CBT for drug abuse

Chapter1

CognitiveBehavioralTherapy:AnOverview

Cognitivebehavioral coping skills treatment (CBT) is a shortterm, focused approach to helping

cocainedependent individuals (In this manual, the term cocaine abuser or cocainedependent
individualisusedtorefertoindividualswhomeetDSMIVcriteriaforcocaineabuseordependence.)
become abstinent from cocaine and other substances. The underlying assumption is that learning
processes play an important role in the development and continuation of cocaine abuse and
dependence.Thesesamelearningprocessescanbeusedtohelpindividualsreducetheirdruguse.

Verysimplyput,CBTattemptstohelppatientsrecognize,avoid,andcope.Thatis,RECOGNIZEthe
situationsinwhichtheyaremostlikelytousecocaine,AVOIDthesesituationswhenappropriate,and
COPEmoreeffectivelywitharangeofproblemsandproblematicbehaviorsassociatedwithsubstance
abuse.

WhyCBT?

SeveralimportantfeaturesofCBTmakeitparticularlypromisingasatreatmentforcocaineabuseand
dependence:

CBTisashortterm,comparativelybriefapproachwellsuitedtotheresourcecapabilitiesofmost
clinicalprograms.

CBThasbeenextensivelyevaluatedinrigorousclinicaltrialsandhassolidempiricalsupportas
treatmentforcocaineabuse.Inparticular,evidencepointstothedurabilityofCBT'seffectsaswellas
itseffectivenesswithsubgroupsofmoreseverelydependentcocaineabusers(seeappendixB).

CBTisstructured,goaloriented,andfocusedontheimmediateproblemsfacedbycocaineabusers
enteringtreatmentwhoarestrugglingtocontroltheircocaineuse.

CBTisaflexible,individualizedapproachthatcanbeadaptedtoawiderangeofpatientsaswellas
avarietyofsettings(inpatient,outpatient)andformats(group,individual).

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CBT is compatible with a range of other treatments the patient may receive, such as
pharmacotherapy.

CBT'sbroadapproachencompassesseveralimportantcommontasksofsuccessfulsubstanceabuse
treatment.

ComponentsofCBT

CBThastwocriticalcomponents:

functionalanalysis
skillstraining

FunctionalAnalysis

Foreachinstanceofcocaineuseduringtreatment,thetherapistandpatientdoafunctionalanalysis,
thatis,theyidentifythepatient'sthoughts,feelings,andcircumstancesbeforeandafterthecocaine
use. Early in treatment, the functional analysis plays a critical role in helping the patient and
therapistassessthedeterminants,orhighrisksituations,thatarelikelytoleadtococaineuseand
provides insights into some of the reasons the individual may be using cocaine (e.g., to cope with
interpersonaldifficulties,toexperienceriskoreuphorianototherwiseavailableinthepatient'slife).
Laterintreatment, functional analysesof episodes of cocaineuse may identifythosesituations or
statesinwhichtheindividualstillhasdifficultycoping.

SkillsTraining

CBTcanbethoughtofasahighlyindividualizedtrainingprogramthathelpscocaineabusersunlearn
oldhabitsassociatedwithcocaineabuseandlearnorrelearnhealthierskillsandhabits.Bythetime
thelevelofsubstanceuseissevereenoughtowarranttreatment,patientsarelikelytobeusingcocaine
astheirsinglemeansofcopingwithawiderangeofinterpersonalandintrapersonalproblems.This
mayoccurforseveralreasons:

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Theindividualmayhaveneverlearnedeffectivestrategiestocopewiththechallengesandproblems
ofadultlife,aswhensubstanceusebeginsduringearlyadolescence.

Althoughtheindividualmayhaveacquiredeffectivestrategiesatonetime,theseskillsmayhave
decayedthroughrepeatedrelianceonsubstanceuseasaprimarymeansofcoping.Thesepatientshave
essentiallyforgotteneffectivestrategiesbecauseof chronicinvolvementina drugusinglifestylein
whichthebulkoftheirtimeisspentinacquiring,using,andthenrecoveringfromtheeffectsofdrugs.

Theindividual'sabilitytouseeffectivecopingstrategiesmaybeweakenedbyotherproblems,such
ascocaineabusewithconcurrentpsychiatricdisorders.Becausecocaineabusersareaheterogeneous
groupandtypicallycometotreatmentwithawiderangeofproblems,skillstraininginCBTismadeas
broadaspossible.Thefirstfewsessionsfocusonskillsrelatedtoinitialcontrolofcocaineuse(e.g.,
identificationofhighrisksituations,copingwiththoughtsaboutcocaineuse).Oncethesebasicskills
aremastered,trainingisbroadenedtoincludearangeofotherproblemswithwhichtheindividual
may have difficulty coping (e.g., social isolation, unemployment). In addition, to strengthen and
broaden the individual's range of coping styles, skills training focuses on both intrapersonal (e.g.,
copingwithcraving)andinterpersonal(e.g.,refusingoffersofcocaine)skills.Patientsaretaughtthese
skillsasbothspecificstrategies(applicableinthehereandnowtocontrolcocaineuse)andgeneral
strategiesthatcanbeappliedtoavarietyofotherproblems.Thus,CBTisnotonlygearedtohelping
eachpatientreduceandeliminatesubstanceusewhileintreatment,butalsotoimpartingskillsthat
canbenefitthepatientlongaftertreatment.

CriticalTasks

CBT addresses several critical tasks that are essential to successful substance abuse treatment
(RounsavilleandCarroll1992).

Foster the motivation for abstinence. An important technique used to enhance the patient's
motivationtostopcocaineuseistodoadecisionalanalysiswhichclarifieswhattheindividualstands
toloseorgainbycontinuedcocaineuse.

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Teachcopingskills.ThisisthecoreofCBTtohelppatientsrecognizethehighrisksituationsin
whichtheyaremostlikelytousesubstancesandtodevelopother,moreeffectivemeansofcopingwith
them.

Changereinforcementcontingencies.Bythetimetreatmentissought,manypatientsspendmostof
theirtimeacquiring,using,andrecoveringfromcocaineusetotheexclusionofotherexperiencesand
rewards.InCBT,thefocusisonidentifyingandreducinghabitsassociatedwithadrugusinglifestyle
bysubstitutingmoreenduring,positiveactivitiesandrewards.

Fostermanagementofpainfulaffects.Skillstrainingalsofocusesontechniquestorecognizeand
copewithurgestousecocaine;thisisanexcellentmodelforhelpingpatientslearntotolerateother
strongaffectssuchasdepressionandanger.

Improveinterpersonalfunctioningandenhancesocialsupports.CBTincludestraininginanumber
ofimportantinterpersonalskillsandstrategiestohelppatientsexpandtheirsocialsupportnetworks
andbuildenduring,drugfreerelationships.

ParametersofCBT

Format

AnindividualformatispreferredforCBTbecauseitallowsforbettertailoringoftreatmenttomeetthe
needs of specific patients. Patients receive more attention and are generally more involved in
treatment when they have the opportunity to work with and build a relationship with a single
therapist over time. Individual treatment affords greater flexibility in scheduling sessions and
eliminatestheproblemofeitherhavingtodelivertreatmentina"rollingadmissions"formatorasking
patientstowaitseveralweeksuntilsufficientnumbersofpatientsarerecruitedtoformagroup.Also,
the comparatively high rates of retention in programs and studies may reflect, in part, particular
advantagesofindividualtreatment.

However,anumberofresearchersandclinicianshaveemphasizedtheuniquebenefitsofdelivering
treatmenttosubstanceusersinthegroupformat(e.g.,universality,peerpressure).Itisrelatively

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straightforwardtoadaptthetreatmentdescribedinthismanualforgroups.Thisgenerallyrequires
lengtheningthesessionsto90minutestoallowallgroupmemberstohaveanopportunitytocomment
on their personal experiences in trying out skills, give examples, and participate in roleplaying.
Treatmentwillalsobemorestructuredinagroupformatbecauseoftheneedtopresentthekeyideas
andskillsinamoredidactic,lessindividualizedformat.

Length

CBThasbeenofferedin12to16sessions,usuallyover12weeks.Thiscomparativelybrief,shortterm
treatmentisintendedtoproduceinitialabstinenceandstabilization.Inmanycases,thisissufficientto
bring about sustained improvement for as long as a year after treatment ends. Preliminary data
suggestthatpatientswhoareabletoattain3ormoreweeksofcontinuousabstinencefromcocaine
during the 12week treatment period are generally able to maintain good outcome during the 12
monthsaftertreatmentends.Formanypatients,however,brieftreatmentisnotsufficienttoproduce
stabilization or lasting improvement. In these cases, CBT is seen as preparation for longer term
treatment. Further treatment is recommended directly when the patient requests it or when the
patient has not been able to achieve 3 or more weeks of continuous abstinence during the initial
treatment. We are currently evaluating whether additional booster sessions of CBT during the 6
months following the initial treatment phase improves outcome. The maintenance version of CBT
focusesonthefollowing:

identifyingsituations,affects,andcognitionsthatremainproblematicforpatientsintheireffortsto
maintainabstinenceorwhichemergeaftercessationorreductionofcocaineuse.

maintaininggainsthroughsolidifyingthemoreeffectivecopingskillsandstrategiesthesubjecthas
implemented.

encouragingpatientinvolvementinactivitiesandrelationshipsthatareincompatiblewithdrug
use. Rather than introducing new material or skills, the maintenance version of CBT focuses on
broadening and mastering the skills to which the patient was exposed during the initial phase of
treatment.

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Setting

Treatmentisusuallydeliveredonanoutpatientbasisforseveralreasons:

CBTfocusesonunderstandingthedeterminantsofsubstanceuse,andthisisbestdoneinthe
contextofthepatient'sdaytodaylife.Byunderstandingwhothepatientsare,wheretheylive,and
howtheyspendtheirtime,therapistscandevelopmoreelaboratefunctionalanalyses.

Skills training is most effective when patients have an opportunity to practice new skills and
approacheswithinthecontextoftheirdailyroutine,learnwhatdoesanddoesnotworkforthem,and
discussnewstrategieswiththetherapist.

Patients

CBT has been evaluated with a broad range of cocaine abusers. The following are generally not
appropriateforCBTdeliveredonanoutpatientbasis:

Thosewhohavepsychoticorbipolardisordersandarenotstabilizedonmedication

Thosewhohavenostablelivingarrangements

Thosewhoarenotmedicallystable(asassessedbyapretreatmentphysicalexamination)

Thosewhohaveotherconcurrentsubstancedependencedisorders,withtheexceptionofalcoholor
marijuanadependence(althoughweassesstheneedforalcoholdetoxificationintheformer)

Nosignificantdifferenceshavebeenfoundinoutcomeorretentionforpatientswhoseektreatment
becauseofcourtorprobationpressureandthosewhohaveDSMIVdiagnosesofantisocialpersonality
disorderorotherAxisIIdisorders,norhasoutcomevariedbypatientrace/ethnicityorgender.

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CompatibilityWithAdjunctiveTreatments

CBTishighlycompatiblewithavarietyofothertreatmentsdesignedtoaddressarangeofcomorbid
problemsandseveritiesofcocaineabuse:

Pharmacotherapyforcocaineuseand/orconcurrentpsychiatricdisorders

SelfhelpgroupssuchasCocaineAnonymous(CA)andAlcoholicsAnonymous(AA)

Familyandcouplestherapy

Vocationalcounseling,parentingskills,andsoonWhenCBTisprovidedaspartofalargertreatment
package, it is essential for the CBT therapist to maintain close and regular contact with other
treatmentproviders.

ActiveIngredientsofCBT

All behavioral or psychosocial treatments include both common and unique factors or "active
ingredients." Common factors are those dimensions of treatment that are found in most
psychotherapies the provision of education, a convincing rationale for the treatment, enhancing
expectationsofimprovement,provisionofsupportandencouragement,and,inparticular,thequality
of the therapeutic relationship (Rozenzweig 1936; Castonguay 1993). Unique factors are those
techniquesandinterventionsthatdistinguishorcharacterizeaparticularpsychotherapy.

CBT, like most therapies, consists of a complex combination of common and unique factors. For
example, in CBT mere delivery of skills training without grounding in a positive therapeutic
relationship leads to a dry, overly didactic approach that alienates or bores most patients and

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ultimatelyhastheoppositeeffectofthatintended.ItisimportanttorecognizethatCBTisthoughtto
exertitseffectsthroughthisintricateinterplayofcommonanduniquefactors.

A major task of the therapist is to achieve an appropriate balance between attending to the
relationship and delivering skills training. For example, without a solid therapeutic alliance, it is
unlikelythatapatientwillstayintreatment,besufficientlyengagedtolearnnewskills,orshare
successes and failures in trying new approaches to old problems. Conversely, empathic delivery of
skillstrainingastoolstohelppatientsmanagetheirlivesmoreeffectivelymayformthebasisofa
strongworkingalliance.

EssentialandUniqueInterventions

ThekeyactiveingredientsthatdistinguishCBTfromothertherapiesandthatmustbedeliveredfor
adequateexposuretoCBTincludethefollowing:

Functionalanalysesofsubstanceabuse

Individualizedtraininginrecognizingandcopingwithcraving,managingthoughtsaboutsubstance
use,problemsolving,planningforemergencies,recognizingseeminglyirrelevantdecisions,andrefusal
skills

Examinationofthepatient'scognitiveprocessesrelatedtosubstanceuse

Identificationanddebriefingofpastandfuturehighrisksituations

Encouragementandreviewofextrasessionimplementationofskills

Practiceofskillswithinsessions

RecommendedButNotUniqueInterventions

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Interventionsorstrategiesthatshouldbedelivered,asappropriate,duringthecourseofeachpatient's
treatmentbutthatarenotnecessarilyuniquetoCBTincludethoselistedbelow.

Discussing,reviewing,andreformulatingthepatient'sgoalsfortreatment

Monitoringcocaineabuseandcraving

Monitoringothersubstanceabuse

Monitoringgeneralfunctioning

Exploringpositiveandnegativeconsequencesofcocaineabuse

Exploringtherelationshipbetweenaffectandsubstanceabuse

Providingfeedbackonurinalysisresults

Settingtheagendaforthesession

Makingprocesscommentsasindicated

Discussingadvantagesofanabstinencegoal

Exploringthepatient'sambivalenceaboutabstinence

Meetingresistancewithexplorationandaproblemsolvingapproach

Supportingpatientefforts

Assessingleveloffamilysupport

Explainingthedistinctionbetweenaslipandarelapse

Includingfamilymembersorsignificantothersinuptotwosessions

AcceptableInterventions

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FourinterventionsarenotrequiredorstronglyrecommendedaspartofCBTbutarenotincompatible
withthisapproach:

Exploringselfhelpinvolvementasacopingskill

Identifyingmeansofselfreinforcementforabstinence

Exploringdiscrepanciesbetweenapatient'sstatedgoalsandactions

Elicitingconcernsaboutsubstanceabuseandconsequences

InterventionsNotPartofCBT

Interventionsthat aredistinctive of dissimilar approaches totreatment and less consistent with a

cognitivebehavioralapproachincludethoselistedbelow.

Extensiveselfdisclosurebythetherapist

Useofaconfrontationalstyleoraconfrontationofdenialapproach

Requiringthepatienttoattendselfhelpgroups

Extendeddiscussionof12steprecovery,higherpower,"BigBook"philosophy

Useofdiseasemodellanguageorslogans

Extensiveexplorationofinterpersonalaspectsofsubstanceabuse

Extensivediscussionorinterpretationofunderlyingconflictsormotives

Provisionofdirectreinforcementforabstinence(e.g.,vouchers,tokens)

InterventionsassociatedwithGestalttherapy,structuralinterventions,rationalemotivetherapy,or
otherprescriptivetreatmenttechniques

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CBTComparedtoOtherTreatments

Itisofteneasiertounderstandatreatmentintermsofwhatitisnot.ThissectiondiscussesCBTfor
cocaineabuseintermsofitssimilaritiestoanddifferences fromotherpsychosocialtreatmentsfor
substanceabuse.

SimilarApproaches

CBTismostsimilartoothercognitiveandbehavioraltherapies,allofwhichunderstandsubstance
abuseintermsofitsantecedentsandconsequences.TheseincludeBeck'sCognitiveTherapy(Becket
al.1991)andtheCommunityReinforcementApproach(CRA)(Azrin1976;MeyersandSmith1995),
andparticularly,Marlatt'sRelapsePrevention(MarlattandGordon1985),fromwhichitwasadapted.

CognitiveTherapy

Cognitivetherapy"isasystemofpsychotherapythatattemptstoreduceexcessiveemotionalreactions
andselfdefeatingbehaviorbymodifyingthefaultyorerroneousthinkingandmaladaptivebeliefsthat
underliethesereactions"(Becketal.1991,p.10).

CBTisparticularlysimilartocognitivetherapyinitsemphasisonfunctionalanalysisofsubstance
abuseand identifyingcognitionsassociatedwithsubstanceabuse.Itdiffersfromcognitivetherapy
primarilyintermsofemphasisonidentifying,understanding,andchangingunderlyingbeliefsabout
theselfandtheselfinrelationshiptosubstanceabuseasaprimaryfocusoftreatment.Rather,inthe
initialsessionsofCBT,thefocusisonlearningandpracticingavarietyofcopingskills,onlysomeof
whicharecognitive.

InCBT,initialstrategiesstressbehavioralaspectsofcoping(e.g.,avoidingorleavingthesituation,
distraction,andsoon)ratherthan"thinking"one'swayoutofasituation.Incognitivetherapy,the
therapist'sapproachtofocusingoncognitionsisSocraticandbasedonleadingthepatientthrougha
series of questions; in CBT, the approach is somewhat more didactic. In cognitive therapy, the

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treatmentisthoughttoreducesubstanceusebychangingthewaythepatientthinks;inCBT,the
treatmentisthoughttoworkbychangingwhatthepatientdoesandthinks.

CommunityReinforcementApproach

TheCommunityReinforcementApproach(CRA)"isabroadspectrumbehavioraltreatmentapproach
forsubstanceabuseproblems...thatutilizessocial,recreational,familial,andvocationalreinforcersto
aidclientsintherecoveryprocess"(MeyersandSmith1995,p.1).

Thisapproachusesavarietyofreinforcers,oftenavailableinthecommunity,tohelpsubstanceusers
moveintoadrugfreelifestyle.TypicalcomponentsofCRAtreatmentinclude(1)functionalanalysisof
substance use, (2) social and recreational counseling, (3) employment counseling, (4) drug refusal
training, (5) relaxation training, (6) behavioral skills training, and (7) reciprocal relationship
counseling.IntheverysuccessfulapproachdevelopedbyHigginsandcolleaguesforcocainedependent
individuals(Higginsetal.1991,1994),acontingencymanagementcomponentisaddedthatprovides
vouchersforstayingintreatment.Thevouchersareredeemableforitemsconsistentwithadrugfree
lifestyleandarecontingentuponthepatient'sprovisionofdrugfreeurinetoxicologyspecimens.

Thus,CRAandCBTshareanumberofcommonfeatures,mostimportantly,thefunctionalanalysisof
substanceabuseandbehavioralskillstraining.CBTdiffersfromCRAinnottypicallyincludingthe
direct provision of either contingency management (vouchers) for abstinence or intervening with
patientsoutsideoftreatmentsessionsorthetreatmentclinic,asdocommunitybasedinterventions
(joborsocialclubs).

MotivationalEnhancementTherapy

CBThassomesimilaritiestoMotivationalEnhancementTherapy(MET)(MillerandRollnick1992).
MET"isbasedonprinciplesofmotivationalpsychologyandisdesignedtoproducerapid,internally
motivatedchange.Thistreatmentstrategydoesnotattempttoguideandtraintheclient,stepbystep,

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through recovery, but instead employs motivational strategies to mobilize the client's own change
resources"(Milleretal.1992,p.1).

