CBT - Treating Cocaine Addiction - Termination

Final Session: Termination

Tasks for the Termination Session

  • Reviewing the treatment plan and goals
  • Getting feedback from therapists on their view of patients' progress
  • Getting patients' feedback on the most and least helpful aspects of treatment

Session Goals

The major function of the last session is a final review.

    • Review the treatment plan and goals, identifying areas in which the patients' goals were met and progress was made, as well as areas where less progress was made and further attention may be warranted.
    • Therapists should provide feedback on their view of the progress made by the patients, and particularly the skills and principles that were mastered and those that patients might continue to focus on.
    • Patients should provide feedback on the most and least helpful aspects of treatment, as well as their concerns about what will happen after they leave treatment.

Some patients, particularly those who have not achieved stable abstinence, should be encouraged to continue in treatment in either a clinical program or inpatient or day-treatment facilities, as appropriate.

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CBT - Treating Cocaine Addiction - Significant Other

Significant Other Sessions

Tasks for Significant Other Sessions

  • Offering significant others the opportunity to learn about the treatment in which the patient is involved
  • Exploring strategies through which they can help the patient become and remain abstinent

Session Goals

Therapists may allow patients to invite a close family member or friend to attend up to two of the CBT sessions. The purpose of their attendance is to enhance the level of social support.

Significant other sessions are conducted within a cognitive-behavioral model.(This is drawn from the work of O'Farrell 1993 and McCrady and Epstein 1995.) Therapists should remember that the goals of these sessions are limited and should not reflect marital or family therapy.

The goals of this session are to:

    • Offer significant others the opportunity to learn about the treatment in which patients are involved.
    • Explore strategies through which they can help patients become and remain abstinent.

Key Interventions

Plan Ahead

Significant other sessions should be carefully planned in advance by patients and therapists together. Three key issues should be addressed:

    • Who should attend the significant other session?In selecting significant others, patients and therapists should focus on identifying others who are likely to be able to provide support to the patient, as well as individuals who are close to the patient (spouses, partners, parents, siblings) and who are not substance abusers themselves. Significant others who are substance abusers are unlikely to offer substantial, meaningful support to the patients.
    • What are the goals of the session?Unless clear goals are articulated and shared with the significant other in advance, the sessions may become a mere recounting of old wrongs and resentments, rather than focusing on planning for positive change.
    • How can the significant other offer support?It is advisable for patients to think in advance about what kind of support they would like from the significant other. These should be as concrete and clear as possible.

Provide Information/Set Goals

Typically, therapists begin the session by greeting the significant others, praising them for coming in and offering support to the patient, providing some ground rules for the session, and reiterating the session goals. Substantial amounts of time should be allotted for answering questions about the treatment. Some significant others see this as an opportunity to relate complaints and express anger and distrust about the patient. Some limited "letting off steam" may be expedient and, if well managed, can enhance the patient's motivation to change (e.g., "What changes would you like Kris to make?" or "What concerns you about Kris' cocaine use?"). However, therapists should not allow destructive criticism or dredging up of old wrongs. This can be done by reorienting patients and significant others to the goals of the session as soon as is appropriate.

"It sounds like Kris' cocaine use has been of concern to you for some time; it has hurt the family finances, and you feel like you can't trust him. I'd like to move on now to spend some time talking about specific changes you both would like each other to make, to make it easier for Kris to stay clean and for your relationship to be more enjoyable for both of you."

Identify Strategies

As a prelude to exploring how significant others can help patients in their efforts to become abstinent, therapists should spend some time reiterating the CBT treatment model (topic 1) to establish a framework for the session. Patients should then describe the ways in which the significant other can offer support. These might include:

    • Providing transportation to and from the clinic.
    • Helping reduce cocaine and other substance abuse cues in the environment.
    • Engaging in pleasant activities as a reward for sobriety and behavior change.
    • Offering support and talking with them while they are experiencing craving or thoughts about cocaine.
    • Helping patients make the "all-purpose coping plan" more concrete.
    • Monitoring the patients' compliance with medication.

Patients should also be prepared for the significant other to ask for behavior changes; these usually start with continued abstinence but may include other things, such as helping more around the house, accounting for money, and so on. The changes requested should be stated clearly and as specifically as possible (e.g., "I'd like to have at least 15 minutes of quiet time with you every day" or "I'd like you to watch the kids one night a week so I can go see my mother").

Practice Exercises

The patient and significant other should be asked to develop a contract, with each person specifying the behavior changes desired from the other.

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CBT - Treating Cocaine Addiction - Topic 8 - HIV Risk Reduction

Topic 8: HIV Risk Reduction

Tasks for Topic 8

  • Assessing the patients' risk for HIV infection and building motivation to change risk behaviors
  • Setting behavior change goals
  • Problem solving barriers to risk reduction
  • Distributing specific risk-reduction guidelines

Session Goals

Generally, few cocaine abusers who do not engage in concurrent opioid use also use injection works (syringe, cotton, water), and thus tend to have low levels of risk for HIV infection from unsafe needle practices. However, most have substantial risk from unsafe sexual practices. Depending upon their level and type of risk for HIV infection, patients may be offered an HIV risk-reduction module in addition to their regular sessions.

The goals for this session are to:

    • Assess the patients' risk for HIV infection and build motivation to change risk behaviors.
    • Set behavior change goals.
    • Problem-solve barriers to risk reduction.
  • Distribute specific risk-reduction guidelines.

Key Interventions

Assess Risk

Therapists should help patients review their level of risk and their history of HIV testing. This can be done in discussion or by having patients complete a standardized instrument such as the HIV Risk Behaviors Inventory (Metzger et al. 1992). When using a formal test, scores should be presented in writing, with copies for the patients. Therapists should ask for patients' reactions to their level of risk and reflect and elaborate on their reactions.

Patient: "I guess I didn't realize how many people I had sex with since I've been on this run."

Therapist: "What do you make of this?"

This strategy can bolster awareness of risk and increase motivation for change.

Build Motivation To Change

In assessing and reviewing the level of risk, therapists should use the following motivational strategies. (From Miller et al. 1992.)

    • Affirm the patient ("I think its great that you're willing to be honest with yourself and take time to look at your level of risk.").
    • Reframe ("You're concerned about your level of risk, but you can't see yourself being celibate, either.").
    • Roll with resistance ("You're jumping ahead a bit here. Right now, we're just getting a sense of where you are regarding drug injection practices and unsafe sex behaviors. Later on, we can talk about what, if anything, you want to do about it.").
    • Explore consequences of action and inaction.
    • Communicate free choice.
    • Elicit self-motivational statements ("What do you want to do about this," "Tell me why you think you might need to make a change.").

