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C O G N I T I V E T H E R A P Y O F S U B S T A N C E A B U S E -•̂ .̂ '̂ ySi:'yf̂ '̂ ''->->*' 'r... ^'i-'Mt .#''a^K"'-M>' • M ^ i € • ̂ ^. M'^::. A A R O N T . B E C K • ^ • r f - F R E D D . W R I G H T C O R Y F . N E W H A N B R U C E S . L I E S E C O G N I T I V E T H E R A P Y O F S U B S T A N C E A B U S E C o... |
w l e d g m e n t s w w e would like to offer our thanks to our highly esteemed colleagues in the field of substance abuse treatment and research, Drs. Dan Baker, Lino Covi, Tom Horvath, Jerome Piatt, Hal Urschel, David Wilson, and Emmett Velten, for their extremely help ful insights and suggestions on earlier version... |
the social costs of illicit drug abuse, it is estimated that more than 2 5 % of property crimes and 1 5 % of violent crimes are related to illicit drug use by the criminal. Financial losses related to these crimes have been estimated at $1.7 billion per year. Homicides are also strongly linked to activities surrounding... |
In fact, an important component of cognitive therapy involves the case conceptualization (Persons, 1989), defined as the evaluation and integration of historical information, psychiatric diag nosis, cognitive profile, and other aspects of functioning (see Chap ter 5, this volume, for a detailed description of the cas... |
mous and other disease-model programs) view total abstinence as the only acceptable goal of treatment. Proponents of these models view addiction as an all-or-nothing phenomenon, with any use seen as pathological and abstinence considered a state of "recovering" (rather than "recovered"). Alternatively, proponents of co... |
barbiturates, benzodiaz epines, and alcohol may be preferred because of their relaxing effect and, perhaps, their presumed relief of inhibitions. Hallucinogens are attractive to some to relieve boredom and "expand consciousness." Most people addicted to cocaine have also abused other drugs and/or alcohol (N. S. Miller... |
a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behavior by modifying the faulty or erroneous thinking and maladap tive beliefs that underlie these reactions (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). The approach to a particular patient is derived from a thorough... |
patient will act on the craving (Carroll, Rounsaville, & Keller, 1991). Urges are governed by the anticipated consequences, for example, reward for doing something or pain for not doing it. The urge may be accompanied by a positive feeling when it is driven by a positive expectation or a negative feeling when it is dri... |
the patient's life ranging from low frustration tolerance to marital problems. "Will Power" In the context of drug using, "will power" refers to a deliberate conscious decision (plus sufficient drive and technical self- help know-how to enforce it) to halt or delay the implementation of Cognitive Model of Addiction 37 ... |
cognitive perspective, the way people interpret specific situations influences their feelings, motiva tions, and actions. Their interpretations, in turn, are shaped in many instances by the relevant beliefs that become activated in these situ ations. A social situation, for example, m a y activate an idiosyncratic be... |
drug dealer, or receiving a weekly pay check. Internal circumstances (or cues) include various emotional states such as depression, anxiety, or boredom, which can trigger drug- using beliefs and, consequently, craving for the drug. As shown in Figure 3.5, drug use may be regarded as represent ing the final common pat... |
con viction) the reasons for not using, drug users have difficulty in recall ing or attaching the same significance to these reasons once they are in the throes of a specific drug-using episode. Since all their atten tion is focused on the mechanics of obtaining the drug, the reasons for using at that time become ve... |
the patient's thoughts, followed by sincere involvement by way of questioning and direct, honest, humble feedback, will be a boon to the establishing of rapport. As patients attempt to engage in the process of treatment, thera pists can help facilitate the establishment of rapport by giving posi tive verbal reinforce... |
their home tele phone numbers for use in emergency situations, we realize that some therapists may prefer instead to make use of an intermediary such as an answering service. In either case, we believe that it is necessary for patients to be able to make contact with their therapist after hours in the event of critica... |
process that is associated with their emotional life. The patient's behaviors are the end products of the vulnerable situations, and the activation of beliefs, automatic thoughts, and emotions. C o m m o n dysfunctional behaviors include actively seeking drugs, using drugs, engaging in irresponsible activities (e.g., u... |