CBTandMETshareanexploration,earlyinthetreatmentprocess,ofwhatpatientsstandtogainor
lose through continued substance use as a strategy to build patients' motivation to change their
substanceabuse.

CBTandMETdifferprimarilyinemphasisonskilltraining.InMET,responsibilityforhowpatients
aretogoaboutchangingtheirbehaviorislefttothepatients;itisassumedthatpatientscanuse
available resources to change behavior and training is not required. CBT theory maintains that
learningandpracticeofspecificsubstancerelatedcopingskillsfosterabstinence.Thus,becausethey
focusondifferentaspectsofthechangeprocess(METonwhypatientsmaygoaboutchangingtheir
substance use, CBT on how patients might do so), these two approaches may be seen as
complementary.Forexample,forapatientwithlowmotivationandfewresources,aninitialfocuson
motivational strategiesbeforeturningtospecific copingskills (MET beforeCBT) maybe the most
productiveapproach.

DissimilarApproaches

Whileitisimportanttorecognizethatallpsychosocialtreatmentsfordrugabuseshareanumberof
featuresand mayoverlaporcloselyresembleoneanotherinseveralways,someapproaches differ
significantlyfromCBT.

TwelveStepFacilitation

CBT is dissimilar to 12step, or diseasemodel approaches, in a number of ways. TwelveStep

Facilitation(TSF)(Nowinskietal.1994)"isgroundedintheconceptofalcoholismasaspiritualand
medical disease. The content of this intervention is consistent with the 12 Steps of Alcoholics
Anonymous(AA),withprimaryemphasisgiventoSteps1through5.Inadditiontoabstinencefromall
psychoactivesubstances,amajorgoalofthetreatmentistofostertheparticipant'scommitmenttoand
participationinAAorCocaineAnonymous(CA).Participantsareactivelyencouragedtoattendself

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helpmeetingsandtomaintainjournalsoftheirAA/CAattendanceandparticipation"(ProjectMATCH
ResearchGroup1993).

WhileCBTandTSFsharesomeconceptsforexample,thesimilaritybetweenthediseasemodel's
"people, places, and things" and CBT's "highrisk situations" there are a number of important
differences.Thediseasemodelapproachesaregroundedinaconceptofaddictionasadiseasethatcan
becontrolledbutnevercured.InCBT,substanceabuseisalearnedbehaviorthatcanbemodified.The
emphasisindiseasemodelapproachesisonpatients'lossofcontroloversubstanceabuseandother
aspectsoftheirlives;theemphasisinCBTisonselfcontrolstrategies,thatis,whatpatientscandoto
recognizetheprocessesandhabitsthatunderlieandmaintainsubstanceuseandwhatcanbedoneto
changethem.

Similarly,themajorchangeagentindiseasemodelapproachesisinvolvementwiththefellowshipof
AA/CAandworkingthe12Steps,thatis,thewaytocopewithnearlyalldrugrelatedproblemsisby
goingtomeetingsordeepeninginvolvementwithfellowshipactivities.InCBT,copingstrategiesare
muchmoreindividualizedandbasedonthespecifictypesofproblemsencounteredbypatientsand
theirusualcopingstyle.

WhileattendingAAorCAmeetingsisnotrequiredorstronglyencouragedinCBT,somepatientsfind
attendingmeetingsveryhelpfulintheireffortstobecomeorremainabstinent.CBTtherapiststakea
neutralstancetoattendingAA;theyencouragepatientstoviewgoingtomeetingsasa,notthecoping
strategy.TheCBTtherapistmayexplorewiththepatientthewaysinwhichgoingtoameetingwhen
facedwith strongurgestousemaybeaveryuseful andimportant strategytocopewithcraving;
however, therapists will also encourage patients to think about and have ready a range of other
strategiesaswell.

InterpersonalPsychotherapy

CBTisalsodifferentfrominterpersonalandshorttermdynamicapproachessuchasInterpersonal
Psychotherapy(IPT)(RounsavilleandCarroll1993)orSupportiveExpressiveTherapy(SE)(Luborsky
1984).IPT"isbasedontheconceptthatmanypsychiatricdisorders,includingcocainedependence,are

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intimatelyrelatedtodisordersininterpersonalfunctioningwhichmaybeassociatedwiththegenesis
or perpetuation of the disorder. IPT, as adapted for cocaine dependence, has four definitive
characteristics: (1) adherence to a medical model of psychiatric disorders, (2) focus on patients'
difficultiesincurrentinterpersonalfunctioning,(3)brevityandconsistencyoffocus,and(4)useofan
exploratorystancebythetherapistthatissimilartothatofsupportiveandexpressivetherapies."

IPT differs from CBT in several ways: CBT has a structured approach, whereas IPT is more
exploratory.ExtensiveeffortsaremadeinCBTtoteachandencouragepatientstouseskillstocontrol
theirsubstanceabuse,whileinthemoreexploratoryIPTapproaches,substanceabuseisviewedasa
symptomofotherdifficultiesandconflictsandthusmaydeallessdirectlywiththesubstanceuse.

Chapter2

BasicPrinciplesofCBT

CBT is collaborative. The patient and therapist consider and decide together on the appropriate
treatmentgoals,thetypeandtimingofskillstraining,whetherasignificantotherisbroughtintosome
of the sessions, the nature of outside practice tasks, and so on. Not only does this foster the
developmentofagoodworkingrelationshipandavoidanoverlypassivestancebythetherapist,butit
alsoassuresthattreatmentwillbemostusefulandrelevanttothepatient.

LearnedBehavior

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CBTisbasedonsociallearningtheory.Itisassumedthatanimportantfactorinhowindividualsbegin
touseandabusesubstancesisthattheylearntodoso.Theseveralwaysindividualsmaylearntouse
drugsincludemodeling,operantconditioning,andclassicalconditioning.

Modeling

Peoplelearnnewskillsbywatchingothersandthentryingitthemselves.Forexample,childrenlearn
languagebylisteningtoandcopyingtheirparents.Thesamemaybetrueformanysubstanceabusers.
By seeing their parents use alcohol, individuals may learn to cope with problems by drinking.
Teenagersoftenbeginsmokingafterwatchingtheirfriendsusecigarettes.So,too,maysomecocaine
abusersbegintouseafterwatchingtheirfriendsorfamilymembersusecocaineorotherdrugs.

OperantConditioning

Laboratory animals will work to obtain the same substances that many humans abuse (cocaine,
opiates,andalcohol)becausetheyfindexposuretothesubstancepleasurable,thatis,reinforcing.Drug
usecanalsobeseenasbehaviorthatisreinforcedbyitsconsequences.Cocainemaybeusedbecauseit
changesthewayapersonfeels(e.g.,powerful,energetic,euphoric,stimulated,lessdepressed),thinks
(Icandoanything,IcanonlygetthroughthisifIamhigh),orbehaves(lessinhibited,moreconfident).

The perceived positive (and negative) consequences of cocaine use vary widely from individual to
individual.Peoplewithfamilyhistoriesofsubstanceabuse,ahighneedforsensationseeking,orthose
withaconcurrentpsychiatricdisordermayfindcocaineparticularlyreinforcing.Itisimportantthat
cliniciansunderstandthatanygivenindividualusescocaineforimportantandparticularreasons.

ClassicalConditioning

Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with
another(e.g.,thepresentationoffood)couldelicitareliableresponse(e.g.,adogsalivating).Overtime,
cocaineabusemaybecomepairedwithmoneyorcocaineparaphernalia,particularplaces(bars,places
tobuy drugs), particular people (drugusing associates, dealers), times of dayor week (after work,
weekends), feeling states (lonely, bored), and so on. Eventually, exposure to those cues alone is
sufficienttoelicitveryintensecravingsorurgesthatareoftenfollowedbycocaineabuse.

FunctionalAnalysis

ThefirststepinCBTishelpingpatientsrecognizewhytheyareusingcocaineanddeterminingwhat
they need to do to either avoid or cope with whatever triggers their use. This requires a careful
analysisofthecircumstancesofeachepisodeandtheskillsandresourcesavailabletopatients.These
issuescanoftenbeassessedinthefirstfewsessionsthroughanopenendedexplorationofthepatients'
substanceabusehistory,theirviewofwhatbroughtthemtotreatment,andtheirgoalsfortreatment.
Therapistsshouldtrytolearntheanswerstothefollowingquestions.

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DeficienciesandObstacles

Havethepatientsbeenabletorecognizetheneedtoreduceavailabilityofcocaine?

Havetheybeenabletorecognizeimportantcocainecues?

Havetheybeenabletoachieveevenbriefperiodsofabstinence?

Havetheyrecognizedeventsthathaveledtorelapse?

Havethepatientsbeenabletotolerateperiodsofcocainecravingoremotionaldistresswithout
resortingtodruguse?

Do they recognize the relationship of their other substance abuse (especially alcohol) in
maintainingcocainedependence?

Dothepatientshaveconcurrentpsychiatricdisordersorotherproblemsthatmightconfound
effortstochangebehavior?

SkillsandStrengths

Whatskillsorstrengthshavetheydemonstratedduringanypreviousperiodsofabstinence?

Havetheybeenabletomaintainajoborpositiverelationshipswhileabusingdrugs?

Aretherepeopleinthepatients'socialnetworkwhodonotuseorsupplydrugs?

Aretheresocialsupportsandresourcestobolsterthepatients'effortstobecomeabstinent?

Howdothepatientsspendtimewhennotusingdrugsorrecoveringfromtheireffects?

Whatwastheirhighestleveloffunctioningbeforeusingdrugs?

Whatbroughtthemtotreatmentnow?

Howmotivatedarethepatients?

DeterminantsofCocaineUse

Whatistheirindividualpatternofuse(weekendsonly,everyday,bingeuse)?

Whattriggerstheircocaineuse?

Dotheyusecocainealoneorwithotherpeople?

Wheredotheybuyandusecocaine?

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Whereandhowdotheyacquirethemoneytobuydrugs?

Whathashappenedto(orwithin)thepatientsbeforethemostrecentepisodesofabuse?

Whatcircumstanceswereatplaywhencocaineabusebeganorbecameproblematic?

Howdotheydescribecocaineanditseffectsonthem?

Whataretheroles,bothpositiveandnegative,thatcocaineplaysintheirlives?

RelevantDomains

In identifying patients' determinants of drug abuse, it may be helpful for clinicians to focus their
inquiriestocoveratleastfivegeneraldomains:

Social:Withwhomdotheyspendmostoftheirtime?Withwhomdotheyusedrugs?Dothey
haverelationshipswiththoseindividualsthatdonotinvolvesubstanceabuse?Dotheylivewith
someonewhoisasubstanceabuser?Howhastheirsocialnetworkchangedsincedrugabuse
beganorescalated?

Environmental:Whataretheparticularenvironmentalcuesfortheirdrugabuse(e.g.,money,
alcoholuse,particulartimesoftheday,certainneighborhoods)?Whatistheleveloftheirday
todayexposuretothesecues?Cansomeofthesecuesbeeasilyavoided?

Emotional: Research has shown that feeling states commonly precede substance abuse or
craving. These include both negative (depression, anxiety, boredom, anger) and positive
(excitement,joy)affectstates.Becausemanypatientsinitiallyhavedifficultylinkingparticular
emotional states to their substance abuse (or do so, but only at a surface level), affective
antecedentsofsubstanceabusetypicallyaremoredifficulttoidentifyintheinitialstagesof
treatment.

Cognitive: Particular sets of thought or cognition frequently precede cocaine use (I need to
escape,Ican'tdealwiththisunlessI'mhigh,WithwhatIamgoingthroughIdeservetoget
high).Thesethoughtsareoftenchargedandhaveasenseofurgency.

Physical: Desire for relief from uncomfortable physical states such as withdrawal has been
implicatedasafrequentantecedentofdrugabuse.Whilecontroversysurroundingthenatureof
physicalwithdrawalsymptomsfromcocainedependencecontinues,anecdotally,cocaineabusers
frequentlyreportparticularphysicalsensationsasprecursorstosubstanceabuse(e.g.,tingling
intheirstomachs,fatigueordifficultyconcentrating,thinkingtheysmellcocaine).

AssessmentTools

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Standardizedinstrumentsmayalsobeusefulinroundingout thetherapist's understandingofthe

patientandidentifyingtreatmentgoals.Thefollowingassessmenttoolshavebeenhelpful.

Substanceabuseandrelatedproblems

o TheAddictionSeverityIndex(McLellanetal.1992)assessesthefrequencyandseverity
of substance abuse as well as the type and severity of psychosocial problems that
typicallyaccompany substanceabuse (e.g., medical, legal, family/ social, employment,
psychiatric).

o The Change Assessment Scale (DiClemente and Hughes 1990) assesses the patient's
current position on readiness for change (e.g., precontemplation, contemplation,
commitment), which may be an important predictor of response to substance abuse
treatment(Prochaskaetal.1992).

o Arecordofdailysubstanceusecanbeusedtocollectinformationoncocaineandother
substanceusedaybydayoverasignificantperiod.

o The Treatment Attitudes and Expectation form, a selfreport instrument, has been
adapted from the National Institute of Mental Health Treatment of Depression
CollaborativeResearchProgram(Elkinetal.1985)andmodifiedforusewithcocaine
abusers. Greater congruence between patients' expectations of treatment and beliefs
aboutthecausesofsubstanceuseandthoseofthetreatmenttheyreceivemayresultin
improvedoutcome,ascomparedtopersonswhosetreatmentexpectationscontrastwith
thetreatmentreceived(Halletal.1991).

Psychiatricdiagnosisandsymptoms

o The StructuredClinical Interview for DSMIV(SCID) and SCIDP (First et al. 1995)
providesDSMIVdiagnoses(forAxisIandIIpsychiatricdiagnoses).Itcanalsobeused
toassessseverityofcocainedependencebythetotalnumberofdependencesyndrome
elementsendorsed(fromtheDSMIIIRsubstanceabusecriteria).

o TheCaliforniaPsychologicalInventorySocializationScale(CPISo)hasbeenfoundtobe
a valid continuous measure of sociopathy in alcoholics (Cooney et al. 1990) and an
importantvariableforpatienttreatmentmatchinginalcoholics(Kaddenetal.1989).

o TheselfreportBeckDepressionInventory(BDI)(Becketal.1961)andaclinicianrated
instrument,the HamiltonDepressionRatingScale (Hamilton1960),assessdepression.
The Symptom Checklist (SCL90) (Derogatis et al. 1973) assesses a broader range of
symptoms.

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Baselinelevelofcopingskillsandselfefficacy

o The Cocaine Use Situations Inventory monitors changes in patients' selfefficacy and
expectationsofabstinence.Thisselfreportformlistsapproximately30differenttypesof
highrisksituationsandhelpsclinicianspinpointspecificsituationsthatthepatientdoes
notcopewitheffectively.Thisinstrumentwasderivedfromtheselfefficacyinstrument
developedbyCondiotteandLichtenstein(1981)forusewithalcoholics.

SkillsTraining

LearningservesasanimportantmetaphorforthetreatmentprocessthroughoutCBT.Therapiststell
patientsthatagoalofthetreatmentistohelpthem"unlearn"old,ineffectivebehaviorsand"learn"
new ones. Patients, particularly those who are demoralized by their failure to cease their cocaine
abuse, or for whom the consequences of cocaine abuse have been highly negative, are frequently
surprisedtoconsidercocaineabuseasatypeofskill,assomethingtheyhavelearnedtodoovertime.
Afterall,theyaresurprisedwhentheythinkofthemselvesashavinglearnedacomplexsetofskills
thatenabledthemtoacquirethemoneyneededtobuycocaine(whichoftenledtoanothersetoflicitor
illicit skills), acquire cocaine without being arrested, use cocaine and avoid detection, and so on.
Patientswhocanreframetheirselfappraisalsintermsofbeingskilledinthiswayoftenseethatthey
alsohavethecapacitytolearnanewsetofskillsthatwillhelpthemremainabstinent.

LearningStrategiesAimedatCessationofCocaineUse

InCBT,itisassumedthatindividualsessentiallylearntobecomecocaineabusersthroughcomplex
interplaysofmodeling,classicalconditioning,oroperantconditioning.Eachoftheseprinciplesisused
tohelpthepatientstopabusingcocaine.

Modelingisusedtohelpthepatientlearnnewbehaviorsbyhavingthepatientparticipateinroleplays
withthetherapistduringtreatment.Thepatientlearnstorespondinnew,unfamiliarwaysbyfirst
watching the therapist model thosenew strategies and thenpracticing those strategies withinthe
supportivecontextofthetherapyhour.Newbehaviorsmayincludehowtorefuseanofferofdrugsor
howtobreakofforlimitarelationshipwithadrugusingassociate.

OperantconditioningconceptsareusedseveralwaysinCBT.

Through a detailed examination of the antecedents and consequences of substance abuse,

therapistsattempttounderstandwhypatientsmaybemorelikelytouseinagivensituation
and to understand the role that cocaine plays in their lives. This functional analysis of
substanceabuseisusedtoidentifythehighrisksituationsinwhichtheyarelikelytoabuse
drugs and, thus, to provide the basis for learning more effective coping behaviors in those
situations.

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Therapistsattempttohelppatientsdevelopmeaningfulalternativereinforcerstodrugabuse,
that is, other activities and involvements (relationships, work, hobbies) that serveas viable
alternativestococaineabuseandhelpthemremainabstinent.

Adetailedexaminationoftheconsequences,bothlongandshortterm,ofcocaineandother
substanceabuseisemployedasastrategytobuildorreinforcethepatient'sresolvetoreduceor
ceasesubstanceabuse.

Classical conditioning concepts also play an important role in CBT, particularly in interventions
directedatreducingsomeformsofcravingforcocaine.JustasPavlovdemonstratedthatrepeated
pairingsofaconditionedstimuluswithanunconditionedstimuluscouldelicitaconditionedresponse,
healsodemonstratedthatrepeatedexposuretotheconditionedstimulus without theunconditioned
stimuluswould,overtime,extinguishtheconditionedresponse.Thus,thetherapistattemptstohelp
patients understand and recognize conditioned craving, identify their own idiosyncratic array of
conditionedcuesforcraving,avoidexposuretothosecues,andcopeeffectivelywithcravingwhenit
doesoccursothatconditionedcravingisreduced.

GeneralizableSkills

SinceCBTtreatmentisbrief,onlyafewspecificskillscanbeintroducedtomostpatients.Typically,
theseareskillsdesignedtohelpthepatientgaininitialcontrolovercocaineandothersubstanceabuse,
suchascopingwithcravingandmanagingthoughtsaboutdrugabuse.However,thetherapistshould
makeitcleartothepatientthatanyoftheseskillscanbeappliedtoavarietyofproblems,notjust
cocaineabuse.

ThetherapistshouldexplainthatCBTisanapproachthatseekstoteachskillsandstrategiesthatthe
patient can use long after treatment. For example, the skills involved in coping with craving
(recognizingandavoidingcues,modifyingbehaviorthroughurgecontroltechniques,andsoon)canbe
used to deal with a variety of strong emotional states that may also be related to cocaine abuse.
Similarly,thesessiononproblemsolvingskillscanbeappliedtonearlyanyproblemthepatientfaces,
whetherdrugabuserelatedornot.

BasicSkillsFirst

Thismanualdescribesasequenceofsessionstobedeliveredtopatients;eachfocusesonasingleor
relatedsetofskills(e.g.,craving,copingwithemergencies).Theorderofpresentationoftheseskills
has evolved with experience with the types of problems most often presented by cocaineabusing
patientscomingintotreatment.

