Learning serves as an important metaphor for the treatment process
throughout CBT. Therapists tell patients that a goal of the treatment is
to help them "unlearn" old, ineffective behaviors and "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 surprised to consider cocaine abuse
as a type of skill, as something they have learned to do over time. After
all, they are surprised when they think of themselves as having
learned a complex set of skills that enabled them to acquire the
money needed to buy cocaine (which often led to another set of licit or
illicit skills), acquire cocaine without being arrested, use cocaine and
avoid detection, and so on. Patients who can reframe their self-appraisals
in terms of being skilled in this way often see that they also have the
capacity to learn a new set of skills that will help them remain
abstinent.
In CBT, it is assumed that individuals essentially learn to become
cocaine abusers through complex interplays of modeling, classical
conditioning, or operant conditioning. Each of these principles is used to
help the patient stop abusing cocaine.
Classical conditioning concepts also play an important role in
CBT, particularly in interventions directed at reducing some forms of
craving for cocaine. Just as Pavlov demonstrated that repeated pairings of
a conditioned stimulus with an unconditioned stimulus could elicit a
conditioned response, he also demonstrated that repeated exposure to the
conditioned stimulus without the unconditioned stimulus would, over
time, extinguish the conditioned response. Thus, the therapist attempts to
help patients understand and recognize conditioned craving, identify their
own idiosyncratic array of conditioned cues for craving, avoid exposure to
those cues, and cope effectively with craving when it does occur so that
conditioned craving is reduced.
Generalizable Skills
Since CBT treatment is brief, only a few specific skills can be
introduced to most patients. Typically, these are skills designed to help
the patient gain initial control over cocaine and other substance abuse,
such as coping with craving and managing thoughts about drug abuse.
However, the therapist should make it clear to the patient that any of
these skills can be applied to a variety of problems, not just cocaine
abuse.
The therapist should explain that CBT is an approach that seeks to
teach skills and strategies that the patient can use long after treatment.
For example, the skills involved in coping with craving (recognizing and
avoiding cues, modifying behavior through urge-control techniques, and so
on) can be used to deal with a variety of strong emotional states that may
also be related to cocaine abuse. Similarly, the session on problemsolving
skills can be applied to nearly any problem the patient faces, whether
drug abuse-related or not.
Basic Skills First
This manual describes a sequence of sessions to be delivered to
patients; each focuses on a single or related set of skills (e.g.,
craving, coping with emergencies). The order of presentation of these
skills has evolved with experience with the types of problems most often
presented by cocaine-abusing patients coming into treatment.
Early sessions focus on the fundamental skills of addressing
ambivalence and fostering motivation to stop cocaine abuse, helping the
patient deal with issues of drug availability and craving, and other
skills intended to help the patient achieve initial abstinence or control
over use. Later sessions build on these basic skills to help the patient
achieve stronger control over cocaine abuse by working on more complex
topics and skills (problemsolving, addressing subtle emotional or
cognitive states). For example, the skills patients learn in achieving
control over craving (urge control) serve as a model for helping them
manage and tolerate other emotional states that may lead to cocaine abuse.
Match Material to Patient Needs
CBT is highly individualized. Rather than viewing treatment as cookbook
psychoeducation, the therapist should carefully match the content,
timing, and nature of presentation of the material to the
patient. The therapist attempts to provide skills training at the moment
the patient is most in need of the skill. The therapist does not belabor
topics, such as breaking ties with cocaine suppliers, with a patient who
is highly motivated and has been abstinent for several weeks. Similarly,
the therapist does not rush through material in an attempt to cover all of
it in a few weeks; for some patients, it may take several weeks to truly
master a basic skill. It is more effective to slow down and work at a pace
that is comfortable and productive for a particular individual than to
risk the therapeutic alliance by using a pace that is too aggressive.
Similarly, therapists should be careful to use language that is
compatible with the patient's level of understanding and sophistication.
For example, while some patients can readily understand concepts of
conditioned craving in terms of Pavlov's experiments on classical
conditioning, others require simpler, more concrete examples, using
familiar language and terms.
Therapists should frequently check with patients to be sure they
understand a concept and that the material feels relevant to them. The
therapist should also be alert to signals from patients who think the
material is not well suited to them. These signals include loss of eye
contact and other forms of drifting away, overly brief responses, failure
to come up with examples, failure to do homework, and so on.