is the only way to cure the boredom." His circumstances and beliefs have led to the following behavioral patterns: brief periods of abstinence from drug and alcohol followed by solitary use of alcohol with Valium, which, in turn, leads to intermit tent use of crack cocaine, and then to daily use of crack cocaine. Mike... |
statement applies to himself or herself. Half of the questions indicate a sociotropic personality style, and the other half indicate an autonomous personality style. One example of a socio tropic item is, "I find it difficult to say no to people." There are five possible responses-this appUes to m e (1) 0%, (2) 25%, (... |
expect to make progress in future sessions. The therapist, recognizing that this feed back indicated that the patient held very negative views about therapy, suggested that this be discussed at some length in the current ses sion. To get a sense of the patient's world, it is helpful to review briefly the patient's li... |
anything, it can suppress your ability to feel well after you stop taking the medi cation. You see, if the medication runs out, and you've sup pressed your body's own natural abilities to kill pain, you're going to go into withdrawal and be in a lot of discomfort. Then, you won't be able to get a refill of the dentis... |
a t i n g P a t i e n t s i n the Cognitive Model A J. ̂ s the cognitive therapy of substance abuse is a collaborative enterprise between therapist and patient, it is essential that patients gain a conceptual grasp of the key components in the model, such as understanding the associations and causal relation ships bet... |
of money he was spending on cocaine. Furthermore, he was not as productive because he began to miss days at work after cocaine binges. Later, when he tried to stop and he began to experience strong urges and cravings, Mr. C's beliefs centered on the cravings themselves. Some of these were, "I can't stand the craving," ... |
The initial goal in therapy was to help the patient develop better ways of coping with his anxiety about some of the urges and cravings that were reappearing. Although this was the primaty focus of therapy, it became obvious after several sessions (when the patient was less anxious about relapse) that he was also exper... |
so I can't possibly have a drinking problem." "My life's a mess anyway, so drags couldn't make it worse." "If I stop using, I'll get depressed." Individuals who abuse drugs are typically not attentive to their drag-related beliefs, often viewing their drug use as a function of extrinsic factors. For example, they attri... |
sad, 1. Write rational response 1. Re-rate belief 1. Actual event leading to preceded emotion(s) anxious/angry automatic thought(s) in automatic unpleasant emotion, or 2. Rate tielief in automatic etc. 2. Rate belief in rational thought(s) 2. Stream of thoughts, 0-100%. 2. Rate degree 0-100%. 0-100%. daydreams or recol... |
has been described by Moorey (1989), who suggests that drag abusers can learn to empa thize with important people in their lives by role-playing the part of a significant other who has been hurt by the patients' drag use. This exercise also serves to highlight the destruction that the drag abuse has wrought on the pat... |
patient to understand the various factors that contribute to craving, to reframe the experience, and to develop better ways to deal with this problem. Horvath (1988) has distinguished the phenomenon of cravings from urges, describing the former as the subjective sense (e.g., physi cal arousal, emotional arousal, "need... |
him from taking the first drink. Positive image replacement is a related technique to help cope with cravings and urges. For example, one patient experienced vety strong negative images about his current situation, that almost his entire family was Strang out on drags. His father was about to lose the house where the p... |
I'll be a nervous wreck all day. Evetyone will think I'm having a breakdown." "I'll never have a normal life again. I'm a slave to the drag. I simply have to have it to get through the day." "If I resist taking the drag now, I'll just need twice as much later to feel normal later. I might even overdose if that hap pen... |
She is calling m e all kinds of names: "lazy," "worthless," you know the list. Anyway, I feel this urge to ran, but I know there's nowhere to go. I want to hit her but of course I don't. I want to cty, but I wouldn't give her the satisfaction of seeing that she has hurt me. And finally I start thinking about going to M... |
led a drug-free lifestyle. Roland's drag use had led to numerous negative consequences in his life, yet his sense of helplessness in dealing with these mounting difficulties, coupled with his desire to "forget all his troubles" through the use of drags such as cocaine, perpetuated his drag-related lifestyle. These were... |
