Boss won’t talk to me about returning

22. I.C.E. cont.
(Step 4-5)
Evaluate (re-rate) the thought:
a) Post challenge truthfulness rating = 45%
b) Revise thought to make it more truthful:
“There is a higher probability I can lose my
job if I don’t get help and continue to drink,
than if I take time off to get help”

23. Practice I. C. E.

24. Cognitive Grid (Step 6)
 Situation: My boss cryptically said
“that alcohol is not a treatment for
stress”
 Automatic Thoughts: “My boss
thinks I’m alcoholic; I have to show
him I’m always a reliable employee”
 Emotions: fear and panic
 Behavior(s): can’t take time off;
work harder

25. Cognitive Grid (continued)
 Relevant Childhood and Developmental
Data: both parents abused alcohol;
neglected; had to care for myself and sibs
 Core Belief: “I’m unlovable; defective and
lonely”
 Conditional assumptions (if/then): “If I
care for and give to others, than I’m worthy of
love!”
 Compensatory strategy: “Make sure I am
always available to others/family what ever
the cost.”

26. Identifying Core Beliefs
Cognitive Grid (Step 5-6)
 Start with the AT- common themes
 Completion of a “If” clause
 Eliciting a rule
 You and the client complete/compare
Grid
 Strength of belief and associated affect

27. Amending Core Beliefs
(Step 5-6)
Options:
 “I’m worthy of love; even if I don’t always
please others.”
 “I’m worthy of love; someone will always
love me.”
 “I’m lovable; regardless of what I give or
don’t give to others”

28. Amending Core Beliefs via
‘Experiments’ (Step 7)
 MI or Socratic questions
 Act as if…
 Others as reference points
 Cognitive Continuum
 Self disclosure- use with caution!

29. Maintenance and Validate (Step 8)
 Re-issue Thought Log
 “What is different?”
 “What situations would your ‘old’ thinking and
feelings return?”

30. A Mindfulness Meditation

31. Mindfulness and CBT Becoming More
Aware More Often
“A powerful influence taking us away from being
‘fully present’ in each moment is our automatic
tendency to judge our experience as being not quite
right in some way—that it is not what should be
happening, not good enough, or not what we
expected or wanted. These judgments can lead to
sequences of thoughts about blame, what needs to
be changed or how things could or should be
different. Often, these thoughts will take us, quite
automatically down some fairly well-worn paths in
our minds. In this way, we may lose awareness of
the moment, and also the freedom to choose what if
any, action needs to be taken.”
Segal, et al. 2002

32. CR with Mindfulness
1. Observe thoughts 5. Construct
-non-striving alternative
2. Identify thinking thoughts
patterns -Letting go
-patience
3. Identify cognitive
6. Complete
distortions cognitive schema
-Non-judging/accepting 7. Behavioral
mind
Experiments
4. Challenge cognitive -Trust/patience
distortions
-Fresh mind 8. Validate -non-
striving/patience

33. CBT/Mindfulness in craving states
 Cravings - normal in recovery
 Time limited
 Individualized and descriptive
 Identify cues and triggers
 Urge Surfing- A Marlatt (2002)
 Recall negative consequences

34. Bibliography
Beck, A., Wright, F., Newman, C. Liese, B. (1993). Cognitive Therapy of
Substance Abuse. New York: The Guilford Press, Inc.
Beck, Judith. (1995). Cognitive Therapy: Basics and Beyond. New York:
The Guilford Press.
Burns, David. (1999). Feeling Good (revised edition). New York: Avon
Books.
Kabat-Zinn, John. (1994). Wherever you go there you are: mindfulness
meditation in everyday life. New York: Hyperion.
Kabat-Zinn, John. (1990). Full catastrophe living: using the wisdom of
your body and mind to face stress, pain, and illness. New York:
Dell Publishing.
Marlatt, G. A. (2002). Buddhist philosophy and the treatment of addictive
behavior. Cognitive and Behavioral Practice, 9, 44–49.
Project MATCH Research Group. (1993 and 2000). Project MATCH:
Rationale and methods for a multisite clinical trial matching
patients to alcoholism treatment. Alcoholism: Clinical and
Experimental Research, 17, 1130-1145.
Segal, ZV, Williams, JM, Teasdal, JD. (2002). Mindfulness-Based
Cognitive therapy for Depression: A new approach to preventing
relapse. New York: The Gilford Press.