An important strategy in matching material to patient needs (and
providing treatment that is patient driven rather than manual driven) is
to use, whenever possible, specific examples provided by the
patients, either through their history or relating events of the week. For
example, rather than focusing on an abstract recitation of "Seemingly
Irrelevant Decisions," the therapist should emphasize a recent, specific
example of a decision made by the patient that ended in an episode of
cocaine use or craving. Similarly, to make sure the patient understands a
concept, the therapist should ask the patient to think of a specific
experience or example that occurred in the past week that illustrates the
concept or idea.
"It sounds like you had a lot of difficulty this week and
wound up in some risky situations without quite knowing how you got
there. That's exactly what I'd like to talk about this week, how by not
paying attention to the little decisions we make all the time, we can
land in some rough spots. Now, you started out talking about how you had
nothing to do on Saturday and decided to hang out in the park, and 2
hours later you were driving into the city to score with Teddy. If we
look carefully at what happened Saturday, I bet we can come up with a
whole chain of decisions you made that seemed pretty innocent at the
time, but eventually led to you being in the city. For example, how did
it happen that you felt you had nothing to do on
Saturday?"
Use Repetition
Learning new skills and effective skill-building requires time and
repetition. By the time they seek treatment, cocaine users' habits related
to their drug abuse tend to be deeply ingrained. Any given 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 important that therapists
recognize how difficult, uncomfortable, and even threatening it is to
change these established habits and try new behaviors. For most patients,
mastering a new approach to old situations takes several attempts.
Moreover, many patients come to treatment only after long periods of
chronic use, which may affect their attention, concentration, and memory
and thus their ability to comprehend new material. Others seek treatment
at a point of extreme crisis (e.g., learning they are HIV positive, after
losing a job); these patients may be so preoccupied with their current
problems that they find it difficult to focus on the therapist's thoughts
and suggestions. Thus, in the early weeks of treatment, repetition is
often necessary if a patient is to be able to understand or retain a
concept or idea.
In fact, the basic concepts of this treatment are repeated throughout
the CBT process. For example, the idea of a functional analysis of cocaine
abuse occurs formally in the first session as part of the rationale for
treatment, when the therapist describes understanding cocaine abuse in
terms of antecedents and consequences. Next, patients are asked to
practice conducting a functional analysis as part of the homework
assignment for the first session. The concept of a functional analysis
then recurs in each session; the therapist starts out by asking about any
episodes of cocaine use or craving, what preceded the episodes, and how
the patient coped.
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 cocaine abuse and are
the focus of two early sessions. These sessions encourage patients to
identify their own obvious and more subtle determinants of cocaine abuse,
with a slightly different focus each time. Similarly, each session ends
with a review of the possible pitfalls and high-risk situations that may
occur before the next session, to again stimulate patients to become aware
of and change their habits related to cocaine abuse.
While key concepts are repeated throughout the manual, therapists
should recognize that repetition of whole sessions, or parts of sessions,
may be necessary for patients who do not readily grasp these concepts
because of cognitive impairment or other problems. Therapists should feel
free to repeat session material as many times and in as many different
ways as needed with particular patients.
Practice Mastering Skills
We do not master complex new skills by merely reading about them or
watching others do them. We learn by trying out new skills ourselves,
making mistakes, identifying those mistakes, and trying again.
In CBT, practice of new skills is a central, essential component of
treatment. The degree to which the treatment is skills training
over merely skills exposure has to do with the amount of practice.
It is critical that patients have the opportunity to try out new skills
within the supportive context of treatment. Through firsthand experience,
patients can learn what new approaches work or do not work for them, where
they have difficulty or problems, and so on.
CBT offers many opportunities for practice, both within sessions and
outside of them. Each session includes opportunities for patients to
rehearse and review ideas, raise concerns, and get feedback from the
therapist. Practice exercises are suggested for each session; these are
basically homework assignments that provide a structured way of helping
patients test unfamiliar behaviors or try familiar behaviors in new
situations.
However, practice is only useful if the patient sees its value and
actually tries the exercise. Compliance with extra-session assignments is
a problem for many patients. Several strategies are helpful in encouraging
patients to do homework.
Give a Clear Rationale
Therapists should not expect a patient to practice a skill or do a
homework assignment without understanding why it might be helpful. Thus,
as part of the first session, therapists should stress the importance of
extra-session practice.