patient whose significant other is abusing drags, the belief that "if I stay off drugs I will have to give up the person I love and be all alone" may prime the patient to resume using drags. "Walter" had told his therapist many times that the love of his children was one of the only things he cared about in his life. T... |
a livelihood, (2) dealing with continuing cravings for cocaine (although they have diminished somewhat over time), and (3) rebuild ing his self-esteem, which deflated when he lost his high-profile lifestyle and had to look at himself without the masked feelings pro vided by cocaine. Another high socioeconomic status ... |
to remain drag free. Walter also experienced a significant degree of dysphoria in reaction to automatic thoughts about his legal statiis. In particular, he was frastrated and angered by the limitations set on his traveling by the terms of his parole. He believed that most of his problems had to do with his family membe... |
It was only after Ray began to experience significant physical malaise that he finally relented and contacted his doctor. Once there was open communication between patient, therapist, and physician, the next phase of treatment could begin. This entailed having Ray bring his insulin and needles to session, so that inten... |
crisis in a constractive manner. Yet another red flag for the therapist to notice and address is the patient's sounding or looking abnormally groggy, on the telephone or in person, especially during the middle of the day. One of our patients used the excuse that she had worked "the late shift" the day before a session ... |
patient's abstinence. For example, a patient who derived most of his self-worth from his job will prob ably react quite adversely to being laid off. He may then believe that he has nothing to lose (including his pride, which has already been damaged) by going out and getting "stoned." In this scenario, the patient mig... |
situation except [to engage in the illegal activities]." Violent Confrontation with the Therapist Another related crisis—that we have been fortunate enough rarely to have encountered at the Center for Cognitive Therapy—is one in which the patient threatens the therapist with bodily harm. If the threat is purely verbal,... |
Depression 229 which strategies to use initially, the therapist should consider t following questions: 1. Is the depression so painful that the emphasis should be on symptom relief rather than on an immediate confrontation of the using or drinking problem? 2. Is it likely that relieving some of the symptoms will reduce... |
pro cedure. Dealing with Suicidal Ideation The therapist needs to be alert to covert suicidal ten dencies and to deal with them frankly. A number of interventions are available (see Beck et al., 1979, Chapter 10). As in the preceding illustration, the therapist needs to address the underlying hopeless ness and negat... |
demonstrating to them that they are capable of utilizing their time constractively. Severely depressed patients may report a sense of "going through the motions" with the notion that there is little purpose in their activities. By planning the day with the 240 COGNITIVE THERAPY OF SUBSTANCE ABUSE therapist, they are of... |
exerts as powerful an influence on other people, particularly if the offended individual is in a position of strength. The patient assumes that punishment, whether in the form of a complaint, a reproach, or a tantrum, will help to shape the other person's future behavior properly. The implicit punishment will supposedl... |
patients per ceive themselves as the cause of the problem, they criticize themselves and feel even more helpless. Issue of Control The problem of control is particularly pertinent to the treatment of drug abusers since the therapy involves, in essence, the therapist's attempting to control patients' behavior. This pro... |
sarcastically and walked away in a huff. He was so upset that he felt incUned to go to the bar next door and have a few drinks. Much later he learned that one of his colleagues had picked up the package and delivered it to Bob's secretary. In the therapy session, Bob realized that he had "personalized" the problem—as t... |
booze." Such messages from his par ents taught Rick to have dichotomous beliefs about alcohol. For example, he believed, "If 1 am going to drink at all, 1 might as well get totally drunk." As a result of his extreme thoughts about alcohol, Rick had difficulty drinking in moderation. Rick's anxiety, loneliness, and iso... |
can at least calm myself to avoid having a panic attack." Rick's therapist also engaged him in assertiveness training in order to provide him with essential communication skills. SUMMARY Unnecessary or exaggerated anger takes its toll not only on other persons but also on the person who is angered. Sub stance abusers ... |
