Adapting, Implementing, and Maintaining a Group Cognitive Behavioral Therapy Program at an Inpatient Addiction Treatment Facility

Figures & data

Table 1 Measures and Related Outcomes Included in This Project

Outcome	Questions	Data Type
Barriers: Processes that are hindering the CBT manual and groups.	Three things working best in the clinical program Three things not working well in the clinical program Three things working the best with the CBT manual Three things not working well with the CBT manual	Qualitative
Feasibility: How easily the manual is used.	Tell me about how you use the manual What was your first exposure to the manual? How does it fit into your CBT style? Which of these sessions do you use the manual for? How much of the manual are you delivering for each session? How helpful do you find the manual? How does it fit into the clinical flow of this organization?	Qualitative
Useability: How easily the CBT manual can be used, from access to visual design.^Citation34	Content: The CBT manual makes its purpose completely evident The CBT manual does not include information or content that distracts from its purpose Word choice and style: The CBT manual uses common, everyday language Medical terms are used only to familiarize audience with the terms. When used, medical terms are defined in the CBT manual. Use of numbers: Numbers appearing in the CBT manual are clear and easy to understand Organization: The CBT manual breaks or “chunks” information into short sections The CBT manual sections have information headers The CBT manual presents information in a logical sequence The CBT manual provides a summary Layout & design: The CBT manual uses cues (eg, arrows, boxes, bullets, bold, larger font, highlighting) to draw attention to key points Use of visual aids: The CBT manual uses visual aids whenever possible to make content more easily understood (eg, illustration of a healthy portion size) The CBT manual’s visual aids reinforce rather than distract from the content The CBT manual’s visual aids have clear titles or captions The CBT manual uses illustrations and photographs that are clear and uncluttered The CBT manual uses simple tables with short and clear row and column headings	Quantitative
Appropriateness: Whether the CBT manual fits in at the facility.^Citation35	This CBT manual seems right This CBT manual seems suitable This CBT manual seems applicable This CBT manual seems like a good match between research and clinical goals This CBT manual seems well aligned with the goals of this organization	Quantitative
Acceptability: The ease with which clinicians incorporate the CBT manual into their workflow.^Citation35	This CBT manual meets my approval I have no objection to this CBT manual This CBT manual is appealing I like this CBT manual I welcome the use of this CBT manual	Quantitative
Burden: Complexity and cost of creating, maintaining, and monitoring the CBT manual.^Citation36	The CBT manual is clear and understandable. The CBT manual is easy to use.	Quantitative
Trialability: How well the CBT manual can be tested and altered without disruption.^Citation36	The CBT manual can be tested out with patients without disrupting the flow of the group. It is easy to try out the CBT manual and see how it performs.	Quantitative

Table 2 Changes Made to the CBT Manual per Results in Aim 1 (Evaluation)

Section	Changes
Introduction	Add a section of “how to use this manual” with clear instructions of what is for the clinician’s use, what is to be printed for patients, etc. Pull in principles of CBT that are currently buried in the individual CBT section Clarify that MI is done to support CBT principles
Overall (in each session)	Each session was structured to have the same sections, as outlined below: Pre-group needs Clinician flow and script Check-in Background Key concepts and skills to be learned Activity to do in the group and/or discussions to have Assign homework (that will be discussed in the next Process Group) Recap handout for patients that includes a brief summary of: title, purpose, key definitions / topics, skills learned A PowerPoint was created to assist with flow and focus General restructuring and organization including use of colors, spacing, bold, etc. Ensured language was inclusive and non-stigmatizing (eg, more non-alcohol examples, not using words such as “addict”)

Notes: Without having access to the manual, specific changes beyond what is listed is devoid of context and is unhelpful to readers. Specific changes made to each session of the manual are available by request.

Table 3 Overview of the Updated Group CBT Manual

Session	Key Topics	Key Skills
1: Coping with cravings and urges	Urge surfing Triggers Self-monitoring Getting through cravings	Recognizing triggers Mindfulness for cravings How to identify evidence for urge-related thoughts
2: Managing thoughts about drug and alcohol use	Connection between urges and negative/positive outcomes Cognitive analysis / restructuring “Negative tapes” “Stinkin’ thinkin’”	Identify ways to change the situation Identify ways to change thoughts Identify ways to change behavior
3: Problem solving	Problem recognition Appropriate situations to use problem solving skills	Learn appropriate ways to respond to a problem Consider various approaches Select best approach Assess effectiveness
4: Refusal skills	Refusal skill definition Situations where refusal skills may be necessary Risk of decreased social network	Learn the difference between avoidance and refusal Say no Suggest alternative Request behavior change Avoid excuses
5: Planning for emergencies and coping with a lapse	Rationale for coping with a lapse Awareness around a lapse and major life events	Create an emergency plan (remind self of recovery goals; remind self of tools / strategies; call emergency contacts; keep self accountable) Identify events that could lead to a lapse
6: Seemingly irrelevant decisions	Definition of seemingly irrelevant decisions	Review thoughts, behaviors, and decision that may lead to a high-risk situation Learn tools to articulate and think through decisions
7: Anger management – part 1	Clarify what anger is Outcomes of anger	Distinction between feeling an emotion and behavioral consequences Behavioral reactions can be constructive or destructive Concept of a behavior chain
8: Anger management – part 2	How to change thoughts How to change behaviors	Reinforce refusal skills learned previously Role play strategies (leave the situation; take time to cool down; assertiveness; analyze how to cope; talk rationally) Practice changing a negative thought into a positive thought
9: Managing negative thinking	How negative moods relate to use Consequences of negative thinking Categories of negative thoughts Positive thoughts	Identifying negative thoughts and cognitive distortions (unrealistic goals; catastrophizing; overgeneralization; expecting the worst; self-put-downs; black-and-white thinking) Learn options for catching and stopping a negative thought pattern (recall good things; challenge irrational beliefs; de-catastrophize; relabel; hopefulness statements; blame the event; stay on task; self-reinforcement) Behavior chain refresher
10: Assertiveness and communication skills training – part 1	Why assertiveness is helpful People’s rights Interpersonal styles	Identify types of interpersonal styles Learn to recognize different interpersonal styles Introduce ways to control reactions and communication in an upsetting situation
11: Assertive and communication skills training – part 2	Practice assertiveness interpersonal style Connect communication to cognition and behavior	Learn how to be respectfully assertive (think before you speak; be specific and direct; body language; give full attention; compromise; restate the request) Role play being assertive
12: Increasing social and recreational activities	Importance of a strong social network Relationship between social support and recovery / relapse	Steps to creating a strong network (who; what; where; how) Identify how social network has been impacted by substance use Learn how to feel comfortable in social situations

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