Other Psychiatric Problems

The clinical focus of CRA + Vouchers is on resolving cocaine abuse. Other psychiatric problems are only addressed when they appear to keep patients from achieving or maintaining cocaine abstinence. The symptoms that most commonly interfere with treatment are related to affective and anxiety disorders. These are addressed with behavioral interventions and, when appropriate, referrals for additional care.

When patients exhibit psychiatric problems that have no apparent relationship to cocaine abstinence but are of concern to them or the staff, they should be referred elsewhere for treatment of those problems. Patients with psychosis and dementia have so far been excluded from CRA + Vouchers treatment, so no data are available about treating them for cocaine problems.

The majority of cocaine-dependent patients enter treatment reporting clinical levels of depressive symptomatology. In most cases, these symptoms appear to be a consequence of cocaine and other substance abuse and dissipate precipitously with several weeks of treatment. For approximately 10 percent of patients, depressive symptoms continue to be a significant problem despite abstinence. The following protocol was developed for treating that subset of patients. This protocol should be used in conjunction with, rather than as a substitute for, an appropriate referral for evaluation for pharmacotherapy or other medical interventions.

Evaluate Suicide Risk

If there is any indication of suicidality, a supervisor or clinician trained in assessing suicide risk should be informed and meet with the patient. If suicide risk is high, patients should be referred immediately for further evaluation. If patients are not an imminent threat for suicide, therapists should proceed with treatment as usual, but evaluate suicide risk at each patient contact. This evaluation should include standard clinical questions used to assess suicide risk. If possible, therapists should obtain written agreements from patients to engage in "safe" behavior, which includes agreeing to call the therapist or designated agency (e.g., crisis clinic) if feeling suicidal. Therapists should keep the supervisor informed of any changes related to suicidal status. Any time therapists feel uncomfortable about a patient's level of risk, the patient should be referred to an appropriate service.

Monitor Symptoms

The intake assessment should identify patients with depressive symptoms. Those who score high on tests such as the BDI or have a history of depression should be monitored throughout treatment. The BDI can be administered every 2 weeks until the score falls into the normal range, after which it can be administered monthly. Most patients who comply with their treatment plan for cocaine dependence show significant drops in their depression scores.

Treatment

A decision to intervene with depression is typically not made until patients have achieved a relatively stable period of abstinence from cocaine as well as any other drugs or alcohol (usually 2 to 4 weeks). However, in some cases, when patients continue to use cocaine and depression appears pervasive, treatment directly targeting depression may be initiated before abstinence is achieved.

Depression can be targeted in two ways.

• Patients can be given a copy of the book "Control Your Depression" by Lewinsohn et al. (1986). Therapists and patients then systematically work through the chapters in the book in the manner suggested by the authors. The theoretical basis for this treatment is that depression is associated with a low density of positive reinforcement and a high density of aversive events. The primary therapeutic goal is to help patients alter their environment to increase the density of reinforcement and decrease aversive events. This treatment is readily integrated into the CRA + Vouchers approach because it involves similar components and behavioral targets.
• Patients can be offered a referral for evaluation for pharmacotherapy for depression.

As patients try to implement needed lifestyle changes, they may exhibit various levels of social anxiety about meeting new people, dating, and so forth. If the social anxiety interferes with treatment goals, therapists should provide a combination of social-skills and relaxation training. In addition, a number of patients complain about persistent insomnia, which can also be treated by behavioral methods.

Relaxation Protocol

Relaxation training can be used in the context of CRA + Vouchers to reduce anxiety that interferes with patients' ability to develop a new social network, to cope with restlessness that may contribute to insomnia, and for general stress reduction.(This relaxation training protocol was adapted from McCrady 1986 and Goldfried and Davison 1994.)

Therapists should begin by discussing with patients how learning to relax is an effective way to cope with their anxiety. The rationale should be tailored to the patients' situations.

"If you find that anxiety is preventing you from meeting new people or going to new, drug-free social settings, relaxation skills may help you overcome these barriers to change. Relaxation skills can be used in the same way you have used alcohol, cocaine, or other drugs to deal with these social situations. You can learn to feel more relaxed and confident and to be more effective in social situations."

After discussing the rationale, therapists should emphasize that relaxation is a skill that patients develop through practice. Learning to relax, like any other skill, takes time to learn, and it will take awhile for them to become "good" at it. With practice, however, they will be able to use their new skill effectively in many situations that are relevant to their cocaine problem.

Relaxation Exercise and Practice

Therapists should use guidelines and instructions, such as those developed by Goldfried and Davison (1994), to teach patients progressive muscle relaxation skills. During the session, therapists should guide patients through a relaxation exercise. Audiotapes of the exercise can be made so patients can take them home and practice this new skill. Patients should be instructed to practice twice a day, if possible. Therapists should provide patients with self-monitoring forms for recording how relaxed they feel after each practice.