such that responsibilities toward others become ignored (symptom of narcissistic personality disorder), as well as numerous other behaviors. As we can see, the particular problems that accom pany the Axis I substance abuse disorder often look suspiciously like— and need to be distinguished from—full-blown Axis II diso... |
experience chronic cross-situational, exaggerated feelings of threat to their physical and psychological well-being, fall into this category. They maintain beliefs that make the use of drugs seem quite enticing, certainly more Personality Disorders 277 attractive than facing up to (and solving) real problems. Such bel ... |
will serve as the basis for necessary therapeutic confron tations. For example, a patient who missed an appointment with his thera pist gave the alibi that, since his driver's license had been revoked, he was dependent on others to drive him to his sessions. He claimed that his "driver" failed to show up; therefore t... |
thoughts that discour aged the patient from doing the assignment. Sometimes the responses are quite surprising, such as one patient who resisted reading a book that we had recommended, even to the point of purchasing it and then throwing it out when he got home. After much careful probing by the therapist, the patient... |
the antisocial drug-abusing patient, it is vitally impor tant to carefully nurture and make clinical use of the therapeutic relationship (see Beck et al., 1990; Layden et al., 1993; Young, 1990; Chapter 4, this volume, for more detailed explications). The all-or- none thinking style of the borderline patient often sho... |
have to believe that he was in an irreversible free fall. Instead, he could practice reciting some control beliefs that might help him to "pull out of the nose dive" (Shiffman, 1992) if confronted with similar situations in the future. Such control beliefs might be "If I stop now, I can show myself that I am stronger t... |
in spite of his cravings and urges. As Mike's case illus- frates, relapse prevention necessitates that patients learn to cope with both general life stressors (e.g., marital discord) and discomfort that specifically is related to temptation to use drugs (Wills & Shiffman, 1985). A long-term goal for Mike, essential to ... |
positive advantages from using that substance. In fact, such people typically minimize or ignore the disadvantages of their drug use, especially when in high-risk situations. The advantages-disadvantages analysis is a technique commonly used in cognitive therapy (see Chapter 9, this volume). This technique is particula... |
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any observed changes in the experience of those af- fected by the law can be attributed to the law itself or whether changes in experience merely reflect the environment in which the law was passed. If the latter were true, this would not be to say that the ADA was unnecessary, just that it did not have the dramatic im... |
to the multiple dimensions of the potential effect of the ADA on disabled workers, there are at least as many more ways in which the ADA influences the lives of all disabled Americans; these other outcomes are not the subject of the present discussion, but may in fact amount to a much greater overall impact than that f... |
premise, of course, is that identical disabled and nondis- abled workers should have the same labor market experience. This presupposition, which holds in making any comparisons across groups of workers (i.e., men versus women, or blacks versus whites), is more problematic in making comparisons across disability status... |
Further details of the history and provision of the Rehabilitation Act of 1973 can be found in Ellner and Bender (1980). 2. See Advisory Commission on Intergovernmental Relations (1989). 3. Data provided by the Roper Center for Public Opinion Research, University of Connecticut, Storrs, Connecticut. By 1999, 67 percent... |
CPS, 1981–2000 Difference in 0 probability -0.03 -0.06 -0.09 -0.12 -0.15 -0.18 -0.21 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 (a) ADA Enactment (a) (b) (c) (b) ADA Phase I (c) ADA Phase II 26 Hotchkiss and Rovba between 1994 and 2000. In other words, having a work-limiting dis- ability decreased an individual’... |
Force Participation and Employment Bivariate Probit with Selection Results, CPS, Combined Years 1981–2000 Labor force participation Employment Regressor equation equation Intercept 2.9988*** 0.6421*** (0.0152) (0.0215) Age (00) 13.3928*** 1.3265*** (0.0742) (0.1176) Age2 (0000) 16.6844*** 2.2159*** (0.0905) (0.1544)... |