Earlysessionsfocusonthefundamentalskillsofaddressingambivalenceandfosteringmotivationto
stopcocaineabuse,helpingthepatientdealwithissuesofdrugavailabilityandcraving,andother
skillsintendedtohelpthepatientachieveinitialabstinenceorcontroloveruse.Latersessionsbuildon

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thesebasicskillstohelpthepatientachievestrongercontrolovercocaineabusebyworkingonmore
complex topics and skills (problem solving, addressing subtle emotional or cognitive states). For
example,theskillspatientslearninachievingcontrolovercraving(urgecontrol)serveasamodelfor
helpingthemmanageandtolerateotheremotionalstatesthatmayleadtococaineabuse.

MatchMaterialtoPatientNeeds

CBT is highly individualized. Rather than viewing treatment as cookbook psychoeducation, the
therapistshouldcarefullymatchthecontent,timing,andnatureofpresentationofthematerialtothe
patient.Thetherapistattemptstoprovideskillstrainingatthemomentthepatientismostinneedof
theskill.Thetherapistdoesnotbelabortopics,suchasbreakingtieswithcocainesuppliers,witha
patientwhoishighlymotivatedandhasbeenabstinentforseveralweeks.Similarly,thetherapistdoes
notrushthroughmaterialinanattempttocoverallofitinafewweeks;forsomepatients,itmaytake
severalweekstotrulymasterabasicskill.Itismoreeffectivetoslowdownandworkatapacethatis
comfortableandproductiveforaparticularindividualthantoriskthetherapeuticalliancebyusinga
pacethatistooaggressive.

Similarly,therapistsshouldbecarefultouselanguagethatiscompatiblewiththepatient'slevelof
understandingandsophistication.Forexample,whilesomepatientscanreadilyunderstandconcepts
of conditioned craving in terms of Pavlov's experiments on classical conditioning, others require
simpler,moreconcreteexamples,usingfamiliarlanguageandterms.

Therapistsshouldfrequentlycheckwithpatientstobesuretheyunderstandaconceptandthatthe
materialfeelsrelevanttothem.Thetherapistshouldalsobealerttosignalsfrompatientswhothink
thematerialisnotwellsuitedtothem.Thesesignalsincludelossofeyecontactandotherformsof
driftingaway,overlybriefresponses,failuretocomeupwithexamples,failuretodohomework,andso
on.

Animportantstrategyinmatchingmaterialtopatientneeds(andprovidingtreatmentthatispatient
driven rather than manual driven) is to use, whenever possible, specific examples provided by the
patients,eitherthroughtheirhistoryorrelatingeventsoftheweek.Forexample,ratherthanfocusing
onanabstractrecitationof"SeeminglyIrrelevantDecisions,"thetherapistshouldemphasizearecent,
specificexampleofadecisionmadebythepatientthatendedinanepisodeofcocaineuseorcraving.
Similarly,tomakesurethepatientunderstandsaconcept,thetherapistshouldaskthepatientto
thinkofaspecificexperienceorexamplethatoccurredinthepastweekthatillustratestheconceptor
idea.

"Itsoundslikeyouhadalotofdifficultythisweekandwoundupinsomeriskysituationswithoutquite
knowinghowyougotthere.That'sexactlywhatI'dliketotalkaboutthisweek,howbynotpaying
attentiontothelittledecisionswemakeallthetime,wecanlandinsomeroughspots.Now,youstarted

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outtalkingabouthowyouhadnothingtodoonSaturdayanddecidedtohangoutinthepark,and2
hourslateryouweredrivingintothecitytoscorewithTeddy.Ifwelookcarefullyatwhathappened
Saturday,Ibetwecancomeupwithawholechainofdecisionsyoumadethatseemedprettyinnocentat
thetime,buteventuallyledtoyoubeinginthecity.Forexample,howdidithappenthatyoufeltyou
hadnothingtodoonSaturday?"

UseRepetition

Learningnewskillsandeffectiveskillbuildingrequirestimeandrepetition.Bythetimetheyseek
treatment,cocaineusers'habitsrelatedtotheirdrugabusetendtobedeeplyingrained.Anygiven
patient's routine around acquiring, using, and recovering from cocaine use is well established and
tends to feel comfortable to the patient, despite the negative consequences of cocaine abuse. It is
importantthattherapistsrecognizehowdifficult,uncomfortable,andeventhreateningitistochange
theseestablishedhabitsandtrynewbehaviors.Formostpatients,masteringanewapproachtoold
situationstakesseveralattempts.

Moreover,manypatientscometotreatmentonlyafterlongperiodsofchronicuse,whichmayaffect
theirattention,concentration,andmemoryandthustheirabilitytocomprehendnewmaterial.Others
seektreatmentatapointofextremecrisis(e.g.,learningtheyareHIVpositive,afterlosingajob);
thesepatientsmaybesopreoccupiedwiththeircurrentproblemsthattheyfinditdifficulttofocuson
thetherapist'sthoughtsandsuggestions.Thus,intheearlyweeksoftreatment,repetitionisoften
necessaryifapatientistobeabletounderstandorretainaconceptoridea.

Infact,thebasicconceptsofthistreatmentarerepeatedthroughouttheCBTprocess.Forexample,the
ideaofafunctionalanalysisofcocaineabuseoccursformallyinthefirstsessionaspartoftherationale
fortreatment,whenthetherapistdescribesunderstandingcocaineabuseintermsofantecedentsand
consequences. Next, patients are asked to practice conducting a functional analysis as part of the
homeworkassignmentforthefirstsession.Theconceptofafunctionalanalysisthenrecursineach
session;thetherapiststartsoutbyaskingaboutanyepisodesofcocaineuseorcraving,whatpreceded
theepisodes,andhowthepatientcoped.

The idea of cocaine use in the context of its antecedents and consequences is inherent in most
treatment sessions. For example, craving and thoughts about cocaine are common antecedents of
cocaineabuseandarethefocusoftwoearlysessions.Thesesessionsencouragepatientstoidentify
theirownobviousandmoresubtledeterminantsofcocaineabuse,withaslightlydifferentfocuseach
time.Similarly,eachsessionendswithareviewofthepossiblepitfallsandhighrisksituationsthat
mayoccurbeforethenextsession,toagainstimulatepatientstobecomeawareofandchangetheir
habitsrelatedtococaineabuse.

Whilekeyconceptsarerepeatedthroughoutthemanual,therapistsshouldrecognizethatrepetitionof
wholesessions,orpartsofsessions,maybenecessaryforpatientswhodonotreadilygraspthese

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concepts because of cognitive impairment or other problems. Therapists should feel free to repeat
sessionmaterialasmanytimesandinasmanydifferentwaysasneededwithparticularpatients.

PracticeMasteringSkills

Wedonotmastercomplexnewskillsbymerelyreadingaboutthemorwatchingothersdothem.We
learn by trying out new skills ourselves, making mistakes, identifying those mistakes, and trying
again.

InCBT,practiceofnewskillsisacentral,essentialcomponentoftreatment.Thedegreetowhichthe
treatmentisskills training overmerelyskills exposure hastodowiththeamountofpractice.Itis
critical that patients have the opportunity to try out new skills within the supportive context of
treatment.Throughfirsthandexperience,patientscanlearnwhatnewapproachesworkordonotwork
forthem,wheretheyhavedifficultyorproblems,andsoon.

CBToffersmanyopportunitiesforpractice,bothwithinsessionsandoutsideofthem.Eachsession
includesopportunitiesforpatientstorehearseandreviewideas,raiseconcerns,andgetfeedbackfrom
the therapist. Practice exercises are suggested for each session; these are basically homework
assignmentsthatprovideastructuredwayofhelpingpatientstestunfamiliarbehaviorsortryfamiliar
behaviorsinnewsituations.

However,practiceisonlyusefulifthepatientseesitsvalueandactuallytriestheexercise.Compliance
with extrasession assignments is a problem for many patients. Several strategies are helpful in
encouragingpatientstodohomework.

GiveaClearRationale

Therapists should not expect a patient to practice a skill or do a homework assignment without
understandingwhyitmightbehelpful.Thus,aspartofthefirstsession,therapistsshouldstressthe
importanceofextrasessionpractice.

"Itwillbeimportantforustotalkaboutandworkonnewcopingskillsinoursessions,butitiseven
moreimportanttoputtheseskillsintouseinyourdailylife.Youarereallytheexpertonwhatworks
anddoesn'tworkforyou,andthebestwaytofindoutwhatworksforyouistotryitout.It'svery
importantthatyougiveyourselfachancetotryoutnewskillsoutsideoursessionssowecanidentify
anddiscussanyproblemsyoumighthaveputtingthemintopractice.We'vefound,too,thatpeoplewho
trytopracticethesethingstendtodobetterintreatment.ThepracticeexercisesI'llbegivingyouatthe
endofeachsessionwillhelpyoutryouttheseskills.We'llgooverhowwelltheyworkedforyou,what
youthoughtoftheexercises,andwhatyoulearnedaboutyourselfandyourcopingstyleatthebeginning
ofeachsession."

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GetaCommitment

Weareallmuchmorelikelytodothingswehavetoldotherpeoplewewoulddo.Ratherthanassume
thatpatientswillfollowthroughonatask,CBTtherapistsshouldbedirectandaskpatientswhether
theyarewillingtopracticeskillsoutsideofsessionsandwhethertheythinkitwillbehelpfultodoso.
Aclear"yes"conveysthemessagethatthepatientunderstandstheimportanceofthetaskandits
usefulness.Moreover,itsetsupadiscussionofdiscrepancyifthepatientfailstofollowthrough.

Ontheotherhand,hesitationorrefusalmaybeacriticalsignalofclinicalissuesthatareimportantto
explorewiththepatient.Patientsmayrefusetodohomeworkbecausetheydonotseethevalueofthe
task,becausetheyareambivalentabouttreatmentorrenouncingcocaineabuse,becausetheydonot
understandthetask,orforvariousotherreasons.

AnticipateObstacles

Itisessentialtoleaveenoughtimeattheendofeachsessiontodeveloporgoovertheupcomingweek's
practice exercise in detail. Patients should be given ample opportunity to ask questions and raise
concernsaboutthetask.Therapistsshouldaskpatientstoanticipateanydifficultiestheymighthave
in carrying out the assignment and apply a problemsolving strategy to help work through these
obstacles.Patientsshouldbeactiveparticipantsinthisprocessandhavetheopportunitytochangeor
developthetaskwiththetherapist,toplanhowtheskillwillbeputintopractice,andsoon.

Workingthroughobstaclesmayincludeadifferentapproachtothetask(e.g.,usingataperecorderfor
selfmonitoringinsteadofwriting),thinkingthroughwhenthetaskwillbedone,whethersomeoneelse
will be asked to help, and so on. The goal of this discussion should be the patient's expressed
commitmenttodotheexercise.

MonitorClosely

Followinguponassignmentsiscriticaltoimprovingcomplianceandenhancingtheeffectivenessof
thesetasks.Checkingontaskcompletionunderscorestheimportanceofpracticingcopingskillsoutside
ofsessions.Italsoprovidesanopportunitytodiscussthepatient'sexperiencewiththetaskssothat
anyproblemscanbeaddressedintreatment.

Ingeneral,patientswhodohomeworktendtohavetherapistswhovaluehomework,spendalotoftime
talkingabouthomework,andexpecttheirpatientstoactuallydothehomework.Theearlypartofeach
sessionmustincludeatleast 5minutes forreviewingthepracticeexerciseindetail;itshouldnotbe
limitedtoaskingpatientswhethertheydidit.Ifpatientsexpectthetherapisttoaskaboutthepractice
exercise,theyaremorelikelytoattemptitthanarepatientswhosetherapistdoesnotfollowthrough.

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Similarly,ifanyothertaskisdiscussedduringasession(e.g.,implementationofaspecificplanto
avoidapotentialhighrisksituation),besuretobringitupinthefollowingsession.For example,
"Wereyouabletotalktoyourbrotheraboutnotcomingoverafterhegetshigh?"

UsetheData

Theworkpatientsdoinimplementingapracticeexerciseandtheirthoughtsaboutthetaskconveya
wealth of important information about the patients, their coping style and resources, and their
strengthsandweaknesses.Itshouldbevaluedbythetherapistandputtouseduringthesessions.

Asimpleselfmonitoringassignment,forexample,canquicklyrevealpatients'understandingofthe
taskorbasicconceptsofCBT,levelofcognitiveflexibility,insightintotheirownbehavior,levelof
motivation, coping style, level of impulsivity, verbal skills, usual emotional state, and much more.
Ratherthansimplycheckinghomework,theCBTtherapistshouldexplorewiththepatientswhatthey
learnedaboutthemselvesincarryingoutthetask.This,alongwiththetherapist'sownobservations,
willhelpguidethetopicselectionandpacingoffuturesessions.

ExploreResistance

Somepatientsliterallydothepracticeexerciseinthewaitingroombeforeasession,whileothersdo
noteventhinkabouttheirpracticeexercises.Failuretoimplementcopingskillsoutsideofsessions
mayhaveavarietyofmeanings:patientsfeelhopelessanddonotthinkitisworthtryingtochange
behavior;theyexpectchangetooccurthroughwillpoweralone,withoutmakingspecificchangesin
particularproblemareas;thepatients'lifeischaoticandcrisisridden,andtheyaretoodisorganizedto
carryoutthetasks;andsoon.Byexploringthespecificnatureofpatients'difficulty,therapistscan
helpthemworkthroughit.

PraiseApproximations

Justasmostpatientsdonotimmediatelybecomefullyabstinentontreatmententry,manyarenot
fully compliant with practice exercises. Therapists should try to shape the patients' behavior by
praising even small attempts at working on assignments, highlighting anything they reveal was
helpful or interesting in carrying out the assignment, reiterating the importance of practice, and
developingaplanforcompletionofthenextsession'shomeworkassignment.

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Chapter3

TheStructureandFormatofSessions

CBT ishighlystructured and ismore didactic than manyother treatments. Thus, CBT therapists
assumeamoredirectiveandactivestancethantherapistsconductingsomeotherformsofsubstance
abusetreatment.

Agreatdealofworkisdoneduringeachsession,includingreviewingpracticeexercises,debriefing
problemsthatmayhaveoccurredsincethelastsession,skillstraining,feedbackonskillstraining,in
sessionpractice,andplanningforthenextweek.Thisactivestancemustbebalancedwithadequate
timeforunderstandingandengagingwiththepatient.

20/20/20Rule

Toachieveagoodintegrationofmanualdrivenandpatientdrivenmaterialineachsession,wehave

developedthe"20/20/20Rule"fortheflowofatypical60minuteCBTsession (exhibit1).Duringthe
first20minutes,therapistsfocusongettingaclearunderstandingofpatients'currentconcerns,level

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of general functioning, and substance use and craving during the past week, as well as their
experienceswiththepracticeexercise.Thispartofthesessiontendstobecharacterizedbypatients
doingmostofthetalking,althoughtherapistsguidewithquestionsandreflectionastheygetasenseof
thepatients'currentstatus.

The second 20 minutes is devoted to introduction and discussion of a particular skill. Therapists
typicallytalkmorethanpatientsduringthispartofthesession,althoughitiscriticalthattherapists
personalize the didactic material and check back with patients frequently for examples and
understanding.

Thefinal20minutesrevertstobeingmorepatientdominated,aspatientsandtherapistsagreeona
practiceexercise forthe next week and anticipate and plan for any difficulties thepatients might
encounterbeforethenextsession.

Exhibit1:SessionFlowinCBT,The20/20/20Rule

First20minutes

Assesssubstanceabuse,craving,andhighrisksituationssincelastsession.

Listenfor/elicitpatients'concerns

Reviewanddiscussthepracticeexercise

Second20minutes

Introduceanddiscussthesessiontopic

Relatethesessiontopictocurrentconcerns

Third20minutes

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 CBT for drug abuse

Explorethepatient'sunderstandingofandreactionstothetopic.

Assignapracticeexerciseforthenextweek

Reviewplansfortheweekandanticipatepotentialhighrisksituations.

FirstThirdofSession

AssessPatientStatus

Therapistsgreetthepatientsandtypicallystartthesessionbyaskingthemhowtheyaredoing.Most
patientsrespondbyspontaneouslyreportingwhethertheyusedcocaineorhadcravingsduringthelast
week.Ifpatientsdonotreportsubstanceuse,therapistsshouldaskaboutthisdirectly.Particularlyin
thebeginningoftreatment,therapistsshouldobtaindetailed,daybydaydescriptionsofhowmuch
cocainewasused.

Foreachepisodeofuse,therapistsshouldspendseveralminutesdoingafunctionalanalysis(what
happenedbeforetheepisode,whenwasthepatientfirstawareofthedesireorurgetouse,whatwas
thefeeling,howandwheredidthepatientacquirethecocaine,whatwasthehighlike,whathappened
afterward).Ifpatientsreportnococaineuse,therapistsshouldprobeforanyhighrisksituationsor
cravingstheymayhaveexperiencedanddebrieftheseaswell.Thetherapists'goalistogetadetailed
senseofthepatients'currentleveloffunctioning,motivation,andcocaineuse.

UrineTests

Objective feedback on patients' clinical status and progress through urine toxicology screens is an
importantpartofthisandanyotherdrugtreatmentprogram.Urinespecimensshouldbecollectedby
therapists at every clinical contact (and at least weekly). The early part of the session is a good
opportunitytoreviewtheresultsofthemostrecenturinetoxicologyreportwithpatients.Ideally,the
clinicwouldhaveaccesstoadipstickmethodwhereurinecanbetestedonthespot,anddrugabuse
withinthepast3dayscanbedetected.

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Whilediscussingurinetestresultsisstraightforwardwhenpatientsreportbeingdrugfreeandthe
laboratoryresultsconfirmthis,itissomewhatmorecomplicatedwhenpatientsdenycocaineusebut
theurinescreenispositive.Whilepatientsoftenpresentexcusesorcreativeexplanationsforwhythe
toxicologyscreenwasinerror,itisbesttopointoutthatlaboratoryerrorsarequiteunusual,that
patientshavelittletogainfromnotbeinghonestaboutsubstanceabuse,andinfact,havemuchto
lose,sincetreatmentwillbelesshelpfulifpatientsarenotopenaboutthekindsofproblemstheyare
having.

Confronting patientsabout discrepancies in self versus laboratoryreports of substance useis very

important; done well, this can advance the therapeutic relationship and the process of treatment
significantly.However,pointingoutthesediscrepanciesshouldnotbedoneinaconfrontationalstyle.
Rather,therapistsmightpointoutdiscrepanciesbetweenthepatients'statedtreatmentgoalsandthe
urineresults("You'vesaidthingsareallgoinggreat,buttheurineresultsmakemewonderifit'sall
beenaseasyasyousay.Whatdoyoumakeofthis?").Therapistsmightalsopointoutsomereasons
why patients are often reluctant to admit to ongoing drug abuse (fear of being terminated from
treatment,wantingtopleasethetherapist,testingthetherapist),explorethesewiththepatients,and
processtheseasappropriate.

"Itsoundslikeyou'reafraidthattreatmentisnotworkingforyouasquicklyasyou,andespeciallyyour

wife,wouldlike,andadmittingyouusedlastweekmightmeanyouwouldn'tcontinueintreatment.I

wantyoutounderstandthataslongasyoukeepcoming,workinghard,andtryingtostopuse,I'llkeep

workingwithyou.Theonlywaythatwouldchangeisifyourcocaineuseincreasedtoalevelwhereit

wasclearthatoutpatienttreatmentjustwasn'tenoughtohelpyoustop.Inthatcase,we'dtalkabout

increasingthefrequencyofsessionsorotheroptions,likehavingyouenteraninpatientunit.Howdoes

thatsound?"

***

Therapist:"Iknowthecocainelevelfromlastweek'slabtestwasn'thigh,butitdoesindicatesome

recentcocaineabuse.Isitpossibleyouusedevenasmallamountlastweek?"

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Patient:"Well,Ididuseadime,butIdidn'tthinkthatcounted."