Set Goals

If patients are ready to make a change, therapists work with them to set realistic, concrete risk-reduction goals for sexual and/or injection drug behavior risk, as appropriate (e.g., "I want to start using condoms with Jim this week"). Therapists should also encourage patients to identify barriers to risk-reduction goals (e.g., "You've come up with good, realistic goals that should lower your risk substantially. Now, what might get in the way of your meeting those goals?"). Barriers can include anticipated problems with negotiating condom use with a sexual partner, continuing to drink and frequent bars before using intravenously, acquiring condoms, and so on.

Problem-Solve Barriers

Therapists should encourage patients to apply some of the skills and problem solving strategies covered in earlier sessions to the problems they anticipate in meeting risk-reduction goals. This might include, for example, practicing assertiveness in the context of negotiating condom use, using positive self-talk to counter ambivalence about and objections to condom use, or using a problem solving strategy to clarify the connection between ongoing cocaine abuse and unsafe sexual practices.

Provide Specific Guidelines

As part of this module, therapists should offer specific information and provide handouts on risk reduction. Several areas should be covered, depending on the risk profiles of the patients.

    • Clarification of the concepts of harm reduction versus abstinence
    • Methods of transmission of HIV, other sexually transmitted diseases, and tuberculosis
    • Risks associated with sharing injection-drug works
    • Injection-drug works cleaning procedures
    • Effective use of condoms
    • HIV antibody testing

Practice Exercises

The practice exercise for this session involves use of the Change Plan Worksheet (Exhibit 12) to clarify and set patient goals for HIV risk reduction.

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CBT - Treating Cocaine Addiction - Topic 7 - Case Management

Topic 7: Case Management

Tasks for Topic 7

  • Reviewing and applying problem solving skills to psychosocial problems that present a barrier to treatment
  • Developing a concrete support plan for addressing psychosocial problems
  • Monitoring and supporting patients' efforts to carry out the plan

Session Goals

Most patients will present for treatment with a range of concurrent psychosocial problems in addition to cocaine abuse. Some problems are best assessed and addressed after patients have achieved a period of stable abstinence, while other problems, if unaddressed, are likely to present barriers to treatment and undermine the patients' efforts to become abstinent. Thus, to deal with these issues, therapists may engage in modified "case management."

In this approach, therapists do not serve as advocates for patients outside of sessions. Rather, therapists use problem solving strategies within treatment to help patients contact and make use of the social service system. The intent is to build patients' self-efficacy in recognizing and coping with concurrent problems and in successfully using the network of available social service agencies.

To be effective, therapists should be knowledgeable about the community's service system, with current information on the type of services provided by each organization, the types of patients served by the organization, eligibility requirements, sources for alternative services, and reasonable time frames for various types of service delivery. Therapists should help patients transform their goals into a service plan and help them articulate the steps needed to attain these goals.

The goals of this topic are to:

  • Review and apply problem solving skills to psychosocial problems that present a barrier to treatment.
  • Develop a concrete support plan for addressing psychosocial problems.
  • Monitor and support patients' efforts to carry out the plan.

Key Interventions

Problem Identification

Early in treatment, therapists should have identified problems that would be barriers to abstinence. Information useful in identifying relevant psychosocial problems may also come from pretreatment assessments, particularly the Addiction Severity Index.

Goal Setting

Therapists and patients together should identify and prioritize the three or four major problems they will focus on during treatment and specify concrete goals for each (e.g., have a stable place to live by the end of the month, enter a job training program by the end of August). As needed, therapists should also review the basic steps in problem solving, since that model is used to work through these target problems.

Resource Identification

With the goals clarified, therapists and patients then brainstorm solutions and the resources needed to resolve each of the target problems.

Specifying a Plan

Once problems are identified and goals set, therapists and patients should begin to work on the support plan, which is simply a concrete strategy that outlines how patients will follow through on reaching their goals. The support plan should include, for each goal, specification of who or which agency is to be contacted, when the contact is to be made, what services or support are to be requested, and the outcome of the contact. The support plan thus serves as a kind of log, or organizing force, in patients' efforts to obtain needed services. It will also provide a record of their efforts and successes in this area and, thus, bolster their self-efficacy.

Monitoring Progress

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 should take place at every subsequent session; thus, therapists should spend time during the initial phase of the next sessions (e.g., the first 20 minutes of a 20/20/20 session) monitoring patients' success in implementing their plans. Similarly, a portion of the closing of each session should be devoted to reviewing the steps for implementing the support plan during the coming week.

Therapists should affirm patients and praise their efforts in carrying out their plans enthusiastically and genuinely. Even small steps should be seen as significant and be met with praise. Therapists should convey confidence that patients can, and will, successfully complete the support plans and obtain needed services. In this strengths-based approach, therapists assume that patients have the resources and skills to obtain needed services, both within treatment and after treatment ends.

Therapist: "I'm really impressed that you were able to arrange a place for yourself at Transitional Housing. I know you had real questions about whether you could handle all the admission steps on your own, but it sounds like you hung in there, were persistent when Mrs. X put you on hold several times, and kept rescheduling those interviews until you got it. It sounds like it wasn't easy, but you really made it happen. How do you feel about how you handled it?"

Patient: "Like you said, it wasn't easy, and once or twice I felt like telling them off, but I just kept telling myself I really needed a safe place to live and that I could do it."

Therapist: "You know, you sound and look like you're really proud of yourself, and your pride is well deserved. Knowing how to work the social service system is an important skill, and one I see you getting better and better at. Have you thought about your next step?"

Practice Exercises

The practice exercise for this week includes following through on the Support Plan (Exhibit 11) and reporting back on the successes or problems the patients experienced in carrying out the plan. Remind patients that treatment will end soon, and they will be using these skills on their own.

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CBT - Treating Cocaine Addiction - Topic 6 - Problemsolving

Topic 6: Problem Solving

Tasks for Topic 6

  • Introducing the basic steps of problem solving
  • Practicing problem solving skills within the session

Session Goals

Over time, many patients' repertoires of coping and problem solving skills have narrowed such that cocaine or other substance abuse has become their single, over-generalized means of coping with problems. Many patients are unaware of problems when they arise and ignore them until they become crises. Many others, particularly those who have impulsive cognitive styles or who are unaccustomed to thinking through alternative behaviors and consequences, find this topic particularly useful. Others think they have good problem solving skills but, when confronted with a problem, are likely to act impulsively, making practice of this skill within sessions particularly important.