1) P(ui1 uij) for j 2,3. Let Pj (2.8) F(X) for j 1,2, P j j P3 where F () is the cumulative distribution function, X are individual characteristics, and are parameter coefficients. This means that Pj F( jX) (2.9) G(X) for j 1,2. P j 3 1 F( jX) Because of the rules of summation, (2.10) P3 ... |
and Angrist (2001) and DeLeire (2000), their analysis confounds employment outcomes with labor supply effects. 17. See endnote 7. 18. The remaining parameter estimates are consistent with labor/leisure choice the- ory. For example, higher nonlabor income and being female lead to lower labor force participation, and the... |
this two-stage estimation approach is merely to obtain unbiased estimates of the coefficients in the wage equation, in- terpretation of those coefficients is not changed by controlling for selection. All of the parameter estimates in Table 3.1 are of the magnitude and direction one might expect from standard human capi... |
if the lower wages among disabled workers were the result of accommodation costs directly, then the wages of covered workers should fall relative to those of noncovered workers (whose employers are not required to incur the cost of accommodation). This is not what we see from the firm-size analysis. It appears that all... |
across the years; however, as Figure 3.3 shows, the proportion of nondisabled workers relative to disabled workers included in a pension plan has grown over the time period. In 1980, nearly 11 percent more of nondisabled workers were in- cluded in a pension plan than disabled workers were. This difference grew to 17 pe... |
This same strategy is followed by Baldwin and Johnson (2000) in their analysis of labor market discrimination against disabled workers. 14. The data generating this figure are found in Table C.5 in Appendix C. 15. This finding is consistent with the results reported by Hollenbeck and Kimmel (2001) that people with poor... |
percent confidence level. ** significant at the 95 percent confidence level. Hours of Work, Distribution, and Representation 81 estimated coefficients from the bivariate probit into a 5 percentage point greater probability of disabled workers being employed part-time than nondisabled workers, post-ADA relative to pre... |
selection into the labor market. Standard log wage equations are esti- mated separately for disabled and nondisabled workers. In the equa- tions for person i, ‘‘ft’’ denotes full-time, and ‘‘pt’’ denotes part-time: (4.9) ln Wift Xiftft ift ln Wipt Xiptpt ipt where lnWi is the natural log hourly wage of work... |
(1 / K ) emp t1 t j emp j / emp t j j1 0 otherwise where occupation (or industry) k is defined as high-growth if the per- centage change in employment between year t and t 1 for that occu- pation exceeds the average percentage change in employment in all occupations represented in the sample (K corresponds to t... |
or house, did not want to work full-time, full-time work week is less than 35 hours, or other. 9. Table C.7 (column 2) in Appendix C contains the marginal effects used to gener- ate Figure 4.3. 10. These results are consistent with those of Schur (2002), who finds that part-time and contingent work grows among the disa... |
of Baldwin and Schumacher (1999), who find that disabled workers are slightly more likely to experience an involuntary separation than nondisabled workers. Baldwin and Schumacher (1999) explore overall job turnover, where nonseparation plays a large role in the outcomes of workers analyzed; their results are primarily ... |
and search strategy differ- ences. This suggests that discrimination in hiring may not be of great concern, but it does not rule out that employers are more ‘‘careful’’ in screening disabled workers. In other words, it is possible that the characteristics of disabled and nondisabled workers are being valued equally, bu... |
posts is where lnrwageis is the natural log hourly real (1982–19841) wage of worker i in state s, Xi is a set of covariates for each person (demographic and job characteristics), disablei is equal to 1 if person i has a work-limiting disability, and posts is equal to 1 if person is observed in state s post-legisl... |
more generally, across observations) have often been referred to as ‘‘natural experiments’’ and have been applied by a number of researchers. For example, see Chay (1996) and Carrington, McCue, and Pierce (2000). 3. The strategy described here can be likened to a differences-in-differences (DD) methodology but is appli... |
preters).4 While this provision allows firms to be reimbursed for out- of-pocket expenses for accommodating disabled workers, the actual physical process of accommodating (i.e., evaluation of need and modi- 146 Hotchkiss fication of the environment) distracts the organization from its primary focus of business. One thi... |