Therapist:"Onelineinthelastweekisalotlessthanyouwereusingjustafewweeksagoandthat's

reallygreat.Butbeforewegetintohowyouwereabletocutdownyourusethatmuch,Iwaswondering

whyyouthinkthatoneline'doesn'tcount,'sincethere'sprobablyalotwecanlearnabouteventhat

smallamountofuse."

problemsolving

Itisnotunusualforpatients,particularlythosewhohavenotbeenintreatmentbefore,tocomelateto
appointmentsormissappointmentswithoutcalling.Insuchcases,therapistsmayapplyaproblem
solvingstrategy.Thisentailssomeinquiryaboutwhythepatientwaslate,brainstormingsolutionsto
lateness,andworkingthroughhowplanstoattendsessionspromptlymightbeimplemented.

ListenforCurrentConcerns

Inreportingonsubstanceabuseandmajorlifeeventssincethelastsession,patientsarelikelyto
revealagreatdealabouttheirgeneralleveloffunctioningandthetypesofissuesandproblemsofmost
currentconcern.Therapistsshouldlistencarefullyandassesspatientsinanumberofdomains.

Hasthepatientmadesomeprogressinreducingdrugabuse?

Whatisthepatient'scurrentlevelofmotivation?

Isareasonablelevelofsupportavailableineffortstoremainabstinent?

What'sbotheringthispersonmostrightnow?

Therapists should listen intently, clarify when necessary, and where appropriate, relate current
concernstosubstanceabuse.

"Itseemslikeyou'rereallyworriedabouttheguysatworkgettingyouintroublewithyourboss.Are

thesethesameguysyouusedwith?"

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or

"Itsoundslikeyouwerereallylonelyandboredthisweekend,andmaybeyou'vebeenfeelingthisway

foralongtime.Isthatsomethingyou'dliketoworkoninhere?"

Duringthispartofthesession,whilegettingaclearsenseofpatients'currentconcerns,therapists
shouldbeplanningfortherestofthesession,particularlyintermsofhowtheplannedsessiontopic
relatesspecificallytoaproblemorissuethepatienthasexperiencedrecently.

"Talkingabouthowboredyoufeltovertheweekendmakesmewonderifyouweren'thavingalotof

cravingforcocaineaswell.Ifyouthinkthat'strue,I'dliketospendtimeinthissessiontalkingabout

understandingcravingandlearningtodealwithit."

Whendonewell,thisapproachbuildsstrongworkingrelationshipsandheightenstherelevanceofCBT
tremendously,becausepatientsgetthesensethatthetherapistisrespondingtotheirstruggleswith
useful,timelytechniquesandstrategies.

DiscussthePracticeExercise

Theearlypartofeachsessionshouldalsoincludedetailedreviewofthepatients'experiencewithand

reactionstothepracticeexercise.Theprimaryfocusshouldbeonwhatthepatients learned about

themselvesincarryingouttheexercise.

Wasiteasierorharderthanexpected?

Whatcopingstrategiesworkedbest?

Whatdidnotworkaswell?

Didthepatientscomeupwithanynewstrategies?

Iftherapistsspendconsiderabletimeengagedinadetailedreviewofthepatients'experiencewiththe
implementationofextrasessiontasks,notonlywillthetherapistsconveytheimportanceofpractice,

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but both therapists and patients will learn a great deal about the patient. Therapists should not
diminishtheimportanceofpracticebydoinganyofthefollowing.

Merely asking patients whether they completed the task or accepting a one word (yes/no)
responsewithoutfurtherprobing.

Collectingthepatients'practiceexerciseasifitwereahomeworkassignment.Instead,patients
shouldbeencouragedtokeepanotebookorjournalwiththeirpracticeexercises,sincetheymay
findthisausefulreferencelongaftertheyleavetreatment.

Usinganaggressiveorconfrontationalstylewhenpatientsdonotattemptnewskillsordosoin
aperfunctoryway.

Again,therapistsshouldmovepatientstowardpracticingskillsoutsideofsessionsbygivingaclear
rationale, getting a commitment from the patients, anticipating and working through obstacles,
monitoringtaskcompletionclosely,makinggooduseofthedata,exploringresistance,andpraising
approximations.

SecondThirdofSession

IntroducetheTopic

Aftergettingaclearsenseofthepatients'generalfunctioning,currentconcerns,andprogresswith
taskimplementation,therapistsshouldmovetowardatransitiontothesessiontopicforthatweek.
Thismaybeeitherintroducinganewtopicorfinishinguporreviewinganoldone.Inanycase,an
agendafortheremainderofthesessionsshouldbesetorreviewedatthistime.

"SinceyouhadthatproblemwithJerrylastweek,Ithinkitmightbeagoodideatotalkmoreabout

howyoucanavoidorrefuseoffersofcocaineandtopracticeafewmoretimessoyoufeelmoreconfident

thenexttimethatcomesup.Thenwecanspendsometimefiguringouthowyoucanhaveanotherclean

week.Howdoesthatsound?"

RelateTopictoCurrentConcerns

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Therapistsshouldexplicitlypointouttherelevanceofthesessiontopictothepatients'currentcocaine
related concerns and introduce the topic by using concrete examples from the patients' recent
experience.

"Ithinkthisisagoodtimetotalkaboutwhattodowhenyoufindyourselfinareallytoughhighrisk

situation,likewhathappenedattheparkonTuesday.Youcopedwithitreallywellbygettingoutof

therequickly,butmaybetherearesomeotherthingswecancomeupwithifyoufindyourselfinthat

kindofsituationagain."

ExploreReactions

Therapistsshouldneverassumethatpatientsfullyunderstandthesessionmaterialorthatitfeels
timelyandusefultothem.Whilegoingthroughthematerial,therapistsshouldrepeatedlycheckthe
patients'understanding.

Askforconcreteexamplesfromthepatients.

"Canyouthinkofatimelastweekwhenthishappenedtoyou?"

Elicitthepatients'viewsonhowtheymightuseparticularskills.

"Nowthatwe'vetalkedaboutcravingandtalkedabouturgesurfing,distraction,andtalkingitout,

whatdoyouthinkwouldworkbestforyou?Whichofthesetechniqueshaveyouusedinthepast?Is

thereanyotherwayyou'vetriedtocopewithcraving?"

Askfordirectfeedbackfrompatients.

"Doesthisseemlikeit'sanimportantissueforustobeworkingonrightnow,ordoyouhavesomething

elseinmind?"

Askpatientstodescribethetopicorskillintheirownwords.

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"We'vetalkedalotaboutbuildinganemergencyplan.Justtomakesureyou'reconfidentaboutwhat

youwanttodo,canyoutellmewhatyou'replanningthenexttimeyougetintoanemergencysituation?"

Roleplayorpracticetheskillwithinthesession.

"Itsoundslikeyou'rereadytopracticethis.Whydon'twetrythatsituationyouweretellingmeabout

whenyourfathergotangrywhenyouaskedforarideoverhere?"

Payattentiontothepatients'verbalandnonverbalcues.

"InoticethatyoukeeplookingoutthewindowandIwaswonderingwhatyourthoughtsareonwhat

we'retalkingabouttoday."

Inmanycases,patientsfeelthataparticulartopicisnotreallyrelevant.Forexample,patientsmay
deny experiencing any craving for cocaine. While using their clinical judgment in determining the
salienceofparticularmaterialforparticularpatients,therapistsmightworkthroughaparticulartopic
bypointingoutthatsomeproblemsmaycomeupinthefuture,andhavingaparticularskillinthe
patients'repertoiremaybequiteuseful.

"Iknowyou'renotfeelingbotheredbycravingnowanddon'tthinkyou'llexperienceanyinthenear

future,butitmaycomeupinafewweeksorevenafteryouleavetreatment.Inanycase,itmightbe

helpfultospendalittlemoretimetalkingaboutit,soifitdoescomeup,you'llbeprepared.Whatdoyou

think?"

FinalThirdofSession

Thelastthirdofthesessionis,likethefirstthird,likelytobecharacterizedbypatientstalkingmore,
withtherapistsguidingthediscussionbyaskingquestionsandobtainingclarification.

AssignaPracticeExercise

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Aspartofthewinddownofthesession,therapistsandpatientsshoulddiscussthepracticeexercisefor
thenextweek.Itiscriticalthatpatientsunderstandclearlywhatisrequired.Earlyintreatmentfor
most patients, and throughout treatment for others, therapists may find it useful to model the
assignmentduringthesession.Therapistsshouldalsoaskforacommitmentfrompatientstotryout
theskillandtoworkthroughobstaclestoimplementingtheskillbyplanningwhenandwherethey
willcompletethetask.

Asuggestedpracticeexerciseaccompanieseachsession.Anadvantageofusingthesesheetsisthat
theyalsosummarizekeypointsabouteachtopicandthuscanbeusefulreminderstopatientsofthe
materialdiscussedeachweek.However,theextrasessionpracticeofskillsismostusefultopatientsif
itisindividualized.Thus,ratherthanbeingboundbythesuggestedexercises,therapistsandpatients
areencouragedtousetheseasstartingpointsfordiscussingthebestwaytoimplementtheskilland
comeupwithvariationsornewassignments.Similarly,notallassignmentsmustbewritten;anumber
ofpatientsmayhavelimitedliteracy,andtheymaytapetheirthoughtsaboutthepracticeexercise.

AnticipateHighRiskSituations

The final part of each session should include a detailed discussion of the patients' plans for the
upcomingweekandanticipationofhighrisksituations.

"Beforewestop,whydon'twespendsometimethinkingaboutwhatthenextfewdaysaregoingtobe

likeforyou.Whatareyourplansafteryouleaveheretoday?What'sthehardestsituationyouthink

you'llhavetodealwithbeforewemeetonFriday?"

Therapistsshouldtrytomodeltheideathatpatientscanliterallyplanthemselvesoutofusingcocaine.
Foreachanticipatedhighrisksituation,therapistsandpatientsshouldidentifyappropriateandviable
copingskills.Earlyintreatment,thismaybeasconcreteasaskingatrustworthyfriendorsignificant
othertohandleapatient'smoney.

Anticipating and planning for highrisk situations may be difficult in the beginning of treatment,
particularlyforpatientswhoarenotusedtoplanningorthinkingthroughtheiractivities,orwhose

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livesarehighlychaotic.Thismodelsanimportantskillthatisthefocusofthesessionon"Seemingly
IrrelevantDecisions,"thatis,learningtomodifybehaviorbylookingahead.

Forpatientswhoselivesarechaotic,thismayalsohelpreducetheirsenseoflackofcontrol.Similarly,
patientswhohavebeendeeplyinvolvedwithdrugabuseforalongtimewilldiscoverthroughthis
processthattheyhavefewactivitiestofilltheirtimeorserveasalternativestodrugabuse,especially
iftheyhavebeenunemployedorhavefewsocialsupportsunrelatedtotheirsubstanceabuse.This
providesanopportunitytodiscussstrategiestorebuildasocialnetworkorbegintothinkaboutgoing
backtowork.

Topics

EightskilltopicsarecoveredinCBTforcocainedependenceplusaterminationsessionandelective
sessionsthat involvesignificant others. The sequence inwhich thetopics are presentedshould be
basedontheclinicaljudgmentoftherapistsandtheneedsofthepatients.Theyaregivenhereinthe
sequencemostoftenusedwithcocaineabusers.Themostcriticalbehavioralskillsforpatientsjust
enteringtreatmentareintroducedfirst,followedbymoregeneralskills.

SinceCBTisusuallydeliveredin1216sessionsover12weeks,therearefewerskillstrainingtopics
thansessions.Thisprovidessomeflexibilityfortherapiststoallowforgreaterpracticeandmasteryof
asmallbutcriticalsetofskillsaswellasrepetitionofsessionmaterialasneeded.Itisintendedto
preventpatientsfrombeingoverwhelmedwithmaterial.

Several skill guidelinesare givenforeachsession, manymorethancanbe reasonablyintroduced.

Whendeliveredasasinglesession,therapistsshouldcarefullyselectskillstomatchthepatientsand
notattempttocoverthemall.Atherapistmightpickoneortwocopingskillsthepatienthasusedin
thepastandintroduceoneortwomorethatareconsistentwiththepatient'scopingstyle.

Whendeliveredinmorethanonesession,therapistsshouldsplituptheguidelines,discussingand
practicing the most basic and familiarskills in the first sessionand more challenging ones in the
second.Moreover,thetwosessionformatallowspatientstobeintroducedtoaskillinthefirstsession,
practiceitintheintervalbeforethenextsession,anddiscussandworkthroughanydifficultiesduring

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thesecondsession.Practiceexercisesshouldbegivenforbothsessions,withtheexerciseforthesecond
sessionbeingavariantofthefirst(e.g.,tryingoutaskillnotusedtheweekbefore,increasingthe
difficultyorcomplexityofthetask).

Somepatients,particularlylesssevereusers,maymovethroughtheskillsveryquickly.Whenthis

occurs, excellent elective session material can be found in Treating Alcohol Dependence: A Coping

SkillsTrainingGuideintheTreatmentofAlcoholism(Montietal.1989).Sincethismaterialtendsto
focus on broad, interpersonal skills, such as coping with criticism or anger, it is comparatively
straightforwardtoadaptforusewithcocaineabusers.

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Chapter4

IntegratingCBTandMedication

CBT is highly compatible with pharmacotherapy. When used in combination with medication, the
rangeofCBTinterventionsexpandstoincludeafocusonenhancingmedicationcompliance.Generally,
medicationresponseandcompliancearemonitoredduringtheearlypartofeachsession(i.e.,thefirst
thirdofa20/20/20session).Thefollowingspecificstrategies(AdaptedfromCarrollandO'Malley1996.)
havebeenfounduseful:

Inquireastopatients'previousexperiencewithmedication.
o Therapistsshouldaskpatientsabouttheirpriorhistorywithpharmacotherapyforany
psychiatricdisorderorcondition.

o Whywasitprescribed?

o Wasithelpful?

o Underwhatconditionswasitterminated?

o Didtheytakethemedicationasprescribed?

Previousnoncomplianceshouldalerttherapiststotheneedtoestablishthepatients'viewof
whytheydidnotcomplypreviouslyandtoattempttoaddressthoseissuesproactively.

Addresspatients'concernsaboutmedication.

Duringallsessions,therapistsshouldlistencarefullyforanyconcerns,misunderstandings,or
prejudices about taking medication and address these rapidly and assertively. These may
includemisconceptionsaboutexpectedmedicationeffects,timeneededtoexperiencetheeffect,
side effects, dosing, and interactions with cocaine and other substances. Therapists should
provideclarificationinclear,familiartermsandfrequentlycheckbackwithpatientstobesure
theyunderstand.

Whenmedicationeffectsmaynotbeimmediatelyapparent,itisimportanttoinformpatientsthatit
may take several weeks before therapeutic effects emerge; thus, patients should be encouraged to
expect gradual rather than allornothing change. Explaining the gradual emergence of medication

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effectsprovidesanopportunityforthetherapisttoemphasizethatpatientsshouldnotexpecttobenefit
fromanentirelypassivestanceregardingCBTtreatment simplybecausetheyaretakingmedication.
Masteryandimplementationofcopingskillsremainanessentialandimportantpartoftreatment;
medicationmaybeanadditional,usefuladjunctortool.

Assessmedicationcompliancesincelastsession.

Close,consistent,andcarefulmonitoringisoneofthemosteffectivestrategiesforenhancing
compliancewithmedications.Thus,aportionofeachsessionshouldbedevotedtoevaluating
medicationcomplianceandworkingthroughanydifficultiesthatmightarise.Ingeneral,until
the patients' compliance pattern is clearly established, therapists should, at each meeting,
inquireaboutmedicationcompliance,daybyday,sincethelastsession.Thisshouldinclude
asking when patients take the medication, how they take the medication, and a thorough
discussionofanydeviationfromtheprescribeddoseandschedule.

Fawcettetal.(1987)notedthatcomplianceandretentionaremostdifficulttoachieveearlyand
lateintreatmentearlyifthepatientisnotreceivingobviousbenefit,andlaterifthepatient,
afterobtainingapartialorfulltherapeuticresponse,doesnotappreciatetheneedtocontinue
treatment. Thus, therapists should be particularly attentive to compliance and motivation
issuesduringearlyandlatesessions.

Praisemedicationcompliance.

Therapistsshouldalsoconveyconfidenceinthemedicationandinformpatientsofthelikely
benefits. Therapists should be strongly on the side of compliance and praise patients'
complianceenthusiasticallyandgenuinely.

"I seeyou havetakenyourmedicationeverydaysince ourlastmeeting. That'sreally

great.Iknowyouhadyourdoubtsaboutwhetherthemedicationwouldworkforyou,and
I'mgladyouwerewillingtogiveitatry.Haveyounoticedanypositivechangesyouthink
mightberelatedtothemedication?"

Relatepatients'clinicalimprovementtocomplianceandlackofimprovementtononcompliance.

A crucial role of the therapist is to establish and stress the connection between medication
compliance,psychotherapysessions,andimprovement.Therapistsshouldmakeexplicitcausal
linksbetweenpatients'complianceandimprovementincocaineabuseandotherappropriate
targetsymptoms.Conversely,therapistsmighttiepoorcompliancetofailuretoimprove.

"Since you've been taking the medication, I can see a lot of positive changes in your
life....you'vecutwaydownonyourcocaineuseandyousayyou'vebeenfeelingalotbetter.
Ithinkthechangesindicatethatthemedicationishelpingyou.Whatdoyouthink?"

Or

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"Iknowyou'rediscouragedabouthowyou'vebeenfeeling,butsincewe'vebeguntowork
together,you'vealsotoldmeyouhaven'tbeentakingthemedicationeveryday.Aswe've
discussed,Idon'tthinkyou'llnoticearealchangeuntilyoutakethemedicationmore
consistently.Howaboutgivingitatry?"

Useaproblemsolvingstrategyfornoncompliance.

Whenpatientsarenotcompliantwithmedication,therapistsshouldtakeapractical,objective
approach. They should try to help patients clarify reasons or obstacles to compliance and
generatepracticalsolutions.Forexample,patientsmayreportdifficultyrememberingtotake
the medication. Practical strategies to cue the patient (e.g., notes on the bathroom mirror,
takingthemedicationataregularmealtime,enlistingfamilysupportandreminders)shouldbe
generatedandfolloweduponinthenextsession.Inallofthesediscussions,therapistsshould
be nonjudgmental and nonconfrontational. Efforts should be made to help patients feel
ownershipoftheplan.Thiscanbedonebyhavingthemtaketheprimaryroleindevelopingthe
plan,ratherthanhavingtherapiststellingthemwhattodo.

Chapter5

Session1:IntroductiontoTreatmentandCBT

TasksforSession1

Takehistoryandestablishrelationship

Enhancemotivation

PresenttheCBTmodel

Introducefunctionalanalysis

Negotiatetreatmentgoalsandtreatmentcontract

Providearationaleforextrasessiontasks

SessionGoals

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Thefirstsessionisthemostimportantandoftenthemostdifficultbecausethetherapistmustaddress
severalareas.

Begintoestablisharelationshipwiththepatient

Assessthenatureofthepatient'ssubstanceuseandotherproblemsthatmaybeimportant
factorsintreatment

Providearationaleforthetreatment

Establishthestructurefortheremainingsessions

Initiateskillstraining

Because of thecomplexity of the tasksinvolved inthe first session, the therapist should allow 90
minutes,ratherthanrelyonthetypical1hoursession.

KeyInterventions

HistoryandRelationshipBuilding

Therapistsshouldspendaconsiderableamountoftimeduringthefirstsessiongettingtoknowthe
patients, obtaining histories of them and their substance use, getting a sense of their level of
motivation,anddeterminingwhatledthemtoseektreatment.Thiscanoccurthroughaseriesofopen
endedquestionsthatshouldcoveratleastthefollowingareas.Reasons for seekingtreatmentand
treatmenthistory

Whatbroughtyouheretoday?