This session (This section is adapted closely from Monti et al. 1989 as well as Kadden et al. 1992 and D'Zurilla and Goldfried 1971.) provides a basic strategy that can be applied to a range of problems related to cocaine abuse as well as the variety of problems that will invariably arise after patients leave treatment. Despite many patients' fantasies that life will be easier and problem free after stopping cocaine use, often they become aware of problems they have neglected or ignored only after becoming abstinent.

The goals of this session are to:

  • Introduce or review the basic steps of problem solving.
  • Practice problem solving skills within the session.

Key Interventions

Introduce the Basic Steps

Therapists should convey that everyone has problems from time to time and that most can be effectively handled. Also, although having a problem may make one anxious, effective problem solving takes time and concentration, and the impulsive first solution is not necessarily the best.

Therapists should review the basic steps in problem solving summarized below.(Adapted from D'Zurilla and Goldfried 1971 and Monti et al. 1989.)

    • Recognize the problem ("Is there a problem?").Recognition of problems may come from several clues, including worry, anger, and depression; having problems pointed out by others; being preoccupied; and always feeling like one is in crisis.
    • Identify and specify the problem ("What is the problem?").It is easier to solve problems that are concrete and well-defined than those that are global or vague. For large problems that seem overwhelming, it is important to try to break them down into smaller, more manageable steps.
    • Consider various approaches to solving the problem ("What can I do to solve the problem?").An effective way to approach this is to brainstorm, that is, generate as many solutions as possible without considering, at first, which are good or bad ideas. It is more important to try for quantity, rather than quality, in the beginning. Writing these ideas down is very helpful in cases where patients may want to return to the list in the future. It is also important to recognize that not doing anything immediately is an option.
    • Select the most promising approach ("What will happen if . . . ?").This step involves thinking ahead. Review each approach, considering both the positive and negative consequences of all solutions. This step may also involve collecting more information and assessing whether some solutions are feasible (e.g., "Can I borrow Tom's car to take the driving test?").
  • Assess the effectiveness of the selected approach ("What did happen when I . . . ?").Therapists may need to point out that while some problems are easy to solve, others are more difficult. It may be necessary to repeat steps one through five several times before a complex problem is solved.

For impulsive patients, it is important to write down the problem and the selected approach so that the steps are not forgotten when it is time to implement them.

Practice Problem Solving Skills

Therapists should ask patients to identify two recent problems, one that is closely related to cocaine abuse and one that is less so, and work with them through the problem solving steps for both. Therapists may have to help patients slow down, because some will have difficulty recognizing current problems. Others will quickly select a solution since they lack practice with brainstorming and considering alternatives.

Practice Exercises

Therapists ask patients to practice problem solving skills outside of the sessions using a Reminder Sheet for Problem Solving (Exhibit 10). Remind patients that treatment will end soon, and they will be using these skills on their own.

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CBT - Treating Cocaine Addiction - Topic 5 - Coping

Topic 5: An All-Purpose Coping Plan

Tasks for Topic 5

  • Anticipating future high-risk situations
  • Developing a personal, generic coping plan

Session Goals

Despite patients' best efforts, a variety of unforeseen circumstances may arise that result in high-risk situations. These often have to do with major, negative stressful events or crises, such as the death or sickness of a loved one, learning one is HIV positive, losing a job, the loss of an important relationship, and so on. However, positive events can also lead to high-risk situations. These could include receiving a large amount of money or starting a new intimate relationship. Since such events may occur anytime, during as well as after treatment, patients are encouraged to develop an emergency coping plan which they can refer to and use should such crises occur.

The goals of this session are to:

  • Anticipate future high-risk situations.
  • Develop a personal, generic coping plan.

Key Interventions

Anticipate High-Risk Situations

Therapists should point out that although patients will find it helpful to recognize, avoid, and cope with high-risk situations, life is unpredictable, and not all high-risk situations can be anticipated. Crises, negative stressors, and even positive events can result in high-risk situations.

Therapists should ask patients to think of three or four major stressors that might arise over the next few months, as well as what their reactions might be. Then ask them to anticipate anything that might happen to shake their commitment to abstinence. For each of these situations or circumstances, therapists and patients should develop concrete coping plans.

Develop a Coping Plan

When patients are most stressed, they may feel vulnerable and be more likely to return to old, familiar coping strategies than use the healthier but less familiar strategies they have practiced during sessions. It is important to try to develop a generic, "foolproof" coping strategy that can be used in the event of any major crisis. This should include, at minimum, the following:

  • A set of emergency phone numbers of supportive others who can be relied on
  • Recall of negative consequences of returning to use
  • A set of positive thoughts that can be substituted for high-risk cocaine thoughts
  • A set of reliable distracters
  • A list of safe places where the patient can ride out the crisis with few cues or temptations to use (e.g., a parent's or friend's house)

Practice Exercises

The practice exercise for this session includes anticipating some crises and responses and developing the All-Purpose Coping Plan (Exhibit 9). Remind patients that treatment will end soon, and they will be using these skills on their own.

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CBT - Treating Cocaine Addiction - Topic 4 - Decisions

Topic 4: Seemingly Irrelevant Decisions

Tasks for Topic 4

  • Understanding Seemingly Irrelevant Decisions and their relationships to high-risk situations
  • Identifying examples of Seemingly Irrelevant Decisions
  • Practicing safe decision-making

Session Goals

As treatment progresses, patients will invariably encounter high-risk situations related to cocaine, even with the best efforts. Certain exposures are beyond the abuser's control, for example, living in an area where cocaine abounds but lacking the resources to relocate.

Another class of exposures, however, that patients often experience as beyond their control actually involves behaviors determined by the patients. Seemingly Irrelevant Decisions (Marlatt and Gordon 1985) refer to those decisions, rationalizations, and minimizations of risk that move patients closer to or even into high-risk situations, although they may seem unrelated to cocaine use.

Working with these Seemingly Irrelevant Decisions emphasizes the cognitive aspects of treatment. Those who benefit most from this process tend to possess intact cognitive functions and some ability to reflect upon their cognitive and emotional lives. This session is also particularly helpful to individuals who have trouble thinking through their behavior and its consequences, such as patients with residual attention-deficit/hyperactivity disorder, antisocial traits, or difficulty with impulse control. For such individuals, the material in this session (as well as the session on problem solving) often takes some time to be understood and assimilated, but it is usually valued highly.

The goals of this session are to:

  • Understand Seemingly Irrelevant Decisions and their relationships to high-risk situations.
  • Identify examples of Seemingly Irrelevant Decisions.
  • Practice safe decision-making.