"It will be important for us to talk about and work on
new coping skills in our sessions, but it is even more important to put
these skills into use in your daily life. You are really the expert on
what works and doesn't work for you, and the best way to find out what
works for you is to try it out. It's very important that you give
yourself a chance to try out new skills outside our sessions so we can
identify and discuss any problems you might have putting them into
practice. We've found, too, that people who try to practice these things
tend to do better in treatment. The practice exercises I'll be giving
you at the end of each session will help you try out these skills. We'll
go over how well they worked for you, what you thought of the exercises,
and what you learned about yourself and your coping at the
beginning of each session."
Get a Commitment
We are all much more likely to do things we have told other people we
would do. Rather than assume that patients will follow through on a task,
CBT therapists should be direct and ask patients whether they are willing
to practice skills outside of sessions and whether they think it will be
helpful to do so. A clear "yes" conveys the message that the patient
understands the importance of the task and its usefulness. Moreover, it
sets up a discussion of discrepancy if the patient fails to follow
through.
On the other hand, hesitation or refusal may be a critical signal of
clinical issues that are important to explore with the patient. Patients
may refuse to do homework because they do not see the value of the task,
because they are ambivalent about treatment or renouncing cocaine abuse,
because they do not understand the task, or for various other reasons.
Anticipate Obstacles
It is essential to leave enough time at the end of each session to
develop or go over the upcoming week's practice exercise in detail.
Patients should be given ample opportunity to ask questions and raise
concerns about the task. Therapists should ask patients to anticipate any
difficulties they might have in carrying out the assignment and apply a
prob-lemsolving strategy to help work through these obstacles. Patients
should be active participants in this process and have the opportunity to
change or develop the task with the therapist, to plan how the skill will
be put into practice, and so on.
Working through obstacles may include a different approach to the task
(e.g., using a tape recorder for self-monitoring instead of writing),
thinking through when the task will be done, whether someone else will be
asked to help, and so on. The goal of this discussion should be the
patient's expressed commitment to do the exercise.
Monitor Closely
Following up on assignments is critical to improving compliance and
enhancing the effectiveness of these tasks. Checking on task completion
underscores the importance of practicing coping skills outside of
sessions. It also provides an opportunity to discuss the patient's
experience with the tasks so that any problems can be addressed in
treatment.
In general, patients who do homework tend to have therapists who value
homework, spend a lot of time talking about homework, and expect their
patients to actually do the homework. The early part of each session must
include at least 5 minutes for reviewing the practice exercise in
detail; it should not be limited to asking patients whether they did it.
If patients expect the therapist to ask about the practice exercise, they
are more likely to attempt it than are patients whose therapist does not
follow through.
Similarly, if any other task is discussed during a session (e.g.,
implementation of a specific plan to avoid a potential high-risk
situation), be sure to bring it up in the following session. For example,
"Were you able to talk to your brother about not coming over after he gets
high?"
Use the Data
The work patients do in implementing a practice exercise and their
thoughts about the task convey a wealth of important information about the
patients, their coping and resources, and their strengths and
weaknesses. It should be valued by the therapist and put to use during the
sessions.
A simple self-monitoring assignment, for example, can quickly reveal
patients' understanding of the task or basic concepts of CBT, level of
cognitive flexibility, insight into their own behavior, level of
motivation, coping , level of impulsivity, verbal skills, usual
emotional state, and much more. Rather than simply checking homework, the
CBT therapist should explore with the patients what they learned about
themselves in carrying out the task. This, along with the therapist's own
observations, will help guide the topic selection and pacing of future
sessions.
Explore Resistance
Some patients literally do the practice exercise in the waiting room
before a session, while others do not even think about their practice
exercises. Failure to implement coping skills outside of sessions may have
a variety of meanings: patients feel hopeless and do not think it is worth
trying to change behavior; they expect change to occur through willpower
alone, without making specific changes in particular problem areas; the
patients' life is chaotic and crisis ridden, and they are too disorganized
to carry out the tasks; and so on. By exploring the specific nature of
patients' difficulty, therapists can help them work through it.
Praise Approximations
Just as most patients do not immediately become fully abstinent on
treatment entry, many are not 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 developing a plan for
completion of the next session's homework assignment.