Haveyoueverbeenintreatmentforcocaineabusebefore?

Ifyes,whenwasthat?Howlongdidyoustaythere?Whatwasitlike?Whatdidyoulikeornot
likeabouttheprogram?Whydidyouleave?

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Have you ever been in treatment for abuse of other substances, like heroin, alcohol, or
benzodiazepines?

Historyandcurrentpatternofcocaineabuse

Whatisyourcocaineuserightnow?Howdoyouuseit?

Howoftendoyouusecocaine?Howmuchdoyouuse?

Whatisyourlongestperiodofabstinencefromcocaine?Whendiditstart?Stop?

Whatisthelongestperiodofabstinenceyou'vehadinthelast3months?Howdidthatstartand
end?

Whathaveyoutriedtodotocutdownonyourcocaineuse?

Howdoyougetcocaine?

Howmuchalcoholdoyoudrink?Howdoesdrinkingaffectyourcocaineuse?

Howlonghaveyoubeenabletonotdrink?

Whatothertypesofdrugsareyouusing?

Howdoyoufeelafterusingcocaine?

Howdidyourcocaineusegetstarted?

Otherproblemsandresources

Wheredoyoulive?Doesanyoneyoulivewithusecocaine?

Whoamongthepeopleyouspendthemosttimewithusedrugs?Whodoesn'tuse?

Areyouworkingnow?Howhasyourcocaineuseaffectedyouremployment?

Doesyourfamilyknowaboutyourcocaineuse?

Whenwasyourlastphysical?Doyouhaveanymedicalproblemsorworries?

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Doyouhaveanylegalproblems?Isprobationorparoleinvolvedwithyourdecisiontoseek
treatment?

Howdoyoufeelmostofthetime?Haveyoubeendepressedordown?Haveyoueverthought
abouthurtingyourself?Haveyoueverdoneso?Doesthathappenonlywhenyouusecocaine?

Haveyoueverbecomeparanoidorthoughtsomeonewasafteryouwhileusing?Whatwasthat
like?

If patients have been through an extensive pretreatment assessment battery, therapists should
attempttobesensitivetofurtherquestions.

"Iknowyou'vealreadyspentseveralhoursansweringquestions,butnowaswe'rebeginningtreatment,

Ihopeyoucananswerafewmorequestionsthatshouldhelpyouandmeplanwherewegofromhere."

EnhanceMotivation

Aspatientsrespondtotheabovequestions,thetherapistshouldlistencloselyforand,wherepossible,
elicitstatementsorcommentsfromthemconcerningtheirreasonsforseekingtreatmentorreducing
cocaineuse.SomeofthegeneralstrategiesrecommendedbyMillerandcolleagues(1992)forenhancing
motivationandavoidingresistanceareextremelyuseful.Thesearesummarizedbelow.

Elicitselfmotivationalstatements.

"Itsoundslike,fromwhatyou'vetoldme,thatyourparentsandyourprobationofficerareworried

aboutyourcocaineuse,butIwaswonderinghowyoufeelaboutit?"

"Tellmehowusingcocainehasaffectedyou."

"Whatbothersyoumostaboutyourcocaineuse?"

Listenwithempathy.

"Itsoundslikeyou'reworriedabouttakingallthisonatonce."

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"Youfeellikeyouwanttostop,butyou'reworriedbecauseyou'vetriedtreatmentbeforeandyou'vegone

backtococaineuseeachtime."

"Ononehand,youfeelnotseeingJerryasmuchwouldbeanimportantstepforwardforyoubecause

you'vealwaysusedwithhim,butontheotherhand,youworryaboutcuttingyourselfofffromafriend

you'vebeenclosetoforalongtime."

The therapist should avoid interrupting the patient, arguing with or challenging the patient, or

changingthesubject.

Rollwithresistance.

"You'renotsureyou'rereadytospendalotoftimechangingyourlifestylerightnow."

"Ithinkyou'rejumpingaheadabit;wecantakesometimetotalkaboutwhat'sthebestgoalforyou

andhowtoapproachit."

Pointoutdiscrepancies.

"You'renotsurecocaineisthatbigaproblem,butatthesametimealotofpeoplewhocareaboutyou

thinkitis,andgettingarrestedfordrugpossessioniscausingsomeproblemsforyou."

Clarifyfreechoice.

"There'snothingIoranyoneelsecandotomakeyoustopusingcocaine;whatyoudoisreallyupto

you."

"Youcandecidetotakethisonnoworwaituntilanothertime."

Reviewconsequencesofactionandinaction.

"Whatdoyouseehappeningifyoudon'tstopusingcocaine?"

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"Itsoundslikeyou'vegotsomeconcernsaboutslowingthingsdownwithJerry;whatdoyouthinkwill

happenifyoudon't?"

NegotiateTreatmentGoals

CBTforcocainedependenceisanabstinenceorientedtreatmentformanyreasons.Cocaineuse,even
insmallamounts,isassociatedwithavarietyofseriousmedicalandpsychiatricrisks.Furthermore,
unlikealcoholwheresomecognitivebehaviorallyorientedtreatmentsadvocateamoderatedrinking
goal,cocaineisanillicitdrugwithconsiderablelegalrisks.Clinically,betteroutcomesareusuallyseen
forpatientswhoareabstinent.

However,relativelyfewpatientscometotreatmentcompletelycommittedtoabstinence.Manyseek
treatmentbecauseofsomeexternalpersuasionorcoercion;otherswanttocutdowntoapointwhere
thenegativeconsequencesareeliminated,butcocaineusemightgoon.Forhighlyambivalentpatients,
cliniciansmustrecognizethatcommitmenttoabstinenceisaprocessthatoftentakesseveralweeksto
workthrough. Moreover,inmostpatients,abstinencetakesseveralweekstoachieveanddoesnot
occurallatonce.

Therapists should explicitly state that the goal of treatment is abstinence. However, for highly
ambivalentpatients,thisshouldbedoneinamannerthatacknowledgestheiruncertainty.

"Iknowyou'renotsureaboutstoppingcocaineusecompletely,andwe'llspendsometimeoverthenext

fewsessionstalkingaboutwhatyouwanttodecide.However,therearesomegoodreasonstoconsider

abstinencefromcocaine,aswellasabstinencefromotherdrugsandalcohol.Forexample,bytryingto

stopcompletelywhileyou'rehere,you'lllearnalotaboutyourselfandsomeofthefactorsthatmightbe

pushingyoutocontinueusing.Youmightalsofinditeasiertounderstandthecircumstancesthatmake

itmorelikelythatyouwilluseandsomethingsyoucandotostopusing.You'llalsoavoidsubstituting

othersubstancesforcocaine.Afteraperiodofabstinence,youcangetaclearideaofhowyouwillfeel

withoutcocaineinthepictureandcangetasenseofwhetherthat'swhatyoureallywanttodo.Youcan

alwayschangeyourmindlater.Whatdoyouthink?"

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Whilethisisashorttermtreatmentfocusedoncessationofcocaineuse,patientsoftenhaveanumber
ofcoexistingproblemsandconcerns.Somearerelatedtococainedependence,butsomearenot.While
theprimaryfocusoftreatmentshouldbestoppingcocaineabuse,itisimportanttorecognizeandhelp
patientssortthroughotherproblemsandsymptoms.

Therapistsshouldalsoaskwhetherpatientshaveothergoals,aswellashowstoppingsubstanceuse
mighthelpthemreachthosegoals(e.g.,regaincustodyoftheirchildren,gobacktowork).Inthecase
of problems that may be closely related to cocaine dependence (e.g., depressive symptoms, marital
conflict, legal problems), it is critical for therapists to acknowledge these, work with patients to
prioritizegoalsinrelationtococaineuse,negotiatereasonabletreatmentgoalsandhowthegoalsof
treatmentwillbeaddressed,andmonitortheseothertargetsymptomsandproblemsastreatment
proceeds.

"Iknowyou'vebeenfeelingdownandwanttotryProzacagain,butyou'vebeenabusingcocainefora

longtime,andit'sgoingtobehardtosortouthowmuchofhowyou'refeelingisrelatedtococaine

abuseandhowmuchmightbeadepressiveproblemthat'sseparatefromyourcocaineabuse.Thebest

waytotellisafteraperiodofabstinencefromcocaine.Generally,wefindthatdepressedfeelingswhich

last morethan a month afterthe last use indicate the need to address drug abuse and depression

separately,possiblywithmedicationforthedepression.Whatdoyouthinkaboutbeingabstinentfora

month,andthenconsideringareferraltoapsychiatristforamedicationevaluation?Inthemeantime,

italsosoundslikeweshouldspendsometimetalkingaboutfeelingdownandhowthatmightberelated

toyourcocaineuse."

***

"ItsoundsliketherehavebeensomeproblemswithBillyforalongtime,andhe'saskedyoutoleave,

butyouthinkthingsmightgetbetterifyoustopusingcocaine.Onethingwecandoinourworkisto

inviteBillytoattendasessionortwosohecanaskquestionsandlearnmoreaboutthistreatment

program,andthetwoofyoucantalkaboutwheretogofromhere.Afterwecompletethisfirst12weeks,

wemightalsothinkaboutareferraltofamilyservices.Howdoesthatsound?"

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PresenttheCBTModel

Next,therapistsshouldprovideanexplanationandrationaleforthetreatment.Thisshouldcoverthe
followingpoints.

Cocaineusecanbeseenaslearnedbehavior.

"Onewayoflookingatcocaineuseisthatit'ssomethingpeoplelearntodoovertime.Theylearnfrom

watchingotherpeopleuseit;theylearnwaystogetanduseit;theylearnthatcocainehascertaineffects

thatmaymakethemfeelmoreenergeticorattractiveorsocial.Asyou'vebeentalking,itseemslike

you'vebeendoingalotoflearningovertheyears,too."

Overtime,cocaineuseaffectshowpeoplethink,howtheyfeel,andwhattheydo.

"Thislearningprocessaffectsalotofthingsaboutapersonovertime.Peoplestartdevelopingcertain

beliefsaboutcocainelikeit'shardforthemtofunctionwithoutit.You'veprobablydevelopedyourown

setofbeliefsaboutcocaineabuse.Bylookingatthesebeliefs,we'llbeabletounderstandthembetterand

thatwillhelpyoulearnwaystostop.Cocainealsoaffectshowpeoplefeel.Somepeoplefinditmakes

themfeelbetterforashortperiodoftime,otherstalkaboutusingcocainetotrytostopfeelingsobad.

Over time, those feelings become associated with cocaine, and it's important to try to look at and

understandthesereactions.Finally,cocaineaffectswhatpeopledo.You'vealreadytalkedabouthow

cocaineissuchahabitforyou,thatit'ssomethingyoudowithouteventhinking."

Byunderstandingthisprocess,individualsfinditeasiertolearntostopusingcocaineandother
drugs.

"You've said there's a lot about cocaine that's pretty automatic for you, like how you don't even

remembergoingtoNewYorklastweek.Whatwe'lldoisspendalotoftimeslowingthatprocessdown.

Wewilllookatwhathappenslongbeforeyouuse,whatyou'rethinkingandfeelingandwhereyouare

using. We will look at what use is like for you, and we'll look at what happens after you use. By

understandingwhatseemssoautomaticnow,yourcocaineabusewillbealoteasiertocontrol."

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New,moreeffectiveskillscanreplaceoldhabitsthatleadtococaineuse.

"It'snotjustunderstandingtheseautomaticprocesses,it'salsodoingsomethingdifferentthathelps

peoplestopusing.You'vetalkedabouthowjuststoppingthecocaineandnotchanginganythingelse

doesn'treallyworkforyou.Reallystoppingcocainemeans learningtodothings differently.That's

where coping skills comein. Instead of responding to old cues and problems with cocaine, we'll be

talkingabout,andpracticing,new,moreeffectivewaysofcoping.Thisisn'talwayseasy,becauseyou've

learnedyourcocainecopingstyleoveralongperiodoftime.Whatwe'lldoishelpyouunlearnsomeold,

lesseffectivestrategiesandlearnsomenew,moreeffectiveones.It'lltakesometimeandalotofpractice

tolearnsomenewskills,butIbetifwelookatthetimeyouwereabstinentfor4monthslastyear,we'll

findyouusedsomeprettyeffectivecopingmechanisms."

Practiceisessential.

"Ittakespracticetryingoutnewwaysofrespondingtooldsituations.Onethingthatmighthelpisto

rememberthatittookalotoftimeforyoutolearnhowtobesuchaneffectivecocaineabuserhowtoget

themoney,buycocaine,useit,andnotgetcaught.That'sahighlydevelopedskillforyou.Sinceyou've

beendoingitforsolong,alotofotherkindsofskillsthatyoumighthavearen'tbeingpracticedand

won'tbenaturalforyouatfirst.That'swherepracticeofnewskillscomesin.We'llpracticeduring

sessions,buteachweekwe'llalsotalkabouthowyoucanpracticenewskillsoutsideoursessions.This

kind of practice is really important. It won't seem natural or easy at first. By sticking it out and

practicingoutsideofourmeetingsthough,you'lllearnalotaboutyourselfandwhatworksanddoesn't

work for you. You can always bring problems in and talk about new ways of coping. Can you see

yourselfdoingsomepracticeoutsideofsessions?"

EstablishTreatmentGroundRules

Inadditiontotreatmentgoalsandtasks,itisimportanttoestablishclearexpectationsforthepatient
intermsoftreatment,yourobligations,andthepatient'sresponsibilities.Thefollowingareasshould
bereviewedanddiscussed.

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Schedulingofsessionsandlengthoftreatment

Importanceofregularattendance

Callinginadvanceifthepatientwillmissthesessionorbelate

Collectionofaurinespecimenateachsession

Theneedtocometosessionsfreeofcocaine,alcohol,orotherdrugs

IntroduceFunctionalAnalysis

Therapists should work through a recent episode of cocaine use with patients, conducting a full
functionalanalysis.

"Togetanideaofhowallthisworks,let'sgothroughanexample.Tellmeallyoucanaboutthelast

timeyouusedcocaine.Wherewereyouandwhatwereyoudoing?Whathappenedbefore?Howwereyou

feeling?Whenwasthefirsttimeyouwereawareofwantingtouse?Whatwasthehighlikeatthe

beginning?Whatwasitlikelater?Canyouthinkofanythingpositivethathappenedasaresultof

using?Whataboutnegativeconsequences?"

PracticeExercise

The practice exercise (exhibit 2) asks patients to do a functional analysis of at least three recent
episodes of cocaine use. It follows closely the format of the functional analysis conducted by the
therapistwithinthesession.Therapistsmaywanttousethesheetasawithinsessionexample.

Exhibit 2: Functional Analysis

Trigger Thoughts, and Behavior Positive Negative

Feelings Consequences Consequences
What sets me up to What did I do then?
use? What was I What positive thing What negative thing
thinking? happened? happened?
What was I feeling?

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Source: Reprinted with permission from Jaffe et al. 1988.

Chapter5

Topic1:CopingWithCraving

TasksforTopic1

Understandingcraving

Describingcraving

Identifyingtriggers

Avoidingcues

Copingwithcraving

SessionGoals

Becausecravingissuchadifficultproblemforsomanycocaineabusers,thistopicisintroducedvery
earlyintreatment.Episodesofintensesubjectivecravingforcocaineareoftenreportedweeksand

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evenmonthsaftertheinceptionofabstinence.Thisexperiencecanbebothmystifyinganddisturbing
totheabuserandcanresultincocaineabuseifitisnotunderstoodandmanagedeffectively.

Thegoalsofthesessionareto

Understandthepatient'sexperienceofcraving.

Conveythenatureofcravingasanormal,timelimitedexperience.

Identifycravingcuesandtriggers.

Impartandpracticecravingandurgecontroltechniques.

KeyInterventions

UnderstandingCraving

Itisimportantforpatientstorecognizethatexperiencingsomecravingisnormalandquitecommon.
Cravingdoesnotmeansomethingiswrongorthatthepatientreallywantstoresumedruguse.(Much
ofthismaterialonkeyinterventionsusedwithepisodesofcravingwasadaptedfromKaddenetal.
1992.)

Becauseofthefrequencyandthevarietyofcircumstancesinwhichcocaineisselfadministered,a
multitude of stimuli have been paired with cocaine abuse. These may act as conditioned cues or
triggers for cocaine craving. Common triggers include being around people with whom one used
cocaine,havingmoneyorgettingpaid,drinkingalcohol,socialsituations,andcertainaffectivestates,
such as anxiety, depression, orjoy. Triggers for cocaine craving also arehighly idiosyncratic, thus
identificationofcuesshouldtakeplaceinanongoingwaythroughouttreatment.

Toexplaintheideasofconditionedcues,therapistsmightparaphrasePavlov'sclassicalconditioning
paradigmbyequatingfoodtococaine,theanimal'ssalivationtococainecraving,andthebellasthe
trigger. Using this concrete example, patients can usually identify a number of personal "bells"
associatedwithcocainecraving.TheexampleofPavlov'sexperimentsisoftenenoughtodemystifythe
experienceofcravingandhelppatientsidentifyandtolerateconditionedcravingwhenitoccurs.

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Itisalsoimportanttoconveythe timelimitednature ofcocainecraving,thatis,conditionedcraving

usuallypeaksanddissipatesinlessthananhour,ifnotfollowedbycocaineuse.Therapistsshouldalso

explaintheprocessofextinctionofconditionedresponses,againusingconcreteexamplesfromPavlov's
experiments.

DescribingCraving

Next,itisessentialtogetasenseofthepatients'experienceofcraving.Thisincludeselicitingthe
followinginformation.

Whatiscravinglikeforyou?

Cravingsorurgesareexperiencedinavarietyofwaysbydifferentpatients.Forsome,theexperience
isprimarilysomatic;forexample,"Ijustgetafeelinginmystomach"or"Myheartraces"or"Istart
smellingit."Forothers,cravingisexperiencedmorecognitively;forexample,"Ineeditnow"or"Ican't
getitoutofmyhead"or"Itcallsme."Oritmaybeexperiencedaffectively;forexample,"Igetnervous"
or"I'mbored."Itisimportantforthetherapisttogetaclearideaofhowcravingisexperiencedbythe
patient.

Howbotheredareyoubycraving?

Thereistremendousvariabilityinthelevelandintensityofcravingreportedbypatients.Forsome,
achievingandmaintainingcontrolovercravingwillbeaprincipaltreatmentgoalandtakeseveral
weekstoachieve.Otherpatientsdenytheyexperienceanycraving.Gentleexplorationwithpatients
who deny any craving (especially those who continue to use cocaine) often reveals that they
misinterpretavarietyofexperiencesorsimplyignorecravingwhenitoccursuntiltheysuddenlyfind
themselvesusing.Other,abstinentpatientswhodenytheyexperienceanycravingoften,whenasked,
admittointensefearsaboutrelapsing.

Howlongdoescravinglastforyou?

To make the point about the timelimited nature of craving, it is often important to point out to
patientsthattheyhaverarelyletthemselvesexperienceanepisodeofcravingwithoutgivingintoit.

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Howdoyoutrytocopewithit?

Getting a sense of the coping strategies used by patients will help the therapist identify their
characteristiccopingstylesandselectappropriatecopingstrategies.

IdentifyingTriggers

Therapistsshouldthenworkwithpatientstodevelopacomprehensivelistoftheirowntriggers.Some
patientsbecomeoverwhelmedwhenaskedtoidentifycues(onepatientreportedthatevenbreathing
wasassociatedwithcocaineuseforhim).Again,itmaybemosthelpfultoconcentrateonidentifying

thecravingandcuesthathavebeen most problematicinrecentweeks.Thislistshouldbestarted

duringthesession;thepracticeexerciseforthissessionshouldincludeselfmonitoringofcraving,so
patientscanbegintoidentifynew,moresubtlecuesastheyarise.