Key Interventions

Understand Seemingly Irrelevant Decisions

A critical task for therapists is to teach patients how to recognize and interrupt Seemingly Irrelevant Decision chains before the onset of actual use. While it is possible to interrupt such a chain at any point prior to use, it is more difficult toward the end of the chain when patients may already be in situations where cocaine is available and conditioned cues abound. Thus, it is desirable to teach patients how to detect the decisions that commonly occur toward the beginning of the chain, where risk, craving, and availability of cocaine are relatively low.

This may involve patients' learning to detect subtle but painful affect states that they frequently try to counter with cocaine, such as boredom or loneliness. It often involves familiarizing patients with their distortions of thinking (e.g., rationalizations, denial) so these may be detected and used as signals for greater vigilance.

Certain distortions are fairly common, such as the thought, "I could handle going to a bar." Others, however, are more reflective of the patient's cognitive style. For instance, one patient tended to project his thoughts onto others. In describing a relapse, during which the patient had encountered a friend who had cocaine, the patient stated, "I caught him with his guard down." Another patient, recounting a slip, described the various thoughts he experienced prior to winding up in an area of town where his former dealer resided and where the patient eventually used cocaine. He stated that earlier he thought "I have to go to the bakery" which "happened" to be in a high-risk area, but he had not linked this with a desire to use. The therapist pointed out that his use of "I have to..." sounded very much like craving. Here, again, the patient could now catch himself "having" to do certain things which led to high-risk activities or locations.

Another variation of this phenomenon occurs in treatment when patients tell therapists that they "have" to take "this vacation," "attend that party," "spend time" with particular drug-using friends, and so on. These provide therapists with the opportunity to relate the patients' urgency to engage in such activities with the urge to use cocaine.

Seemingly Irrelevant Decisions are dealt with by applying recognize, avoid, and cope-recognizing Seemingly Irrelevant Decisions and the thoughts that go with them, avoiding risky decisions, and coping with high-risk situations.

"I'm going to tell you a story about a person who made several Seemingly Irrelevant Decisions that led to a high-risk situation and, eventually, a relapse. As I tell you the story, try to pick out the decisions that he made along the way that, taken together, made him more vulnerable to using cocaine.

Here is the story:
"Joe, who had been abstinent for several weeks, drove home from work on a night his wife was going to be away. On the way, he turned left rather than right at an intersection so he could enjoy the 'scenic route.' On this route, he drove past a bar he had frequented in the past and where he had bought and used cocaine. Because the weather that day was hot, he decided to stop in for a glass of cola. Once in the bar, however, he decided that since his problem was with cocaine, it would be fine to have a beer. After two beers, he ran into a friend who 'happened' to have a gram of cocaine and a relapse ensued.

"When did you think Joe first got into trouble, or 'thought' about using cocaine? One of the things about these chains of decisions that lead to cocaine use is that they are far easier to stop in the beginning of the chain. Being farther away from cocaine, it is easier to stop the decision-making process than when you're closer to cocaine use and craving kicks in.

"What do you think Joe was saying to himself at the point he took the scenic route home? We often find 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 so-and-so 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 high-risk situations by telling yourself a situation is safe, when it really may not be, like when you told yourself last week that it was safe for you to go hang out in the park with your friends. Can you think of other examples of ways you might have talked yourself into a risky situation?"
Identify Personal Examples

Therapists should encourage patients to relate a recent example of a chain of Seemingly Irrelevant Decisions.

"Can you think of your own relapse story?
"Now, let's go through it and try to pinpoint the places where you made risky decisions, what you were telling yourself, and how you could have interrupted the chain before you wound up in the park with nothing to do."

Practice Safe Decision-Making

Therapists need to stress the notion of safe decision-making.

"Another important thing to know about Seemingly Irrelevant Decisions is that if you can get yourself into the practice of recognizing all the small decisions you make every day, and thinking through safe versus risky consequences for those decisions, you will be less vulnerable to high-risk situations."

"Returning to the story of Joe, what were the Seemingly Irrelevant Decisions he made and what would have been safer decisions for him?"

"Let's go through a few things that have happened to you in the last few weeks and try to work through safe versus risky decisions."

Some Seemingly Irrelevant Decisions are common among cocaine abusers.

  • Using any alcohol, marijuana, or other drugs
  • Keeping alcohol in the house
  • Not destroying cocaine or crack paraphernalia
  • Going to parties where alcohol or cocaine might be available
  • Interacting with people who are cocaine abusers
  • Keeping past cocaine abuse a secret from family members
  • Not telling cocaine-abusing associates of the decision to stop
  • Not planning to fill free time
  • Having a lot of unscheduled time on nights or weekends that can lead to boredom
  • Getting over-tired or stressed

Practice Exercises

The practice exercise for this session includes self-monitoring of decisions over the course of several days and, for each one, Identifying Safe Versus Risky Decisions (Exhibit 8). Remind patients that treatment will end soon, and they will be using these skills on their own.

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CBT - Treating Cocaine Addiction - Topic 3 - Refusal Skills

Topic 3: Refusal Skills/Assertiveness

Tasks for Topic 3

  • Assessing cocaine availability and the steps needed to reduce it
  • Exploring strategies for breaking contacts with individuals who supply cocaine
  • Learning and practicing cocaine refusal skills
  • Reviewing the difference between passive, aggressive, and assertive responding

Session Goals

A major issue for many cocaine abusers is reducing availability of cocaine and effectively refusing offers of cocaine. Patients who remain ambivalent about reducing their cocaine use often have particular difficulty when offered cocaine directly. Many cocaine users' social networks have so narrowed that they associate with few people who do not use cocaine, and cutting off contact may mean social isolation. Also, many individuals have become involved in distribution, and extricating themselves from the distribution network is difficult. Many patients lack the basic assertiveness skills to effectively refuse offers of cocaine or prevent future offers of cocaine. Thus, this session includes sections on reducing availability, refusal skills, and a review of general assertiveness skills.

Therapists should carefully direct questions to ferret out covert indicators of ambivalence and resistance to change and the social forces working against change. Failure of patients to take initial steps toward removing triggers and avoiding cocaine may reveal a number of clinically significant issues.

  • Ambivalence toward stopping cocaine use (e.g., the individual who resists breaking ties with dealers or telling family and friends of his decision to stop use)
  • Failure to appreciate the relationship between cocaine availability and use (e.g., the abuser who sells cocaine but maintains that he will be able to stop using while still dealing)
  • Marked limitations in personal or psychosocial resources (e.g., the unemployed single parent living in a neighborhood where cocaine is readily available)
  • Important indications of how actively patients will take part in treatment. If patients have taken no independent steps toward limiting cocaine availability, they may be expecting mere exposure to treatment to magically produce abstinence with little or no effort on their part.

