Embracing Change: Mapping Problems and Solutions in Troubled Times—The South Carolina Cognitive Behavior Therapy Training Initiative

By Pamela Woll, Southeast Addiction Technology Transfer Center

Like much of the substance use disorders (SUD) treatment field, South Carolina’s providers experienced the early impact of COVID-19 as a steep rise in the need for services combined with a steep decline in capacity to meet that need. In communities, fear, isolation, loneliness, and financial stress escalated, while social support diminished. Traditionally marginalized populations were disproportionately affected.

Many individuals were already deeply troubled long before the pandemic hit. For decades, more and more people had been: 

• suffering the effects of early, chronic, intergenerational, historical, and/or racial trauma; 
• deeply affected by inequities and disparities in the social determinants of health, diminishing their resilience and resources;
• afflicted with multiple substance use disorders, mental health conditions, and chronic physical health conditions; and/or 
• bearing the social, psychological, and financial burdens of years spent in the foster care, juvenile justice, and/or criminal justice systems, or on the street.

 Meanwhile, the pandemic made in-person services more dangerous, so the field experienced severe reductions in resources, treatment capacity, time to connect with clients, and face-to-face mentorship and peer support for staff. Clinicians needed training in interventions that would: 

• be easily transferrable to Zoom and telehealth; allow practitioners to make more progress in shorter sessions; 
• provide coping skills to help clients solve problems even with reduced clinical and social support;
• and include clinical supervision, booster sessions, mentorship, training of trainers, and support for fidelity.

One category of interventions that fit all those criteria was Cognitive Behavior Therapy (CBT), a well-supported evidence-based approach that helps people learn to work with the thoughts, feelings, and actions that keep them stuck in counterproductive patterns (Carroll & Kulik, 2017, p. 847).

The South Carolina Cognitive Behavior Therapy Training Initiative

In 2020, Roberta Braneck, State Opioid Response Director for South Carolina’s Department of Alcohol and Other Drug Abuse Services (DAODAS), requested intensive training on CBT across the statewide system. The Southeast Addiction Technology Transfer Center (SATTC) responded through the efforts of James Campbell, LPC, LAC, MAC, AADC, Training and Technical Assistance Manager.

Together they identified a trainer for the series, R. Trent Codd, III, EdS, LCMHC, Executive Director, CBT Center of Western North Carolina. The team developed a strategic training plan, using implementation science principles to foster sustainability and maintain clinical gains far beyond the end of the formal initiative.

The series began in the first five months of 2021, with multiple sessions in each step of a process that included:

• Initial Training (four hours), Skill-Building Sessions (six hours), 
• Clinical Supervision Sessions (eight hours), 
• Booster Sessions (four hours), and 
• Training of Trainers (four hours).

 A total of 170 participants logged into the initial general content session, with subsequent sessions tailored to smaller groups to increase opportunities for discussion and skill practice. 

 A Focus on Conceptualization

The training subject might not be on the cutting edge, but the trainer’s approach has been innovative and well-tailored to our contemporary challenges. According to Codd, the series has focused, not on the activities that most people think of when they hear “CBT,” but on the conceptualizations that guide clinical decision making.

“I’m a big believer that the conceptualization is one of the biggest things that defines CBT,” Codd said. “The interventions are almost secondary to how people conceptualize what is maintaining the client’s problems, and how they use that conceptualization to develop their treatment targets. If you focus on the technique itself, that’s just the shiny object. Outcomes are really related to the conceptualization, not the interventions.”

The CBT conceptualization process helps clinicians encompass the many thoughts, feelings, and actions that clients disclose, allowing them to isolate those that offer the best opportunities for intervention. If clinicians work in teams, conceptualization can help the team create a shared “map” for more effective communication.

According to Codd, one of the most important reasons for a focus on conceptualization is the complexity of the internal, relational, and environmental challenges that many clients are facing. “Conceptualization tells the clinician how to modify the treatment based on all these factors,” he said. “It’s not a magic pill, but it gives clinicians a good working map that they can flexibly adapt across a wide range of factors.”

Participant evaluations and individual feedback showed strong positive responses to Phase One, though the most valuable data will not be available until the Initiative’s next phase. It starts with a six-hour CBT Fidelity Training in October 2022, with registration still open to South Carolina practitioners.

Reference

Carroll, K.M. and Kiluk, B.D. (2017). Cognitive behavioral interventions for alcohol and drug use disorders: Through the Stage Model and back again. Psychology of Addictive Behaviors, 31(8), 847-861.