AvoidingCues

Keepinmindthatthegeneralstrategyof"recognize,avoid,andcope"isparticularlyapplicableto
craving.Afteridentifyingthepatients'mostproblematiccues,therapistsshouldexplorethedegreeto
which some of these can be avoided. This may include breaking ties or reducing contact with
individualswhouseorsupplycocaine,gettingridofparaphernalia,stayingoutofbarsorotherplaces
wherecocainewasused,ornolongercarryingmoney,asinthefollowingexample:

"You'vesaidthathavingmoneyinyourpocketisthetoughesttriggerforyourightnow.Let'sspend

sometimethinkingthroughwaysthatyoumightnothavetobeexposedtomoneyasmuch.Whatdoyou

thinkwouldwork?Isthereanamountofmoneyyoucancarrywithyouthatfeelssafe?Youtalkedabout

givingyourchecktoyourmotherearlier;doyouthinkthiswouldwork?You'vesaidthatshe'svery

angryaboutyourcocaineuseinthepast;doyouthinkshe'dagreetodothis?Howwouldyounegotiate

herkeepingyourmoneyforyou?Howcouldyouarrangewithhertogetmoneyyouneededforliving

expenses?Howlongwouldthisarrangementgoon?"

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Therapistsshouldspendconsiderabletimeexploringtherelationshipbetweenalcoholandcocainewith
patientswhousethemtogethertosuchanextentthatalcoholbecomesapowerfulcocainecue.Specific
strategiestoreduce,orpreferably,stopalcoholuseshouldbeexplored.

CopingWithCraving

Thevarietyofstrategiesforcopingwithcravingincludethefollowing.

Distraction

Talkingaboutcraving

Goingwiththecraving

Recallingthenegativeconsequencesofcocaineabuse

Usingselftalk

Therapistsmaywishtopointoutthatthesestrategiesmaynotstopcravingcompletely.However,with
practice, they will reduce the frequency and intensity of craving and make it less disturbing and
frustratingwhenitoccurs.

Distraction

In many cases, an effective strategy for coping with conditioned craving for cocaine is distraction,
especiallydoingsomethingphysical.Itisusefultopreparealistofreliabledistractingactivitiesin
conjunctionwithpatientsinanticipationoffuturecraving.Suchactivitiesmightincludetakingawalk,
playingbasketball,anddoingrelaxationexercises.Preparationofsuchalistmayreducethelikelihood
thatpatientswillusesubstances,particularlyalcoholandmarijuana,inillfatedattemptstodealwith
craving.Leavingthesituationandgoingsomewheresafeisoneofthemosteffectivewaysofdealing
withcravingwhenitoccurs.

TalkingAboutCraving

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Whenpatientshavesupportive,abstinentfriendsandfamilymembers,talkingaboutcravingwhenit
occursisaveryeffectivestrategyandcanhelpreducethefeelingsofanxietyandvulnerabilitythat
oftenaccompanyit.Itcanalsohelppatientsidentifyspecificcues.

Closefamilymembersmaybecomedistressedwhentheyhearpatientstalkaboutcravingbecausethey
expect it to lead to use. Therapists might spend some time identifying who patients would feel
comfortabletalkingwithaboutcraving,howthatpersonwouldbelikelytoreact,andwhetheritmakes
sensetoaskthatpersoninadvanceforsupport.

"Itsoundslikeyouthinktalkingtoyourwifemighthelp,butyou'vealsosaidthatshe'sverynervous

aboutwhatwouldhappenifyourelapsed.Doyouthinkshe'dbeabletolistenifyoutalkedwithherthe

next time you felt like using? Maybe you could talk to her about this before the next time you feel

craving,sothetwoofyoucanfigureouthowyou'llhandleitwhenitcomesup."

Sociallyisolatedpatients,orthosewhohavefewnonusingfriends,willfinditdifficulttonominatea
supportiveotherwhocanassistwithcraving,thoughtsaboutcocaine,andotherproblems.Thisshould
alert therapiststo theneed to consider addressing social isolation during treatment. For example,
therapists and patients can brainstorm ways of meeting new, nonusing others, reconnecting with
friendsandfamilymembers,andsoon.Tohelppatients"own"thesestrategiesandbemorelikelyto
initiate positive social contact, therapists might suggest applying the problem solving strategies
discussedintopic7.

GoingWithTheCraving

Theideabehindthistechniqueistoletcravingsoccur,peak,andpass;inotherwords,toexperience
themwithouteitherfightingorgivingintothem.Givingpatientstheimageryofawaveorwalking
overahillmayhelpconveythisconcept,asdoesjudo,thatis,gainingcontrolbyavoidingresistance.

Itoandcolleagues(1984)identifiedthestepsinvolved;theseshouldbepracticedwithinsessionsorat
homebeforecravingoccurs.Also,patientsshouldbetoldthatthepurposeisnottomakethecravings
disappear,buttoexperiencetheminadifferentwaythatmakesthemfeellessanxietyprovokingand
dangerousandthuseasiertorideout.Thestepsaresummarizedbelow.

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Payattentiontothecraving.Thisusuallyinvolves,first,findingsomeplacesafetoletoneself
experiencecraving(e.g.,acomfortableandquietplaceathome).Next,relaxandfocusonthe
experienceofcravingitselfwhereitoccursinthebodyormindandhowintenseitis.

Focusontheareawherethecravingoccurs.Thisinvolvespayingattentiontoallthesomaticand
affectivesignalsandtryingtoputthemintowords.Whatisthefeelinglike?Whereisit?How
strongisit?Doesitmoveorchange?Whereelsedoesitoccur?Afterconcentratinginthisway,
manypatientsfindthecravinggoesawayentirely.Infact,thepatientmayfinditusefultorate
theintensityofcravingbeforeandaftertheexercisetodemonstratetheeffectivenessofthe
technique.

RecallingNegativeConsequences

Whenexperiencingcraving, manypeoplehaveatendencytorememberonlythepositiveeffects of
cocaine; they often forget the negative consequences. Thus, when experiencing craving, it is often
effectiveforthemtoremindthemselvesofthebenefitsofabstinenceandthenegativeconsequencesof
continuingtouse.Thisway,patientscanremindthemselvesthattheyreallywillnotfeelbetterifthey
use.

To thisend, it may beuseful to ask patients tolist on a 3x 5 cardthe reasons theywant to be

abstinentandthenegativeconsequencesofuseandtokeepthecardintheirwalletoranotherobvious
place.Aglimpseofthecardwhenconfrontedbyintensecravingforcocaineorahighrisksituationcan
remindthemofthenegativeconsequencesofcocaineuseatatimewhentheyarelikelytorecallonly
theeuphoria.

UsingSelfTalk

Formanypatients,avarietyofautomaticthoughtsaccompanycravingbutaresodeeplyestablished
thatpatientsarenotawareofthem.Automaticthoughtsassociatedwithcravingoftenhaveasenseof
urgencyandexaggerateddireconsequences(e.g.,"Ihavetousenow,""I'lldieifIdon'tuse,"or"Ican't
doanythingelseuntilIuse").

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Incopingwithcraving,itisimportantbothtorecognizetheautomaticthoughtsandtocounterthem
effectively. To help patients recognize their automatic thoughts, therapists can point out cognitive
distortionsthatoccurduringsessions(e.g.,"Afewtimestodayyou'vesaidyoufeellikeyouhavetouse.
Areyouawareofthosethoughtswhenyouhavethem?").Anotherstrategyistohelppatients"slow
downthetape"torecognizecognitions.

"Whenyoudecidedtogooutlastnight,yousaidthatyoureallyweren'tawareofthinkingaboutusing

cocaine.ButIbetifwegobackandtrytorememberwhatthenightwaslike,sortofplayitbacklikea

movieinslowmotion,wecouldfindacoupleofexamplesofthingsyousaidtoyourself,maybewithout

evenrealizingit,thatledtococaineuse.Canyousortofplaylastnightbackforusnow?"

Onceautomaticthoughtsareidentified,itbecomesmucheasiertocounterorconfrontthem,using

positiveratherthannegativeselftalk.Thisincludescognitionssuchaschallengingthethought(e.g.,"I

won'treallydieifIdon'thavecocaine"),andnormalizingcraving(e.g.,"Cravingisuncomfortable,but
alotofpeoplehaveitandit'ssomethingIcandealwithwithoutusing").,/p>

PracticeExercises

Dependingonhowseriousaproblemcravingisforapatient,thistopiccanbedeliveredinoneortwo
sessions. When presented in two sessions, the first session focuses on recognizing craving and
identifying triggers, and the extrasession task includes making a more elaborate list of craving
triggersthroughselfmonitoring(exhibit3).Thesecondsessionthenfocusesonlearningandpracticing
copingstrategies,andtheextrasessiontasksinvolvecontinuingtoselfmonitorandalsoobservingthe
copingbehaviorsusedwhencravingoccurs.

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Exhibit 3: Coping With Cravings and Urges

Reminders:
Urges are common and normal. They are not a sign of failure. Instead, try to learn from them about what your
craving triggers are.
Urges are like ocean waves. They get stronger only to a point, then they start to go away.

If you don't use, your urges will weaken and eventually go away. Urges only get stronger if you give in to
them.

You can try to avoid urges by avoiding or eliminating the cues that trigger them.

You can cope with urges by -

o Distracting yourself for a few minutes.

o Talking about the urge with someone supportive.

o "Urge surfing" or riding out the urge.

o Recalling the negative consequences of using.

o Talking yourself through the urge.

Each day this week, fill out a daily record of cocaine craving and what you did to cope with craving.

Example:

Intensity
Length
of
Date/Time Situation, thoughts, and feelings of How I Coped
Craving
Craving
(1-100)

20
Friday, 3 pm Fight with boss, frustrated, angry 75 Called home, talked to Mary
minutes

Watching TV, bored, trouble staying 25

Friday, 7 pm 60 Rode it out and went to bed early
awake minutes

Saturday, 9 45
Wanted to go out and get a drink 80 Played basketball instead
pm minutes

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Daily Record of Cocaine Craving

Intensity
Length
of
Date/Time Situation, thoughts, and feelings of How I Coped
Craving
Craving
(1-100)

Adapted from Kadden et al. 1992.

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Chapter6

Topic2:ShoringUpMotivationandCommitmenttoStop

TasksforTopic2

Clarifyingandprioritizinggoals
Addressingambivalence

Identifyingandcopingwiththoughtsaboutcocaine

SessionGoals

Bynow,therapistsandpatientswillhavecompletedseveralfunctionalanalysesofcocaineuseand
highrisk situations, and patients have a clearer idea of the general approach to treatment. Most
patientshavealsoreducedtheircocaineusesignificantly(orevenstopped)atthispointandcanwork
toward a more realistic view of treatment goals than may have been possible in the first session.
Patientsaremoreawareoftherolecocainehasplayedintheirlives;theymaybeawareofrecurrent
thoughtsaboutcocaine,andtheymayalsobemorereadytosortthroughsomeoftheirambivalence
aboutcocaineabuseandtreatment.

Whilesomepatientsintendtofullyceasecocaineandothersubstanceuse,othersmayhaveslightly
differentgoals.

Reductionofcocaineuseto"controlled"levels
Cessationofcocaineusebutcontinuedhighuseofalcoholorothersubstances

Remainingintreatmentuntiltheexternalpressuresthatprecipitatedtreatmentseeking(e.g.,a
spouse'sultimatum,pressurefromanupcomingcourtcase)haveabated

Whilesuchgoalstendtobequiteunrealistic,itmaybewisefortherapists,particularlyintheearly
weeks of treatment, to not directly challenge them until a therapeutic alliance is established that
allows for a more informed reassessment. Allowing patients to recognize for themselves the

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impossibility of controlled cocaine use may be much more persuasive than a therapist's repeated
warnings. For example, a youngwomanmaintainedshecouldnot possiblyceasebothcocaineand
marijuanasimultaneously(becausesheattemptedtousemarijuanatocopewithcocainecraving)until
she discoveredthatherexcursionstobuymarijuanaled toavarietyofpowerfulcocainecuesand
usuallytoextendedcocainebinges.

Thegoalsofthissessionareto

Revisitandclarifytreatmentgoals.
Acknowledgeandaddressambivalenceaboutabstinence.

Learntoidentifyandcopewiththoughtsaboutcocaine.

KeyInterventions

ClarifyGoals

Thisisagoodtimetoexplorewithpatientstheircommitmenttoabstinenceandothertreatmentgoals.
By now, even patients who were pressured into treatment usually have begun to sort out the
consequencesofcontinuedcocaineuseinrelationtoothergoals.Thus,therapistsshouldcheckthe
patients'currentviewoftreatmentandreadinesstochange.

"I noticed that, eventhough youhaven't stopped completely, you've mentionedseveral times all the
problemscocainehascausedyou,likethejobandthetroublewithyourprobationofficer,andsomeof
theopportunitiesithascostyou,likespendingmoretimewithyourkidsastheyweregrowingup.Do
youhaveanythoughtsabouttheseproblems?Atthesametime,Ialsohearthattherearesomethings
aboutusingcocainethatyoureallymissrightnow.Ithoughtwecouldspendsometimethissession
talkingmoreaboutyourgoalsandhowwemightbeabletohelpyougetthere.Doyoufeelreadyfor
that?Whatareyouthinkingaboutyourcocaineuseatthispoint?Arethereotherproblemsyou'dliketo
tacklewhileweworktogether?"

Fromthisdiscussion,therapistsshouldbeabletogetaclearideaofthefollowing:

Thepatients'currentreadinessforchange
Theircurrentstancetowardabstinence

Asenseofothertargetgoalsandproblems

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Thisshouldbeanopenendeddiscussion,withtherapistsrefrainingfromtakingtooactivearoleor
supplying goals for patients. The techniques described by Miller et al. (1992) for strengthening
commitmenttochangecouldbeusedhere.

Communicatefreechoice(e.g.,"It'suptoyouwhatyouwanttodoaboutthis").
Emphasizethebenefitsofabstinenceasagoal.

Provide information and advice around the kinds of problems and issues that should be
addressedifthepatientistoremainabstinent.

Patientsmightbeencouragedtotalkabouttheirtreatmentgoalsanynumberofways(e.g.,"Haveyou
thoughtaboutwhereyouwanttobe12weeksfromnow?Whatabout12monthsfromnow?").This
discussionusuallyelicitsothertargetsymptomsandproblems,someofwhichmaybecloselyrelatedto
cocaine use (e.g., medical, legal, family/social, psychiatric, employment/support, and other types of
substanceabuseordependence).Othersmaybelesscloselyrelatedandthuslessimportanttoaddress
during treatment. Because this is a brief treatment focused on helping patients achieve initial
abstinence, therapists must balance the need to address problems that might pose barriers to
abstinencewiththeneedtokeeptreatmentfocusedonachievingabstinence.

Therapistsshouldworkwithpatientstoprioritizeothertargetproblems:

Isapsychosocialproblemlikelytoposeabarriertopatients'achievingabstinence? Therapists
shouldworkwithpatientstoidentifyseverepsychosocialproblemsthat,ifunaddressed,would
belikelytointerferewitheffortstobecomeabstinentormakelifesochaoticthattheywouldbe
unabletobefullyinvolvedintreatment.Examples includehomelessness,severepsychiatric
problems or symptoms including suicidal ideation or intent, and acute medical conditions.
Therapists should address such problems immediately and as appropriate. Significant
suicidalityorhomicidalityrequiresimmediatereferraltoanemergencyroom.Therapistsshould
alsoconsiderdevotingtimeduringeachsessiontocasemanagement(topic8).
Istheproblembestassessedandaddressedaftersomecontrolovercocaineuseisachieved?Many
patientspresentfortreatmentwithmoreconcernsabouttheconsequencesofchroniccocaine
dependencethanthedependenceitself.Avarietyofproblemsmaybecausedorexacerbatedby
cocainedependencewhich,whileofconcerntopatients,maybestbeaddressedaftertheyhave
become abstinent. For example, many patients' depression resolves with several weeks of
abstinence,oramaritalriftthatseemsunresolvablemayimprovewhenthespouseseesthe
patientmakinganearnestefforttocommittotreatmentandremainabstinent.

Therapists should not ignore such concerns but instead propose a plan for closely monitoring and
addressingtheproblemifitdoesnotimprovewithabstinence.

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"You'vetoldmeyou'vebeenfeelingreallydown,anditfeelslikeallthebillsarecomingdueat
once.That'snotunusualforsomeoneinthefirstfewdaysofabstinence.Sincesomedepressionis
verycommonforpeoplewhoareintheearlyphasesofabstinence,I'dliketocheckinwithyou
veryoftenabouthowyou'refeeling.Ifyoustayabstinentandaren'tfeelingbetterinafewweeks,
we might want to think about doing a more formal assessment of depression, possibly by
referringyoutoapsychiatrist.Howdoesthatsoundtoyou?"

Canaddressingtheproblemwait?Iftheproblemdoesnotposeabarriertotreatmentandisnot
directlyrelatedtococaineabuse,suggestwaitingtoaddressituntilafterthefirst12weeksin
ordertokeeptreatmentfocusedonachievingabstinence.Therapistsmightalsopointoutthat
problemsolvingskillswillbecovered,andtheycanbeappliedtoarangeofproblemsotherthan
cocainedependence.

AddressAmbivalenceAboutAbstinence

Ambivalenceisbestaddressedearlytofosteratherapeuticalliancethatallowsforopenexplorationof
conflictsaboutcessationofcocaineuse.Encouragepatientstoarticulatethereasonstheyhaveused
cocaine, help them "own" thedecision to stop use throughexploringwhat theystandtogain, and
underscoretheideathatcocaineabusecannotbedivorcedfromitsconsequences.

WefrequentlyuseasimplifiedversionofthedecisionmatrixdescribedbyMarlattandGordon(1985).
In this exercise, therapists use an index card and record the patients' descriptions of all possible
benefits of continued cocaine use, however subjective, on one side of the card. Somepatients have
initialdifficultyacknowledginganypositiveconsequencesofcontinuedcocaineabuse,butmostare
abletolistseveraljustificationslike"There'snothingelseasexcitinginmylife"or"Ifeellessanxious
withpeople"or"Igetmostofmymoneyfromsellingcocaine"or"Sexandcokegotogether."

Next,withopenendedquestions,therapistsencouragepatientstoexploreeachofthesestatedbenefits
(e.g.,"Havingmoneyinyourpocketsoundsimportant;whatelsedoessellingdoforyou?").Mostoften,
patientsindicatemanyoftheseareultimatelynegative.Forexample,ifthecocainehighwaslistedas
anadvantage,thenatureofthehighisexplored,andpatientsareremindedofthecrashanddysphoria
thatinvariablyfollowandenduremuchlongerthantheeuphoria.Patientswhosellcocaineremind
themselvesthatalloftheprofitsareusedtosupportcocaineuse.

Therapiststhenaskpatientstolistallpossiblereasonstostopcocaineabuseandwritetheseonthe
othersideofthecard.Thesearetypicallynumerousandreflectnegativeconsequencessuchas"Iwant
tokeepmyjob"or"Fewerfightswithmyparents"or"MoremoneyforthingsIwant."Patientsare

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instructedtokeepthecardintheirwallet,preferablyneartheirmoney.Aglimpseofthecardwhen
confrontedbyintensecravingforcocaineorahighrisksituationcanremindthemofthenegative
consequencesofcocaineabusewhentheyarelikelytorecallonlytheeuphoriaassociatedwiththe
high.

Thepowerofthisconcretereminderwasillustratedbyacocaineabuserwhoremovedthecardfromhis
walletbeforehewentoutoneeveningwhenheintendedtousecocaine;hefeltthecardhadliterally
"stoppedmefromusing"onseveralpreviousoccasions.

IdentifyingandCopingWithThoughtsAboutCocaine

Ambivalenceisoftenmanifestedinthoughtsaboutcocaineandusingthataredifficulttomanage.
Cocainewasanimportant,evendominant,factorinpatients'lives,andthoughts,bothpositiveand
negative,aboutcocainearenormalandlikelytolingerforsometime.Again,thestrategyhereisto
"recognize,avoid,andcope."