The goals for this session are to:

  • Assess cocaine availability and the steps needed to reduce it.
  • Explore strategies for breaking contacts with individuals who supply cocaine.
  • Learn and practice cocaine refusal skills.
  • Review the difference between passive, aggressive, and assertive responding.

Key Interventions

Assess Cocaine Availability

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 involved in selling cocaine, the nature of their cocaine sources, and whether other individuals in their home or workplace use cocaine. Determining the steps patients have already taken toward reducing cocaine availability may be an invaluable index of their internal and external resources. For example, have patients informed cocaine-using associates of their intention to stop using? Have patients who sell cocaine attempted to extricate themselves from the distribution network? It is virtually impossible for an individual to continue to sell cocaine and not use it. Therapists can make some useful inquiries.

"If you wanted to use cocaine, how long would it take to get some? Is there any in your house? Are you still holding onto pipes?"

"The last few times you used, you said Tommy came to your house and suggested you take a drive. Have you thought about talking to Tommy about your decision to stop?"

Handling Suppliers

In spite of its illicit nature, cocaine may be offered by a range 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, extricating oneself is often challenging. Therapists should review the patients' suppliers and explore strategies for reducing contact with them. In some cases, a clear and assertive refusal, followed by a statement that the patient has decided to stop and a request that cocaine no longer be offered, can be surprisingly effective. In other cases, patients can arrange to avoid any contact with particular users or suppliers.

When patients are in a close, intimate relationship with someone who uses and supplies cocaine, the problem is more difficult. For example, it may not be easy for a woman to abstain when her partner supplies cocaine or continues to use, and she may not be ready to break off the relationship. Furthermore, sometimes only limited change in a patient's stance toward such a relationship can be effectively undertaken in 12 weeks of treatment. Rather than seeing this as either-or ("I can either stop cocaine use or get out of the relationship"), therapists should explore the extent to which exposure to cocaine can be renegotiated and limits set.

"I hear you say that you feel like you want to stay with Bob for now, but he's not willing to stop using cocaine. Being there is pretty risky for you, but maybe we can think of some ways to reduce the risk. Have you thought about asking him not to bring cocaine into the house or use it in the house? You've said you know there's a lot of risk to you while he continues to do that, both in terms of your staying abstinent as well as having drugs around your kids."

Cocaine Refusal Skills

There are several basic principles in effective refusal of cocaine and other substances.

  • Respond rapidly (not hemming and hawing, not hesitating).
  • Have good eye contact.
  • Respond with a clear and firm "no" that does not leave the door open to future offers of cocaine.

Many patients feel uncomfortable or guilty about saying no and think they need to make excuses for not using, which allows for the possibility of future refusals. Inform patients that "no" can be followed by changing the subject, suggesting alternative activities, and clearly requesting that the individual not offer cocaine again in the future. ("Listen, I've decided to stop and I'd like you not to ask me to use with you anymore. If you can't do that, I think you should stop coming over to my house.")

Within-Session Role-Play

After reviewing the basic refusal skills, patients should practice them through role-playing, and problems in assertive refusals should be identified and discussed. Since this is the first session that includes a formal role-play, it is important for therapists to set it up in a way that helps patients feel comfortable.

  • Pick a concrete situation that occurred recently for the patients.
  • Ask patients to provide some background on the target person.
  • For the first role-play, have patients play the target individual, so they can convey a clear picture of the style of the person who offers cocaine and the therapist can model effective refusal skills. Then reverse the roles for subsequent role-plays.

Role-plays should be thoroughly discussed afterward. Therapists should praise any effective behaviors shown by patients and also offer clear, constructive criticism:

"That was good; how did it feel to you? I noticed that you looked me right in the eye and spoke right up; that was great. I also noticed that you left the door open to future offers by saying you had stopped cocaine 'for a while.' Let's try it again, but this time, try to do it in a way that makes it clear you don't want Joe to ever offer you drugs again."

Passive, Aggressive, And Assertive Responding 

Quite often, the role-plays will reveal deficits in understanding and feeling comfortable with assertive responding. For such individuals, therapists should devote another session to reviewing and practicing assertive responding. An excellent guide to this topic is given in Monti et al. (1989).

Key areas to review include defining assertiveness, reviewing the differences between response styles (passive, aggressive, passive-aggressive, and assertive), body language and nonverbal cues, and anticipating negative consequences.

Remind Patients of Termination

Beginning about the sixth week of treatment, therapists should start reminding patients of the time-limited nature of the treatment, and in some cases, begin each session thereafter by pointing out "we have xx weeks to work together." It may be helpful to discuss or reframe termination as a potential high-risk situation. Reemergence of slips and other symptoms is common in the last weeks of treatment and may be interpreted in this context (so might emergence of new problem areas).

As termination approaches, therapists might also ask patients to imagine every high-risk situation they might encounter after they leave treatment. After such relapse fantasies are elicited and explored, specific coping strategies can be developed in the weeks approaching termination. This often makes patients feel more comfortable and confident about their ability to end treatment.

Practice Exercises

The practice exercises for this session include mapping cocaine availability and Managing Availability (Exhibit 6) and Cocaine Refusal Skills (Exhibit 7) to a range of individuals who might offer cocaine.

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CBT - Treating Cocaine Addiction - Topic 2 - Motivation

Topic 2: Shoring Up Motivation and Commitment to Stop

Tasks for Topic 2

  • Clarifying and prioritizing goals
  • Addressing ambivalence
  • Identifying and coping with thoughts about cocaine

Session Goals

By now, therapists and patients will have completed several functional analyses of cocaine use and high-risk situations, and patients have a clearer idea of the general approach to treatment. Most patients have also reduced their cocaine use significantly (or even stopped) at this point and can work toward a more realistic view of treatment goals than may have been possible in the first session. Patients are more aware of the role cocaine has played in their lives; they may be aware of recurrent thoughts about cocaine, and they may also be more ready to sort through some of their ambivalence about cocaine abuse and treatment.

While some patients intend to fully cease cocaine and other substance use, others may have slightly different goals.

  • Reduction of cocaine use to "controlled" levels
  • Cessation of cocaine use but continued high use of alcohol or other substances
  • Remaining in treatment until the external pressures that precipitated treatment seeking (e.g., a spouse's ultimatum, pressure from an upcoming court case) have abated

While such goals tend to be quite unrealistic, it may be wise for therapists, particularly in the early 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 impossibility of controlled cocaine use may be much more persuasive than a therapist's repeated warnings. For example, a young woman maintained she could not possibly cease both cocaine and marijuana simultaneously because she attempted to use marijuana to cope with cocaine craving) until she discovered that her excursions to buy marijuana led to a variety of powerful cocaine cues and usually to extended cocaine binges.