pro- posal holds promise. SCREENING AND MATCHING The evidence of job separation and job search experiences of dis- abled workers presented in Chapter 5 is ambiguous. On the one hand, disabled workers search three weeks longer, on average, than similar nondisabled individuals before finding a job. On the other hand, job... |
required matching individ- uals in each of the outgoing rotation groups from March, April, May, and June with the supplemental questionnaire in March. The match rate was approxi- mately 90 percent for each month, except March, where the match rate, of course, was 100 percent. 5. The coding of the variable in the March ... |
Israel Deaconess Medical Cen- ter, Harvard Medical School, Division of Endocrinology, Diabe- tes and Metabolism, Boston, MA, USA Margo Hudson, MD Brigham and Women’s Hospital, Department of Endocrinology, Hypertension and Diabetes, Boston, MA, USA https://www.facebook.com/groups/2202763316616203 Contributors xv Gwendol... |
ples for ACTH and cortisol measurements should be obtained prior to the administration of steroids. The hypothalamic-pitu- itary-adrenal axis usually responds to critical illness with an increase in serum cortisol levels, and it is expected that a random cortisol level will similarly be elevated during the acute phase ... |
evaluation of pitu- itary function. On the other hand, some pituitary hormonal defi- ciencies may recover postoperatively, and such recovery can also be assessed as part of this evaluation. Studies have shown partial or complete recovery of pituitary function in up to 50% of patients. In most cases, patients will be tr... |
useful to measure gonadal and thyroid function in acutely ill patients. Similarly, the growth hor- mone axis is not assessed in hospitalized patients. Genetic Causes Mutations in several genes involved in pituitary development and differentiation, and hormone production and secretion are 2 Panhypopituitarism 21 associa... |
K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_3 28 A. Z. Feldman and P. Hartzband Assess Hormone Status Before Surgery if Possible – Ideally patient should be seen by endocrinology as outpatient prior to surgery. Intraoperative/Postoperative Steroids Patient with ... |
thyroid hormone preparations, antithyroid medication (methimazole or propylthiouracil [PTU]), exposure to iodinated contrast or iodine supplements, weight loss supplements, or other medications, including amiodarone, lithium, tyrosine kinase inhib- itors, and immune checkpoint inhibitors for cancer treatment. Performin... |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Respiratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Genitourinary . . . . . . . . . . . . . . . . . . ... |
type, dose, route, frequency of administration, and duration of therapy. An approach adopted by earlier studies is administration of an intravenous L-thyroxine 300–600 μg loading dose to replete the deficit in the total body thyroid hormone pool, followed by maintenance doses of 50–100 μg LT4 daily by intra- venous or ... |
levels can lead to abnor- mal values in a euthyroid patient. Several TSH isoforms can be expressed in humans that are not biologically active. Some labo- ratory assays may detect these isoforms leading to the reporting of abnormal TSH values that, however, do not correlate with hypothalamic- pituitary-thyroid dysfuncti... |
process Sarcoidosis 6 Abnormal Thyroid Stimulating Hormone Values That Are Not… 67 Table 6.2 (Continued) Histiocytosis X Iron overload (hemochromatosis, blood transfusions) Infectious diseases Tuberculosis Toxoplasmosis Fungal infections Table derived in part from Table 2 of Beck-Peccoz P, Rodari G, Giavoli C, Lania A.... |
have used to administer antithyroid medications. Studies range from healthy volunteers without thyroid dysfunction to case reports of critically ill patients with thyroid disease (Tables 7.1 and 7.2). These studies show that rectal administration of PTU and MMI in either enema or suppository is readily absorbed and wel... |
interfering with thyroxine absorption. Best Pract Res Clin Endocrinol Metab. 2009;23(6):781–92. Nabil N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab. 1982;54(1):180–1. Okamura Y, Shigemasa C, Tatsuhara T. Pharmacokinetics of methimazole in normal subjects and hype... |
(approximately the fraction of oral LT4 that is absorbed) of the oral dosing at 1.6 mcg/kg of body weight per day. The administration of intravenous liothyronine (T3) in addition to IV LT4 is optional. The rationale is that periph- eral T4 to T3 conversion is decreased in acutely ill patients, and IV T3 may accelerate ... |
scenario due to concern of exacer- bating thyrotoxicosis, for the reasons stated previously. As in the case of severe hypothyroidism, patients with severe hyperthyroidism remain high surgical risk despite optimal periop- erative management. A multidisciplinary approach with the sur- geon, anesthesiologist, and endocrin... |