Recognize

Thoughtsassociatedwithcocainethatcanleadtoresumptionofusevarywidelyacrossindividualsand
their cognitive styles. Therapists should help patients identify their own cognitive distortions and
rationalizations("I'venoticedthatyoutalkaboutyourcocaineselfandyourstraightself;canyoutell
me more about your cocaine self?"). It is important that therapists also clearly define automatic
thoughts(e.g.,eitherathoughtorvisualimagethatyoumaynotbeveryawareofunlessyoufocus
yourattentiononit)andcognitions(e.g.,thingsyousaytoyourself).

Commonthoughtsassociatedwithcocaineincludethefollowing.

Testing control: "I can go to parties (see friends who are users, drink or smoke marijuana)
withoutusing."

Lifewillneverbethesame:"Ilovebeinghigh."

Failure:"Previoustreatmentshaven'tworked;there'snohopeforme."

Diminishedpleasure:"Theworldisboringwithoutcocaine."

Entitlement:"Ideserveareward."

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Feelinguncomfortable:"Idon'tknowhowtobewithpeopleifI'mnothigh."

Whatthehell:"Iscrewedupagain,Imightaswellgethigh."

Escape:"Mylifeissobad,Ijustneedabreakforafewhours."

Avoid

Avoiding thoughts associated with cocaine is not always possible, but individuals who tend to be
focusedonpositivegoalsseemtobelesstroubledbythem.Askingpatientstoarticulateandrecord
theirshortandlongtermgoalsoftenhelpsthemseebeyondtheimmediatetemptationsmorereadily
thanindividualswholackaclearfocusonthefuture.

For an insession exercise, have patients record their immediate (next week), shortterm (next 12
weeks),andlongterm(thenextyear)goals.Theseshouldbeasconcreteaspossible(e.g.,insteadof
"havealotofmoney,""haveajobpaying$12anhourbyOctober").

Cope

There are a number of strategies for coping with thoughts about cocaine.<$FThese strategies are
adaptedfromMontietal.1989.>

Thinkingthroughthehigh.Whilepatientsarebesetwithcravingorpositivethoughtsabout
cocaine,itisoftendifficulttorememberthedownsideofacocainebinge.Therapistscanask
patientstorelateaninstanceandcomeupwithanimageoftheendofaparticularlyunpleasant
cocainebinge.Forexample,onepatient'simageofwakingupnaked, robbed,andbeatenin
someone else's car in a town he did not know, was powerful enough to counter a range of
nostalgicthoughtsaboutcocaine.
Challengethethoughts.Foreachnegative,cocainerelatedthought,patientscanbeencouraged
togenerateandpracticepositivebeliefstocounterthem:"I'vedealtwithcravinginthepast,
andIcandoitagain"or"Keepingmyfamilytogetherismoreimportantthangettinghigh"or"I
used to have relationships where cocaine wasn't a part of the picture." These should be
individualized and tailored to each patient's cognitive style. Humor and reframing are
particularlyeffectivewaysofcounteringthoughtsaboutcocaineforsomepatients.

Reviewnegativeconsequences.Reviewinga3x5cardorpieceofpaperthatliststhepatient's
ownviewofthenegativeconsequencesofcocaineuseisapowerfulstrategytocountercraving
orthoughtsaboutcocaine.Makingone'sowncardisoneofthepracticeexercisesforthistopic.

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Distraction. Just as cravings peak and go away if resisted, so do thoughts about cocaine.
Thoughtsaboutcocainewillbecomelessstrong,lessfrequent,andlessupsettingifonedoesnot
giveintothem.Justasdistractionisaneffectivemeansofcopingwithcraving,havingalistof
activities that are pleasant (something enjoyable or stimulating), available (that could be
engaged in day or night, in good or poor weather), and realistic (not expensive or always
dependentontheavailabilityofothers)isaneffectivewayofcopingwiththoughtsforpatients
whohavetroublerelyingonothercognitivestrategies.

Talking.Justastalkingtoasupportivefriendorsignificantothercanbeaneffectivemeansof
pinpointing,understanding,andworkingthroughanepisodeofcraving,talkingthroughcocaine
thoughtsisoftenaneffectivewayofdispellingthem.Thoughtsthatseemcompellinganddire(I
can'tlivewithoutcocaine)oftenlosetheirpotencywhenexpressedtoothers.Therapistsshould
workwithpatientstoidentifyappropriateotherswithwhomtheycandiscussandworkthrough
thoughtsaboutcocainewhentheyoccur.

PracticeExercises

Whendoneastwosessions,thefirstsessionexerciseincludeshavingpatientscompletethe3x5card
ofpositiveandnegativeconsequencesofusingandthegoalworksheet(exhibit4).Thesecondsession's
exercise includes monitoring of thoughts, plus recording of coping skills (exhibit 5), similar to the
cravingsession.

Exhibit 4: Goals Worksheet

The changes I want to make during the next 12 weeks are:

The most important reasons why I want to make those changes are:

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The steps I plan to take in changing are:

The ways other people can help me are:

Some things that might interfere with my plan are:

The changes I want to make during the next 12 months are:

The most important reasons why I want to make those changes are:

The steps I plan to take in changing are:

The ways other people can help me are:

Some things that might interfere with my plan are:

Adapted from Miller et al. 1992.

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Exhibit 5: Coping With Thoughts About Cocaine

There are several ways of coping with thoughts about cocaine:

Thinking through and remembering the end of the last high
Challenging your thoughts

Recalling the negative consequences of cocaine use

Distracting yourself

Talking through the thought

Before the next session, keep track of your automatic thoughts about cocaine when they occur, and then
record a positive thought and coping skills.

Thought about cocaine Positive thought, coping skill used

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Adapted from Monti et al. 1989.

Chapter7

Topic3:RefusalSkills/Assertiveness

TasksforTopic3
Assessingcocaineavailabilityandthestepsneededtoreduceit
Exploringstrategiesforbreakingcontactswithindividualswhosupplycocaine

Learningandpracticingcocainerefusalskills

Reviewingthedifferencebetweenpassive,aggressive,andassertiveresponding

SessionGoals

A majorissue for manycocaine abusers is reducingavailability of cocaine and effectively refusing

offers of cocaine. Patients who remain ambivalent about reducing their cocaine use often have

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particular difficulty when offered cocaine directly. Many cocaine users' social networks have so
narrowedthattheyassociatewithfewpeoplewhodonotusecocaine,andcuttingoffcontactmaymean
social isolation. Also, many individuals have become involved in distribution, and extricating
themselvesfromthedistributionnetworkisdifficult.Manypatientslackthebasicassertivenessskills
toeffectivelyrefuseoffersofcocaineorpreventfutureoffersofcocaine.Thus,thissessionincludes
sectionsonreducingavailability,refusalskills,andareviewofgeneralassertivenessskills.

Therapists should carefully direct questions to ferret out covert indicators of ambivalence and
resistancetochangeandthesocialforcesworkingagainstchange.Failureofpatientstotakeinitial
steps toward removing triggers and avoiding cocaine may reveal a number of clinically significant
issues.

Ambivalencetowardstoppingcocaineuse(e.g.,theindividualwhoresistsbreakingtieswith
dealersortellingfamilyandfriendsofhisdecisiontostopuse)
Failuretoappreciatetherelationshipbetweencocaineavailabilityanduse(e.g.,theabuserwho
sellscocainebutmaintainsthathewillbeabletostopusingwhilestilldealing)

Markedlimitationsinpersonalorpsychosocialresources(e.g.,theunemployedsingleparent
livinginaneighborhoodwherecocaineisreadilyavailable)

Important indications of how actively patients will take part in treatment. If patients have
takennoindependentstepstowardlimitingcocaineavailability,theymaybeexpectingmere
exposuretotreatmenttomagicallyproduceabstinencewithlittleornoeffortontheirpart.

Thegoalsforthissessionareto

Assesscocaineavailabilityandthestepsneededtoreduceit.
Explorestrategiesforbreakingcontactswithindividualswhosupplycocaine.

Learnandpracticecocainerefusalskills.

Reviewthedifferencebetweenpassive,aggressive,andassertiveresponding.

KeyInterventions

AssessCocaineAvailability

Therapists and patients together should assess the current availability of cocaine and formulate
strategies to limit that availability. In particular, therapists should examine whether patients are
involvedinsellingcocaine,thenatureoftheircocainesources,andwhetherotherindividualsintheir
homeorworkplaceusecocaine.Determiningthestepspatientshavealreadytakentowardreducing
cocaineavailabilitymaybeaninvaluableindexoftheirinternalandexternalresources.Forexample,
havepatientsinformedcocaineusingassociatesoftheirintentiontostopusing?Havepatientswhosell
cocaineattemptedtoextricatethemselvesfromthedistributionnetwork?Itisvirtuallyimpossiblefor
anindividualtocontinuetosellcocaineandnotuseit.Therapistscanmakesomeusefulinquiries.

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"Ifyouwantedtousecocaine,howlongwouldittaketogetsome?Isthereanyinyourhouse?Areyou
stillholdingontopipes?"

"Thelastfewtimesyouused,yousaidTommycametoyourhouseandsuggestedyoutakeadrive.Have
youthoughtabouttalkingtoTommyaboutyourdecisiontostop?"

HandlingSuppliers

Inspite of itsillicit nature, cocaine may beoffered by arange of individuals friends, coworkers,
dealers, and even family members. Because such individuals frequently have financial or other
incentives (e.g., maintaining the status quo in a relationship) to keep abusers in the distribution
network,extricatingoneselfisoftenchallenging.Therapistsshouldreviewthepatients'suppliersand
explorestrategiesforreducingcontactwiththem.Insomecases,aclearandassertiverefusal,followed
byastatementthatthepatienthasdecidedtostopandarequestthatcocainenolongerbeoffered,can
besurprisinglyeffective.Inothercases,patientscanarrangetoavoidanycontactwithparticularusers
orsuppliers.

Whenpatientsareinaclose,intimaterelationshipwithsomeonewhousesandsuppliescocaine,the
problemismoredifficult.Forexample,itmaynotbeeasyforawomantoabstainwhenherpartner
supplies cocaine or continues to use, and she may not be ready to break off the relationship.
Furthermore,sometimesonlylimitedchangeinapatient'sstancetowardsucharelationshipcanbe
effectivelyundertakenin12weeksoftreatment.Ratherthanseeingthisaseitheror("Icaneitherstop
cocaineuseorgetoutoftherelationship"),therapistsshouldexploretheextenttowhichexposureto
cocainecanberenegotiatedandlimitsset.

"IhearyousaythatyoufeellikeyouwanttostaywithBobfornow,buthe'snotwillingtostopusing
cocaine.Beingthereisprettyriskyforyou,butmaybewecanthinkofsomewaystoreducetherisk.
Haveyouthoughtaboutaskinghimnottobringcocaineintothehouseoruseitinthehouse?You've
saidyouknowthere'salotofrisktoyouwhilehecontinuestodothat,bothintermsofyourstaying
abstinentaswellashavingdrugsaroundyourkids."

CocaineRefusalSkills

Thereareseveralbasicprinciplesineffectiverefusalofcocaineandothersubstances.

Respondrapidly(nothemmingandhawing,nothesitating).
Havegoodeyecontact.

Respondwithaclearandfirm"no"thatdoesnotleavethedooropentofutureoffersofcocaine.

Manypatientsfeeluncomfortableorguiltyaboutsayingnoandthinktheyneedtomakeexcusesfor
notusing,whichallowsforthepossibilityoffuturerefusals.Informpatientsthat"no"canbefollowed

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bychangingthesubject,suggestingalternativeactivities,andclearlyrequestingthattheindividual
notoffercocaineagaininthefuture.("Listen,I'vedecidedtostopandI'dlikeyounottoaskmetouse
withyouanymore.Ifyoucan'tdothat,Ithinkyoushouldstopcomingovertomyhouse.")

WithinSessionRolePlay

After reviewing the basic refusal skills, patients should practice them through roleplaying, and
problemsinassertiverefusalsshouldbeidentifiedanddiscussed.Sincethisisthefirstsessionthat
includesaformalroleplay,itisimportantfortherapiststosetitupinawaythathelpspatientsfeel
comfortable.

Pickaconcretesituationthatoccurredrecentlyforthepatients.
Askpatientstoprovidesomebackgroundonthetargetperson.

For the first roleplay, have patients play the target individual, so they can convey a clear
pictureofthestyleofthepersonwhoofferscocaineandthetherapistcanmodeleffectiverefusal
skills.Thenreversetherolesforsubsequentroleplays.

Roleplaysshouldbethoroughlydiscussedafterward.Therapistsshouldpraiseanyeffectivebehaviors
shownbypatientsandalsoofferclear,constructivecriticism:

"Thatwasgood;howdiditfeeltoyou?Inoticedthatyoulookedmerightintheeyeandspokerightup;
thatwasgreat.Ialsonoticedthatyouleftthedooropentofutureoffersbysayingyouhadstopped
cocaine'forawhile.'Let'stryitagain,butthistime,trytodoitinawaythatmakesitclearyoudon't
wantJoetoeverofferyoudrugsagain."

Passive,Aggressive,AndAssertiveResponding

Quiteoften,theroleplayswillrevealdeficitsinunderstandingandfeelingcomfortablewithassertive
responding.Forsuchindividuals,therapistsshoulddevoteanothersessiontoreviewingandpracticing
assertiveresponding.AnexcellentguidetothistopicisgiveninMontietal.(1989).

Keyareastoreviewincludedefiningassertiveness,reviewingthedifferencesbetweenresponsestyles
(passive, aggressive, passive aggressive, and assertive), body language and nonverbal cues, and
anticipatingnegativeconsequences.

RemindPatientsofTermination

Beginningaboutthesixthweekoftreatment,therapistsshouldstartremindingpatientsofthetime
limitednatureofthetreatment,andinsomecases,begineachsessionthereafterbypointingout"we
havexxweekstoworktogether."Itmaybehelpfultodiscussorreframeterminationasapotential
highrisk situation. Reemergence of slips and other symptoms is common in the last weeks of
treatmentandmaybeinterpretedinthiscontext(somightemergenceofnewproblemareas).

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Asterminationapproaches,therapistsmightalsoaskpatientstoimagineeveryhighrisksituation
theymightencounteraftertheyleavetreatment.Aftersuchrelapsefantasiesareelicitedandexplored,
specificcopingstrategiescanbedevelopedintheweeksapproachingtermination.Thisoftenmakes
patientsfeelmorecomfortableandconfidentabouttheirabilitytoendtreatment.

PracticeExercises

Thepracticeexercisesforthissessionincludemappingcocaineavailabilityand strategiestoreduce
availability(exhibit6) and anticipatingandrehearsingrefusals(exhibit7) toarangeofindividuals
whomightoffercocaine.

Exhibit 6: Managing Availability

List sources of cocaine here and what you'll do to reduce availability (for example, people who might
offer you cocaine, places you might get it).

Source Steps I'll take to reduce availability

Exhibit 7: Cocaine Refusal Skills

Tips for responding to offers of cocaine:

Say no first.
Make direct eye contact.

Ask the person to stop offering cocaine.

Don't be afraid to set limits.

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Don't leave the door open to future offers (e.g., not today).

Remember the difference between assertive, passive, and aggressive responses

People who might offer me cocaine What I'll say to them

A friend I used to use with:

A coworker:

At a party:

Adapted from Monti et al. 1989.

Chapter8

Topic4:SeeminglyIrrelevantDecisions

TasksforTopic4
UnderstandingSeeminglyIrrelevantDecisionsandtheirrelationshipstohighrisksituations
IdentifyingexamplesofSeeminglyIrrelevantDecisions

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Practicingsafedecisionmaking

SessionGoals

As treatment progresses, patients will invariably encounter highrisk situations related to cocaine,
evenwiththebestefforts.Certainexposuresarebeyondtheabuser'scontrol,forexample,livinginan
areawherecocaineaboundsbutlackingtheresourcestorelocate.

Anotherclassofexposures,however,thatpatientsoftenexperienceasbeyondtheircontrolactually
involvesbehaviorsdeterminedbythepatients.SeeminglyIrrelevantDecisions(MarlattandGordon
1985)refertothosedecisions,rationalizations,andminimizationsofriskthatmovepatientscloserto
orevenintohighrisksituations,althoughtheymayseemunrelatedtococaineuse.

Workingwith these Seemingly Irrelevant Decisions emphasizes the cognitiveaspects of treatment.

Thosewhobenefitmostfromthisprocesstendtopossessintactcognitivefunctionsandsomeabilityto
reflectupontheircognitiveandemotionallives.Thissessionisalsoparticularlyhelpfultoindividuals
whohavetroublethinkingthroughtheirbehavioranditsconsequences,suchaspatientswithresidual
attentiondeficit/hyperactivitydisorder,antisocialtraits,ordifficultywithimpulsecontrol.Forsuch
individuals,thematerialinthissession(aswellasthesessiononproblemsolving)oftentakessome
timetobeunderstoodandassimilated,butitisusuallyvaluedhighly.

Thegoalsofthissessionareto

UnderstandSeeminglyIrrelevantDecisionsandtheirrelationshipstohighrisksituations.
IdentifyexamplesofSeeminglyIrrelevantDecisions.

Practicesafedecisionmaking.

KeyInterventions

UnderstandSeeminglyIrrelevantDecisions

AcriticaltaskfortherapistsistoteachpatientshowtorecognizeandinterruptSeeminglyIrrelevant
Decisionchainsbeforetheonsetofactualuse.Whileitispossibletointerruptsuchachainatany
pointpriortouse,itismoredifficulttowardtheendofthechainwhenpatientsmayalreadybein
situations where cocaine is available and conditioned cues abound. Thus, it is desirable to teach
patientshowtodetectthedecisionsthatcommonlyoccurtowardthebeginningofthechain,where
risk,craving,andavailabilityofcocainearerelativelylow.

Thismayinvolvepatients'learningtodetectsubtlebutpainfulaffectstatesthattheyfrequentlytryto
counterwithcocaine,suchasboredomorloneliness.Itofteninvolvesfamiliarizingpatientswiththeir
distortionsofthinking(e.g.,rationalizations,denial)sothesemaybedetectedandusedassignalsfor
greatervigilance.

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Certaindistortionsarefairlycommon,suchasthethought,"Icouldhandlegoingtoabar."Others,
however,aremorereflectiveofthepatient'scognitivestyle.Forinstance,onepatienttendedtoproject
histhoughtsontoothers.Indescribingarelapse,duringwhichthepatienthadencounteredafriend
whohadcocaine,thepatientstated,"Icaughthimwithhisguarddown."Anotherpatient,recountinga
slip,describedthevariousthoughtsheexperiencedpriortowindingupinanareaoftownwherehis
formerdealerresidedandwherethepatienteventuallyusedcocaine.Hestatedthatearlierhethought
"Ihavetogotothebakery"which"happened"tobeinahighriskarea,buthehadnotlinkedthiswith
adesiretouse.Thetherapistpointedoutthathisuseof"Ihaveto..."soundedverymuchlikecraving.
Here,again,thepatientcouldnowcatchhimself"having"todocertainthingswhichledtohighrisk
activitiesorlocations.

Another variation of this phenomenon occurs in treatment when patients tell therapists that they
"have"totake"thisvacation,""attendthatparty,""spendtime"withparticulardrugusingfriends,and
soon.Theseprovidetherapistswiththeopportunitytorelatethepatients'urgencytoengageinsuch
activitieswiththeurgetousecocaine.

SeeminglyIrrelevant Decisions are dealt with byapplyingrecognize, avoid, and cope recognizing
Seemingly Irrelevant Decisions and the thoughts that go with them, avoiding risky decisions, and
copingwithhighrisksituations.