The goals of this session are to:

  • Revisit and clarify treatment goals.
  • Acknowledge and address ambivalence about abstinence.
  • Learn to identify and cope with thoughts about cocaine.

Key Interventions

Clarify Goals

This is a good time to explore with patients their commitment to abstinence and other treatment goals. By now, even patients who were pressured into treatment usually have begun to sort out the consequences of continued cocaine use in relation to other goals. Thus, therapists should check the patients' current view of treatment and readiness to change.

"I noticed that, even though you haven't stopped completely, you've mentioned several times all the problems cocaine has caused you, like the job and the trouble with your probation officer, and some of the opportunities it has cost you, like spending more time with your kids as they were growing up. Do you have any thoughts about these problems? At the same time, I also hear that there are some things about using cocaine that you really miss right now. I thought we could spend some time this session talking more about your goals and how we might be able to help you get there. Do you feel ready for that? What are you thinking about your cocaine use at this point? Are there other problems you'd like to tackle while we work together?"

From this discussion, therapists should be able to get a clear idea of the following:

  • The patients' current readiness for change Their current stance toward abstinence A sense of other target goals and problems

This should be an open-ended discussion, with therapists refraining from taking too active a role or supplying goals for patients. The techniques described by Miller et al. (1992) for strengthening commitment to change could be used here.

  • Communicate free choice (e.g., "It's up to you what you want to do about this").
  • Emphasize the benefits of abstinence as a goal.
  • Provide information and advice around the kinds of problems and issues that should be addressed if the patient is to remain abstinent.

Patients might be encouraged to talk about their treatment goals any number of ways (e.g., "Have you thought about where you want to be 12 weeks from now? What about 12 months from now?"). This discussion usually elicits other target symptoms and problems, some of which may be closely related to cocaine use (e.g., medical, legal, family/social, psychiatric, employment/support, and other types of substance abuse or dependence). Others may be less closely related and thus less important to address 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 abstinence with the need to keep treatment focused on achieving abstinence.

Therapists should work with patients to prioritize other target problems:

  • Is a psychosocial problem likely to pose a barrier to patients' achieving abstinence?Therapists should work with patients to identify severe psychosocial problems that, if unaddressed, would be likely to interfere with efforts to become abstinent or make life so chaotic that they would be unable to be fully involved in treatment. Examples include homelessness, severe psychiatric problems or symptoms including suicidal ideation or intent, and acute medical conditions. Therapists should address such problems immediately and as appropriate. Significant suicidality or homicidality requires immediate referral to an emergency room. Therapists should also consider devoting time during each session to case management (Topic 7: Case Management).
  • Is the problem best assessed and addressed after some control over cocaine use is achieved?Many patients present for treatment with more concerns about the consequences of chronic cocaine dependence than the dependence itself. A variety of problems may be caused or exacerbated by cocaine dependence which, while of concern to patients, may best be addressed after they have become abstinent. For example, many patients' depression resolves with several weeks of abstinence, or a marital rift that seems un-resolvable may improve when the spouse sees the patient making an earnest effort to commit to treatment and remain abstinent.Therapists should not ignore such concerns but instead propose a plan for closely monitoring and addressing the problem if it does not improve with abstinence.

    "You've told me you've been feeling really down, and it feels like all the bills are coming due at once. That's not unusual for someone in the first few days of abstinence. Since some depression is very common for people who are in the early phases of abstinence, I'd like to check in with you very often about how you're feeling. If you stay abstinent and aren't feeling better in a few weeks, we might want to think about doing a more formal assessment of depression, possibly by referring you to a psychiatrist. How does that sound to you?"

  • Can addressing the problem wait?If the problem does not pose a barrier to treatment and is not directly related to cocaine abuse, suggest waiting to address it until after the first 12 weeks in order to keep treatment focused on achieving abstinence. Therapists might also point out that problem solving skills will be covered, and they can be applied to a range of problems other than cocaine dependence.

Address Ambivalence About Abstinence

Ambivalence is best addressed early to foster a therapeutic alliance that allows for open exploration of conflicts about cessation of cocaine use. Encourage patients to articulate the reasons they have used cocaine, help them "own" the decision to stop use through exploring what they stand to gain, and underscore the idea that cocaine abuse cannot be divorced from its consequences.

We frequently use a simplified version of the decision matrix described by Marlatt and Gordon (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. Some patients have initial difficulty acknowledging any positive consequences of continued cocaine abuse, but most are able to list several justifications like "There's nothing else as exciting in my life" or "I feel less anxious with people" or "I get most of my money from selling cocaine" or "Sex and coke go together."

Next, with open-ended questions, therapists encourage patients to explore each of these stated benefits (e.g., "Having money in your pocket sounds important; what else does selling do for you?"). Most often, patients indicate many of these are ultimately negative. For example, if the cocaine high was listed as an advantage, the nature of the high is explored, and patients are reminded of the crash and dysphoria that invariably follow and endure much longer than the euphoria. Patients who sell cocaine remind themselves that all of the profits are used to support cocaine use.

Therapists then ask patients to list all possible reasons to stop cocaine abuse and write these on the other side of the card. These are typically numerous and reflect negative consequences such as "I want to keep my job" or "Fewer fights with my parents" or "More money for things I want." Patients are instructed to keep the card in their wallet, preferably near their money. A glimpse of the card when confronted by intense craving for cocaine or a high-risk situation can remind them of the negative consequences of cocaine abuse when they are likely to recall only the euphoria associated with the high.

The power of this concrete reminder was illustrated by a cocaine abuser who removed the card from his wallet before he went out one evening when he intended to use cocaine; he felt the card had literally "stopped me from using" on several previous occasions.

Identifying and Coping With Thoughts About Cocaine

Ambivalence is often manifested in thoughts about cocaine and using that are difficult to manage. Cocaine was an important, even dominant, factor in patients' lives, and thoughts, both positive and negative, about cocaine are normal and likely to linger for some time. Again, the strategy here is to "recognize, avoid, and cope."


Thoughts associated with cocaine that can lead to resumption of use vary widely across individuals and their cognitive styles. Therapists should help patients identify their own cognitive distortions and rationalizations ("I've noticed that you talk about your cocaine self and your straight self; can you tell me more about your cocaine self?"). It is important that therapists also clearly define automatic thoughts (e.g., either a thought or visual image that you may not be very aware of unless you focus your attention on it) and cognitions (e.g., things you say to yourself).

Common thoughts associated with cocaine include the following:

  • Testing control: "I can go to parties (see friends who are users, drink or smoke marijuana) without using."
  • Life will never be the same: "I love being high."
  • Failure: "Previous treatments haven't worked; there's no hope for me."
  • Diminished pleasure: "The world is boring without cocaine."
  • Entitlement: "I deserve a reward."
  • Feeling uncomfortable: "I don't know how to be with people if I'm not high."
  • What the hell: "I screwed up again, I might as well get high."
  • Escape: "My life is so bad, I just need a break for a few hours."


Avoiding thoughts associated with cocaine is not always possible, but individuals who tend to be focused on positive goals seem to be less troubled by them. Asking patients to articulate and record their short- and long-term goals often helps them see beyond the immediate temptations more readily than individuals who lack a clear focus on the future.

For an in-session exercise, have patients record their immediate (next week), short-term (next 12 weeks), and long-term (the next year) goals. These should be as concrete as possible (e.g., instead of "have a lot of money," "have a job paying $12 an hour by October").


There are a number of strategies for coping with thoughts about cocaine.These strategies are adapted from Monti et al. 1989.

  • Thinking through the high. While patients are beset with craving or positive thoughts about cocaine, it is often difficult to remember the downside of a cocaine binge. Therapists can ask patients to relate an instance and come up with an image of the end of a particularly unpleasant cocaine binge. For example, one patient's image of waking up naked, robbed, and beaten in someone else's car in a town he did not know, was powerful enough to counter a range of nostalgic thoughts about cocaine.
  • Challenge the thoughts. For each negative, cocaine-related thought, patients can be encouraged to generate and practice positive beliefs to counter them: "I've dealt with craving in the past, and I can do it again" or "Keeping my family together is more important than getting high" 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 particularly effective ways of countering thoughts about cocaine for some patients.
  • Review negative consequences. Reviewing a 3 x 5 card or piece of paper that lists the patient's own view of the negative consequences of cocaine use is a powerful strategy to counter craving or thoughts about cocaine. Making one's own card is one of the practice exercises for this topic.
  • Distraction. Just as cravings peak and go away if resisted, so do thoughts about cocaine. Thoughts about cocaine will become less strong, less frequent, and less upsetting if one does not give in to them. Just as distraction is an effective means of coping with craving, having a list of 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 dependent on the availability of others) is an effective way of coping with thoughts for patients who have trouble relying on other cognitive strategies.
  • Talking. Just as talking to a supportive friend or significant other can be an effective means of pinpointing, understanding, and working through an episode of craving, talking through cocaine thoughts is often an effective way of dispelling them. Thoughts that seem compelling and dire (I can't live without cocaine) often lose their potency when expressed to others. Therapists should work with patients to identify appropriate others with whom they can discuss and work through thoughts about cocaine when they occur.

Practice Exercises

When done as two sessions, the first session exercise includes having patients complete the 3 x 5 card of positive and negative consequences of using and the Goal Worksheet (Exhibit 4). The second session's exercise includes monitoring of thoughts, plus Recording of Coping Skills (Exhibit 5), similar to the craving session.

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CBT - Treating Cocaine Addiction - Topic 1 - Craving

Topic 1: Coping With Craving

Tasks for Topic 1

  • Understanding craving
  • Describing craving
  • Identifying triggers
  • Avoiding cues
  • Coping with craving

Session Goals

Because craving is such a difficult problem for so many cocaine abusers, this topic is introduced very early in treatment. Episodes of intense subjective craving for cocaine are often reported weeks and even months after the inception of abstinence. This experience can be both mystifying and disturbing to the abuser and can result in cocaine abuse if it is not understood and managed effectively.

The goals of the session are to:

  • Understand the patient's experience of craving.
  • Convey the nature of craving as a normal, time-limited experience.
  • Identify craving cues and triggers.
  • Impart and practice craving- and urge-control techniques.

Key Interventions

Understanding Craving

It is important for patients to recognize that experiencing some craving is normal and quite common. Craving does not mean something is wrong or that the patient really wants to resume drug use.(Much of this material on key interventions used with episodes of craving was adapted from Kadden et al. 1992.)

Because of the frequency and the variety of circumstances in which cocaine is self-administered, 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, having money or getting paid, drinking alcohol, social situations, and certain affective states, such as anxiety, depression, or joy. Triggers for cocaine craving also are highly idiosyncratic, thus identification of cues should take place in an ongoing way throughout treatment.

To explain the ideas of conditioned cues, therapists might paraphrase Pavlov's classical conditioning paradigm by equating food to cocaine, the animal's salivation to cocaine craving, and the bell as the trigger. Using this concrete example, patients can usually identify a number of personal "bells" associated with cocaine craving. The example of Pavlov's experiments is often enough to demystify the experience of craving and help patients identify and tolerate conditioned craving when it occurs.

It is also important to convey the time-limited nature of cocaine craving, that is, conditioned craving usually peaks and dissipates in less than an hour, if not followed by cocaine use. Therapists should also explain the process of extinction of conditioned responses, again using concrete examples from Pavlov's experiments.

Describing Craving 

Next, it is essential to get a sense of the patients' experience of craving. This includes eliciting the following information.

  • What is craving like for you?Cravings or urges are experienced in a variety of ways by different patients. For some, the experience is primarily somatic; for example, "I just get a feeling in my stomach" or "My heart races" or "I start smelling it." For others, craving is experienced more cognitively; for example, "I need it now" or "I can't get it out of my head" or "It calls me." Or it may be experienced affectively; for example, "I get nervous" or "I'm bored." It is important for the therapist to get a clear idea of how craving is experienced by the patient.
  • How bothered are you by craving?There is tremendous variability in the level and intensity of craving reported by patients. For some, achieving and maintaining control over craving will be a principal treatment goal and take several weeks to achieve. Other patients deny they experience any craving. Gentle exploration with patients who deny any craving (especially those who continue to use cocaine) often reveals that they misinterpret a variety of experiences or simply ignore craving when it occurs until they suddenly find themselves using. Other, abstinent patients who deny they experience any craving often, when asked, admit to intense fears about relapsing.
  • How long does craving last for you?To make the point about the time-limited nature of craving, it is often important to point out to patients that they have rarely let themselves experience an episode of craving without giving in to it.
  • How do you try to cope with it?Getting a sense of the coping strategies used by patients will help the therapist identify their characteristic coping styles and select appropriate coping strategies.

Identifying Triggers

Therapists should then work with patients to develop a comprehensive list of their own triggers. Some patients become overwhelmed when asked to identify cues (one patient reported that even breathing was associated with cocaine use for him). Again, it may be most helpful to concentrate on identifying the craving and cues that have been most problematic in recent weeks. This list should be started during the session; the practice exercise for this session should include self-monitoring of craving, so patients can begin to identify new, more subtle cues as they arise.