"I'mgoingtotellyouastoryaboutapersonwhomadeseveralSeeminglyIrrelevantDecisionsthatled
toahighrisksituationand,eventually,arelapse.AsItellyouthestory,trytopickoutthedecisions
thathemadealongthewaythat,takentogether,madehimmorevulnerabletousingcocaine.Hereis
thestory:

"Joe,whohadbeenabstinentforseveralweeks,drovehomefromworkonanighthiswifewasgoingto
beaway.Ontheway,heturnedleftratherthanrightatanintersectionsohecouldenjoythe'scenic
route.'Onthisroute,hedrovepastabarhehadfrequentedinthepastandwherehehadboughtand
usedcocaine.Becausetheweatherthatdaywashot,hedecidedtostopinforaglassofcola.Onceinthe
bar,however,hedecidedthatsincehisproblemwaswithcocaine,itwouldbefinetohaveabeer.After
twobeers,heranintoafriendwho'happened'tohaveagramofcocaineandarelapseensued.

"WhendidyouthinkJoefirstgotintotrouble,or'thought'aboutusingcocaine?Oneofthethingsabout
thesechainsofdecisionsthatleadtococaineuseisthattheyarefareasiertostopinthebeginningofthe
chain.Beingfartherawayfromcocaine,itiseasiertostopthedecisionmakingprocessthanwhenyou're
closertococaineuseandcravingkicksin.

"WhatdoyouthinkJoewassayingtohimselfatthepointhetookthescenicroutehome?Weoftenfind
that people making Seemingly Irrelevant Decisions can catch themselves by the way they think
thoughts like 'I have to do this' or 'I really should go home this way' or 'I need to see soandso

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because...' These end up being rationalizations, or ways of talking oneself into cocaine use without
seeming to do so. I've noticed sometimes that you talk yourself into highrisk situations by telling
yourselfasituationissafe,whenitreallymaynotbe,likewhenyoutoldyourselflastweekthatitwas
safeforyoutogohangoutintheparkwithyourfriends.Canyouthinkofotherexamplesofwaysyou
mighthavetalkedyourselfintoariskysituation?"

IdentifyPersonalExamples

TherapistsshouldencouragepatientstorelatearecentexampleofachainofSeeminglyIrrelevant
Decisions.

"Canyouthinkofyourownrelapsestory?

"Now,let'sgothroughitandtrytopinpointtheplaceswhereyoumaderiskydecisions,whatyouwere
tellingyourself,andhowyoucouldhaveinterruptedthechainbeforeyouwoundupintheparkwith
nothingtodo."

PracticeSafeDecisionmaking

Therapistsneedtostressthenotionofsafedecisionmaking.

"AnotherimportantthingtoknowaboutSeeminglyIrrelevantDecisionsisthatifyoucangetyourself
intothepracticeofrecognizingallthesmalldecisionsyoumakeeveryday,andthinkingthroughsafe
versusriskyconsequencesforthosedecisions,youwillbelessvulnerabletohighrisksituations."

"ReturningtothestoryofJoe,whatweretheSeeminglyIrrelevantDecisionshemadeandwhatwould
havebeensaferdecisionsforhim?"

"Let'sgothroughafewthingsthathavehappenedtoyouinthelastfewweeksandtrytoworkthrough
safeversusriskydecisions."

SomeSeeminglyIrrelevantDecisionsarecommonamongcocaineabusers.

Usinganyalcohol,marijuana,orotherdrugs
Keepingalcoholinthehouse

Notdestroyingcocaineorcrackparaphernalia

Goingtopartieswherealcoholorcocainemightbeavailable

Interactingwithpeoplewhoarecocaineabusers

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Keepingpastcocaineabuseasecretfromfamilymembers

Nottellingcocaineabusingassociatesofthedecisiontostop

Notplanningtofillfreetime

Havingalotofunscheduledtimeonnightsorweekendsthatcanleadtoboredom

Gettingovertiredorstressed

PracticeExercise

Thepracticeexerciseforthissessionincludesselfmonitoringofdecisionsoverthecourseofseveral
days and, for each one, identifying safe versus risky decisions (exhibit 8). Remind patients that
treatmentwillendsoon,andtheywillbeusingtheseskillsontheirown.

Exhibit 8: Seemingly Irrelevant Decisions

When making any decision, whether large or small, do the following:

Consider all the options you have.
Think about all the consequences, both positive and negative, for each of the options.

Select one of the options. Pick a safe decision that minimizes your risk of relapse.

Watch for "red flag" thinking - thoughts like "I have to . . .", or "I can handle . . ." or "It
really doesn't matter if . . ."

Practice monitoring decisions that you face in the course of a day, both large and small, and consider
safe and risky alternatives for each.

Decision Safe alternative Risky alternative

Adapted from Monti et al. 1989.

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Chapter9

Topic5:AnAllPurposeCopingPlan

TasksforTopic5
Anticipatingfuturehighrisksituations
Developingapersonal,genericcopingplan

SessionGoals

Despitepatients'bestefforts,avarietyofunforeseencircumstancesmayarisethatresultinhighrisk
situations.Theseoftenhavetodowithmajor,negativestressfuleventsorcrises,suchasthedeathor
sicknessofalovedone,learningoneisHIVpositive,losingajob,thelossofanimportantrelationship,
andsoon.However,positiveeventscanalsoleadtohighrisksituations.Thesecouldincludereceiving
alargeamountofmoneyorstartinganewintimaterelationship.Sincesucheventsmayoccuranytime,
duringaswellasaftertreatment,patientsareencouragedtodevelopanemergencycopingplanwhich
theycanrefertoanduseshouldsuchcrisesoccur.

Thegoalsofthissessionareto

Anticipatefuturehighrisksituations.
Developapersonal,genericcopingplan.

KeyInterventions

AnticipateHighRiskSituations

Therapistsshouldpointoutthatalthoughpatientswillfindithelpfultorecognize,avoid,andcope
with highrisk situations, life is unpredictable, and not all highrisk situations can be anticipated.
Crises,negativestressors,andevenpositiveeventscanresultinhighrisksituations.

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Therapistsshouldaskpatientstothinkofthreeorfourmajorstressorsthatmightariseoverthenext
fewmonths,aswellaswhattheirreactionsmightbe.Thenaskthemtoanticipateanythingthatmight
happen to shake their commitment to abstinence. For each of these situations or circumstances,
therapistsandpatientsshoulddevelopconcretecopingplans.

DevelopaCopingPlan

Whenpatientsaremoststressed,theymayfeelvulnerableandbemorelikelytoreturntoold,familiar
coping strategies than use the healthier but less familiar strategies they have practiced during
sessions.Itisimportanttotrytodevelopageneric,"foolproof"copingstrategythatcanbeusedinthe
eventofanymajorcrisis.Thisshouldinclude,atminimum,thefollowing.

Asetofemergencyphonenumbersofsupportiveotherswhocanbereliedon
Recallofnegativeconsequencesofreturningtouse

Asetofpositivethoughtsthatcanbesubstitutedforhighriskcocainethoughts

Asetofreliabledistracters

Alistofsafeplaceswherethepatientcanrideoutthecrisiswithfewcuesortemptationstouse
(e.g.,aparent'sorfriend'shouse)

PracticeExercise

Thepracticeexerciseforthissessionincludesanticipatingsomecrisesandresponsesanddeveloping
theallpurposecopingplan(exhibit9).Remindpatientsthattreatmentwillendsoon,andtheywillbe
usingtheseskillsontheirown.

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Exhibit 9: All-Purpose Coping Plan

Remember that running into problems, even crises, is part of life and cannot always be avoided,
but having a major problem is a time to be particularly careful about relapse.

If I run into a high-risk situation:

1. I will leave or change the situation.
Safe places I can go:

2. I will put off the decision to use for 15 minutes. I'll remember that my cravings usually go away in ___
minutes and I've dealt with cravings successfully in the past.

3. I'll distract myself with something I like to do.

Good distractors:

4. I'll call my list of emergency numbers:

Name:
Name:
Name:

5. I'll remind myself of my successes to this point:

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6. I'll challenge my thoughts about using with positive thoughts:

Source: Adapted from Jaffee et al. 1988.

Chapter10

Topic6:problemsolving

TasksforTopic6
Introducingthebasicstepsofproblemsolving
Practicingproblemsolvingskillswithinthesession

SessionGoals

Overtime,manypatients'repertoiresofcopingandproblemsolvingskillshavenarrowedsuchthat
cocaine or other substance abuse has become their single, overgeneralized means of coping with
problems.Manypatientsareunawareofproblemswhentheyariseandignorethemuntiltheybecome
crises.Manyothers,particularlythosewhohaveimpulsivecognitivestylesorwhoareunaccustomedto
thinkingthroughalternativebehaviorsandconsequences,findthistopicparticularlyuseful.Others
think theyhavegoodproblemsolvingskillsbut,whenconfrontedwithaproblem,arelikelytoact
impulsively,makingpracticeofthisskillwithinsessionsparticularlyimportant.

Thissession(ThissectionisadaptedcloselyfromMontietal.1989aswellasKaddenetal.1992and
D'ZurillaandGoldfried1971.)providesabasicstrategythatcanbeappliedtoarangeofproblems
relatedtococaineabuseaswellasthevarietyofproblemsthatwillinvariablyariseafterpatients
leave treatment. Despite many patients' fantasies that life will be easier and problem free after
stoppingcocaineuse,oftentheybecomeawareofproblemstheyhaveneglectedorignoredonlyafter
becomingabstinent.

Thegoalsofthissessionareto

Introduceorreviewthebasicstepsofproblemsolving.
Practiceproblemsolvingskillswithinthesession.

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KeyInterventions

IntroducetheBasicSteps

Therapists should convey that everyone has problems from time to time and that most can be
effectivelyhandled.Also,althoughhavingaproblemmaymakeoneanxious,effectiveproblemsolving
takestimeandconcentration,andtheimpulsivefirstsolutionisnotnecessarilythebest.

Therapistsshouldreviewthebasicstepsinproblemsolvingsummarizedbelow.(AdaptedfromD'Zurilla
andGoldfried1971andMontietal.1989.)

Recognizetheproblem("Isthereaproblem?").

Recognitionofproblemsmaycomefromseveralclues,includingworry,anger,anddepression;
havingproblemspointedout byothers;beingpreoccupied;andalways feelinglikeoneis in
crisis.

Identifyandspecifytheproblem("Whatistheproblem?").

Itiseasiertosolveproblemsthatareconcreteandwelldefinedthanthosethatareglobalor
vague.Forlargeproblemsthatseemoverwhelming,itisimportanttotrytobreakthemdown
intosmaller,moremanageablesteps.

Considervariousapproachestosolvingtheproblem("WhatcanIdotosolvetheproblem?").

An effective way to approach this is to brainstorm, that is, generate as many solutions as
possiblewithoutconsidering,atfirst,whicharegoodorbadideas.Itismoreimportanttotryfor
quantity,ratherthanquality,inthebeginning.Writingtheseideasdownisveryhelpfulin
cases where patients may want to return to the list in the future. It is also important to
recognizethatnotdoinganythingimmediatelyisanoption.

Selectthemostpromisingapproach("Whatwillhappenif...?").

Thisstepinvolvesthinkingahead. Revieweachapproach,consideringboththepositiveand
negativeconsequencesofallsolutions.Thisstepmayalsoinvolvecollectingmoreinformation
andassessingwhethersomesolutionsarefeasible(e.g.,"CanIborrowTom'scartotakethe
drivingtest?").

Assesstheeffectivenessoftheselectedapproach("WhatdidhappenwhenI...?").

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Therapistsmayneedtopointoutthatwhilesomeproblemsareeasytosolve,othersaremore
difficult.Itmaybenecessarytorepeatstepsonethroughfiveseveraltimesbeforeacomplex
problemissolved.

Forimpulsivepatients,itisimportanttowritedowntheproblemandtheselectedapproachsothatthe
stepsarenotforgottenwhenitistimetoimplementthem.

PracticeproblemsolvingSkills

Therapistsshouldaskpatientstoidentifytworecentproblems,onethatiscloselyrelatedtococaine
abuse and one that is less so, and work with them through the problem solving steps for both.
Therapistsmayhavetohelppatientsslowdown,becausesomewillhavedifficultyrecognizingcurrent
problems. Others will quickly select a solution since they lack practice with brainstorming and
consideringalternatives.

PracticeExercise

Therapistsaskpatientstopracticeproblemsolvingskillsoutsideof thesessions usinga reminder

sheetforproblemsolving(exhibit10).Remindpatientsthattreatmentwillendsoon,andtheywillbe
usingtheseskillsontheirown.

Exhibit 10: Reminder Sheet For problem solving

These,inbrief,arethestepsoftheproblemsolvingprocess.

"Isthereaproblem?"Recognizethataproblemexists.Wegetcluesfromourbodies,our
thoughts and feelings, our behavior, our reactions to other people, and the ways that
otherpeoplereacttous.

"Whatistheproblem?"Identifytheproblem.Describetheproblemasaccuratelyasyou
can.Breakitdownintomanageableparts.

"WhatcanIdo?"Considervariousapproachestosolvingtheproblem.Brainstormtothink
ofasmanysolutionsasyoucan.Consideractingtochangethesituationand/orchanging

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thewayyouthinkaboutthesituation.

"Whatwillhappenif...?"Selectthemostpromisingapproach.Considerallthepositive
and negative aspects of each possible approach and select the one likely to solve the
problem.

"Howdiditwork?"Assesstheeffectivenessoftheselectedapproach.Afteryouhavegiven
theapproachafairtrial,doesitseemtobeworkingout?Ifnot,considerwhatyoucando
tobeefuptheplan,orgiveitupandtryoneoftheotherpossibleapproaches.

Selectaproblemthatdoesnothaveanobvioussolution.Describeitaccurately.Brainstormalistof
possiblesolutions.Evaluatethepossibilities,andnumberthemintheorderofyourpreference.

Identifytheproblem:

Listbrainstormingsolutions:

Source:Montietal.1989

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Chapter11

Topic7:CaseManagement

TasksforTopic7
Reviewingandapplyingproblemsolvingskillstopsychosocialproblemsthatpresentabarrier
totreatment
Developingaconcretesupportplanforaddressingpsychosocialproblems

Monitoringandsupportingpatients'effortstocarryouttheplan

SessionGoals

Mostpatientswillpresentfortreatmentwitharangeofconcurrentpsychosocialproblemsinaddition
tococaineabuse.Someproblemsarebestassessedandaddressedafterpatientshaveachievedaperiod
ofstableabstinence,whileotherproblems,ifunaddressed,arelikelytopresentbarrierstotreatment
andunderminethepatients'effortstobecomeabstinent.Thus,todealwiththeseissues,therapists
mayengageinmodified"casemanagement."

In this approach, therapists do not serve as advocates for patients outside of sessions. Rather,

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therapistsuseproblemsolvingstrategies within treatmenttohelppatientscontactandmakeuseof

thesocialservicesystem.Theintentistobuildpatients'selfefficacyinrecognizingandcopingwith
concurrentproblemsandinsuccessfullyusingthenetworkofavailablesocialserviceagencies.

Tobeeffective,therapistsshouldbeknowledgeableaboutthecommunity'sservicesystem,withcurrent
informationonthetypeofservicesprovidedbyeachorganization,thetypesofpatientsservedbythe
organization,eligibilityrequirements,sourcesforalternativeservices,andreasonabletimeframesfor
varioustypesofservicedelivery.Therapistsshouldhelppatientstransformtheirgoalsintoaservice
planandhelpthemarticulatethestepsneededtoattainthesegoals.

Thegoalsofthistopicareto

Review and apply problem solving skills to psychosocial problems that present a barrier to
treatment.
Developaconcretesupportplanforaddressingpsychosocialproblems.

Monitorandsupportpatients'effortstocarryouttheplan.

KeyInterventions

ProblemIdentification

Earlyintreatment,therapistsshouldhaveidentifiedproblemsthatwouldbebarrierstoabstinence.
Informationusefulinidentifyingrelevant psychosocial problemsmayalsocomefrom pretreatment
assessments,particularlytheAddictionSeverityIndex.

GoalSetting

Therapistsandpatientstogethershouldidentifyandprioritizethethreeorfourmajorproblemsthey
willfocusonduringtreatmentandspecifyconcretegoalsforeach(e.g.,haveastableplacetoliveby
theendofthemonth,enterajobtrainingprogrambytheendofAugust).Asneeded,therapistsshould
alsoreviewthebasicstepsinproblemsolving,sincethatmodelisusedtoworkthroughthesetarget
problems.

ResourceIdentification

Withthegoalsclarified,therapistsandpatientsthenbrainstormsolutionsandtheresourcesneededto
resolveeachofthetargetproblems.

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SpecifyingaPlan

Once problems are identified and goals set, therapists and patients should begin to work on the
supportplan,whichissimplyaconcretestrategythatoutlineshowpatientswillfollowthroughon
reachingtheirgoals.Thesupportplanshouldinclude,foreachgoal,specificationof who or which
agencyistobecontacted,whenthecontactistobemade,whatservicesorsupportaretoberequested,
andtheoutcomeofthecontact.Thesupportplanthusservesasakindoflog,ororganizingforce,in
patients'effortstoobtainneededservices.Itwillalsoprovidearecordoftheireffortsandsuccessesin
thisareaand,thus,bolstertheirselfefficacy.

MonitoringProgress

Although patients are to take primary responsibility in following the support plan and obtaining
needed services, it is essential that therapists closely monitor their efforts to follow through. This
shouldtakeplaceat everysubsequentsession;thus,therapistsshouldspendtimeduringtheinitial
phaseofthenextsessions(e.g.,thefirst20minutesofa20/20/20session)monitoringpatients'success
inimplementingtheirplans.Similarly,aportionoftheclosingofeachsessionshouldbedevotedto
reviewingthestepsforimplementingthesupportplanduringthecomingweek.

Therapistsshouldaffirmpatientsandpraisetheireffortsincarryingouttheirplansenthusiastically
and genuinely. Even small steps shouldbeseen as significant andbe met with praise. Therapists
should convey confidence that patients can, and will, successfully complete the support plans and
obtainneededservices.Inthisstrengthsbasedapproach,therapistsassumethatpatientshavethe
resourcesandskillstoobtainneededservices,bothwithintreatmentandaftertreatmentends.

Therapist: "I'm really impressed that you were able to arrange a place for yourself at Transitional
Housing.Iknowyouhadrealquestionsaboutwhetheryoucouldhandlealltheadmissionstepsonyour
own,butitsoundslikeyouhunginthere,werepersistentwhenMrs.Xputyouonholdseveraltimes,
andkeptreschedulingthoseinterviewsuntilyougotit.Itsoundslikeitwasn'teasy,butyoureally
madeithappen.Howdoyoufeelabouthowyouhandledit?"

Patient:"Likeyousaid,itwasn'teasy,andonceortwiceIfeltliketellingthemoff,butIjustkepttelling
myselfIreallyneededasafeplacetoliveandthatIcoulddoit."

Therapist:"Youknow,yousoundandlooklikeyou'rereallyproudofyourself,andyourprideiswell
deserved.Knowinghowtoworkthesocialservicesystemisanimportantskill,andoneIseeyougetting

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betterandbetterat.Haveyouthoughtaboutyournextstep?"

PracticeExercise

Thepracticeexerciseforthisweekincludes followingthroughonthe support plan(exhibit 11)and

reportingbackonthesuccessesorproblemsthepatientsexperiencedincarryingouttheplan.Remind
patientsthattreatmentwillendsoon,andtheywillbeusingtheseskillsontheirown.

Exhibit 11: Support Plan

Whoistobe
Whenwillthe
Whatismy contacted? Whatservices
contactbe Outcome
goal? (Phone#, willIrequest?
made?
address)

Goal1

Goal2

Chapter12

Topic8:HIVRiskReduction

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