Avoiding Cues

Keep in mind that the general strategy of "recognize, avoid, and cope" is particularly applicable to craving. After identifying the patients' most problematic cues, therapists should explore the degree to which some of these can be avoided. This may include breaking ties or reducing contact with individuals who use or supply cocaine, getting rid of paraphernalia, staying out of bars or other places where cocaine was used, or no longer carrying money, as in the following example:

"You've said that having money in your pocket is the toughest trigger for you right now. Let's spend some time thinking through ways that you might not have to be exposed to money as much. What do you think would work? Is there an amount of money you can carry with you that feels safe? You talked about giving your check to your mother earlier; do you think this would work? You've said that she's very angry about your cocaine use in the past; do you think she'd agree to do this? How would you negotiate her keeping your money for you? How could you arrange with her to get money you needed for living expenses? How long would this arrangement go on?"

Therapists should spend considerable time exploring the relationship between alcohol and cocaine with patients who use them together to such an extent that alcohol becomes a powerful cocaine cue. Specific strategies to reduce, or preferably, stop alcohol use should be explored.

Coping With Craving

The variety of strategies for coping with craving include the following.

  • Distraction
  • Talking about craving
  • Going with the craving
  • Recalling the negative consequences of cocaine abuse
  • Using self-talk

Therapists may wish to point out that these strategies may not stop craving completely. However, with practice, they will reduce the frequency and intensity of craving and make it less disturbing and frustrating when it occurs.


In many cases, an effective strategy for coping with conditioned craving for cocaine is distraction, especially doing something physical. It is useful to prepare a list of reliable distracting activities in conjunction with patients in anticipation of future craving. Such activities might include taking a walk, playing basketball, and doing relaxation exercises. Preparation of such a list may reduce the likelihood that patients will use substances, particularly alcohol and marijuana, in ill-fated attempts to deal with craving. Leaving the situation and going somewhere safe is one of the most effective ways of dealing with craving when it occurs.

Talking About Craving

When patients have supportive, abstinent friends and family members, talking about craving when it occurs is a very effective strategy and can help reduce the feelings of anxiety and vulnerability that often accompany it. It can also help patients identify specific cues.

Close family members may become distressed when they hear patients talk about craving because they expect it to lead to use. Therapists might spend some time identifying who patients would feel comfortable talking with about craving, how that person would be likely to react, and whether it makes sense to ask that person in advance for support.

"It sounds like you think talking to your wife might help, but you've also said that she's very nervous about what would happen if you relapsed. Do you think she'd be able to listen if you talked with her the next time you felt like using? Maybe you could talk to her about this before the next time you feel craving, so the two of you can figure out how you'll handle it when it comes up."

Socially isolated patients, or those who have few non-using friends, will find it difficult to nominate a supportive other who can assist with craving, thoughts about cocaine, and other problems. This should alert therapists to the need to consider addressing social isolation during treatment. For example, therapists and patients can brainstorm ways of meeting new, non-using others, reconnecting with friends and family members, and so on. To help patients "own" these strategies and be more likely to initiate positive social contact, therapists might suggest applying the problem solving strategies discussed in Topic 7: Case Management.

Going With The Craving

The idea behind this technique is to let cravings occur, peak, and pass; in other words, to experience them without either fighting or giving into them. Giving patients the imagery of a wave or walking over a hill may help convey this concept, as does judo, that is, gaining control by avoiding resistance.

Ito and colleagues (1984) identified the steps involved; these should be practiced within sessions or at home before craving occurs. Also, patients should be told that the purpose is not to make the cravings disappear, but to experience them in a different way that makes them feel less anxiety provoking and dangerous and thus easier to ride out. The steps are summarized below.

  • Pay attention to the craving. This usually involves, first, finding someplace safe to let oneself experience craving (e.g., a comfortable and quiet place at home). Next, relax and focus on the experience of craving itself - where it occurs in the body or mind and how intense it is.
  • Focus on the area where the craving occurs. This involves paying attention to all the somatic and affective signals and trying to put them into words. What is the feeling like? Where is it? How strong is it? Does it move or change? Where else does it occur? After concentrating in this way, many patients find the craving goes away entirely. In fact, the patient may find it useful to rate the intensity of craving before and after the exercise to demonstrate the effectiveness of the technique.

Recalling Negative Consequences

When experiencing craving, many people have a tendency to remember only the positive effects of cocaine; they often forget the negative consequences. Thus, when experiencing craving, it is often effective for them to remind themselves of the benefits of abstinence and the negative consequences of continuing to use. This way, patients can remind themselves that they really will not feel better if they use.

To this end, it may be useful to ask patients to list on a 3 x 5 card the reasons they want to be abstinent and the negative consequences of use and to keep the card in their wallet or another obvious place. A glimpse of the card when confronted by intense craving for cocaine or a high-risk situation can remind them of the negative consequences of cocaine use at a time when they are likely to recall only the euphoria.

Using Self-Talk

For many patients, a variety of automatic thoughts accompany craving but are so deeply established that patients are not aware of them. Automatic thoughts associated with craving often have a sense of urgency and exaggerated dire consequences (e.g., "I have to use now," "I'll die if I don't use," or "I can't do anything else until I use").

In coping with craving, it is important both to recognize the automatic thoughts and to counter them effectively. To help patients recognize their automatic thoughts, therapists can point out cognitive distortions that occur during sessions (e.g., "A few times today you've said you feel like you have to use. Are you aware of those thoughts when you have them?"). Another strategy is to help patients "slow down the tape" to recognize cognitions.

"When you decided to go out last night, you said that you really weren't aware of thinking about using cocaine. But I bet if we go back and try to remember what the night was like, sort of play it back like a movie in slow motion, we could find a couple of examples of things you said to yourself, maybe without even realizing it, that led to cocaine use. Can you sort of play last night back for us now?"

Once automatic thoughts are identified, it becomes much easier to counter or confront them, using positive rather than negative self-talk. This includes cognitions such as challenging the thought (e.g.,"I won't really die if I don't have cocaine"), and normalizing craving (e.g., "Craving is uncomfortable, but a lot of people have it and it's something I can deal with without using").

Practice Exercises

Depending on how serious a problem craving is for a patient, this topic can be delivered in one or two sessions. When presented in two sessions, the first session focuses on recognizing craving and identifying triggers, and the extra-session task includes making a more elaborate list of craving triggers through Self-Monitoring (Exhibit 3). The second session then focuses on learning and practicing coping strategies, and the extra-session tasks involve continuing to self-monitor and also observing the coping behaviors used when craving occurs.

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