At the next session, therapists should take patients through the relaxation exercise again, providing feedback if necessary and soliciting comments and suggestions from them. Relaxation can be induced in many ways, and patients may have important input on what works best for them (e.g., music, meditation). Therapists need to be flexible about procedures and practice, while emphasizing regular, frequent practice.

After 2 to 3 weeks of practice, patients should feel fairly comfortable with the relaxation procedures. It is important to reemphasize the need for practice. Only by continued practice can these skills be applied effectively in daily life.

Once patients report feeling confident in their ability to relax during the practice exercise, therapists should discuss learning to relax more quickly. Discuss the notion that now that they and their bodies have learned what it feels like to relax, it will be much easier to relax on command without going through a 10 - 15 minute relaxation induction procedure.

Have patients try to relax in the office without using the tense-relax techniques they have learned. Instruct them to simply command their body to relax and then briefly scan each muscle group to check and facilitate relaxation. Add that this brief kind of relaxation can be very useful in many situations. Have them try this once more in session and discuss how it feels. Again, therapists should emphasize the need for practice and how with practice they will become very good at this.

Therapists and patients should set a goal to practice this brief type of relaxation during the upcoming week. Patients should be encouraged to try it as many times each day as possible. Reminder prompts should be also discussed, such as the use of a wristwatch that beeps on the hour. Each beep can cue patients to engage in the brief relaxation exercise.

Applications

After patients become fairly proficient with this new skill, therapists can begin to discuss specific applications of relaxation training. Therapists should review the patients' functional analysis of cocaine use to identify situations in which relaxation might serve as an alternative to cocaine use, as a means of avoiding or preventing a trigger from occurring, or in some other way help to reduce cocaine use. Therapists should also look for areas in the patients' lives, such as the job site, while parenting, or in social situations, where relaxation might improve functioning and lead to less stressful and more pleasurable nondrug experiences.

Specific goals for using relaxation that are tailored to the patients' situations should be set for the upcoming week. Patients should choose one or two situations (triggers or stresses) in which to try the relaxation skills. These goals should then become part of the active treatment plan and modified as needed throughout treatment.

Insomnia Protocol

A common symptom that occurs following discontinuation of cocaine use is insomnia. It is important to deal with insomnia if it persists, because a regular sleep pattern is essential to good physical and mental health. For patients, persistent insomnia is likely to interfere with making the lifestyle changes deemed important to abstaining from cocaine use.

Therapists should consider using a behavioral intervention for any patient who reports significant sleep difficulties that do not subside after 2 - 4 weeks of treatment. The one described here is based largely on the effective protocols of Lacks (1987) and Morin (1993). Therapists who implement this protocol should consult one or both of these exellent resources.

Rationale

Therapists should give patients an explanation and rationale for the sleep protocol.

"To help with your sleep difficulties, we can provide a treatment that is consistent with the other parts of your treatment program. This treatment has been widely tested and shown to be effective. We will try to teach you to sleep better by having you -

• Learn more about sleep.
• Keep a record of your sleep patterns.
• Learn to use what we call 'stimulus control' procedures to teach yourself to sleep on a regular schedule.

"Like other aspects of your treatment, this sleep program will involve learning and practice. You will learn to -

• Go to sleep rapidly once you go to bed by practicing not doing anything else in bed except sleep.
• Use the feeling of sleepiness as the cue to go to bed.
• Stop doing things that are associated with staying awake.
• Keep a regular sleep schedule."

"These procedures should result in good sleep habits which will lead to better sleep. Developing these habits will take much planning and practice on your part. However, if you can follow through with what you learn, you will sleep better and will have a skill you can use for the rest of your life."

"Most likely, it will take 4 weeks for you to see any benefits from the sleep program. You may experience continued difficulties for the first few weeks. You may even have additional problems and feel worse. So, it is important not to be in too much of a hurry to sleep better, for like any other skill, it takes time and practice to improve."

"These new habits may seem difficult to develop at first, but you will become more comfortable with the procedure with repeated practice. Expect to be up numerous times in the beginning. You will probably even feel worse after the first week of following these steps. However, teaching your body that the bed is for sleeping, not for worrying, tossing and turning, reading, or other activities, is probably the most important part of this treatment.""

Sleep Diary

Next, explain in detail the importance of keeping a weekly sleep diary (exhibit 33) and provide patients with a copy. Explain to patients that an important part of building new and better sleep habits is closely monitoring sleep-related behaviors to identify and strengthen cues that are associated with falling asleep quickly, and to identify and weaken those cues associated with staying awake. The sleep diary provides an inexpensive, nonintrusive, and efficient method of measuring the experiential component of insomnia.

Therapists should then show patients how to use the sleep diary.

"You are to record, soon after waking up, your estimates of how long it took to fall asleep, how many hours you slept, how difficult it was to fall asleep, and the quality of your sleep. It is important to find a place to keep this form so that you remember to complete it each morning for the next week."

Throughout treatment, patients should closely monitor and chart their sleep-related behaviors.

Sleep-Hygiene Rules

Therapists should next introduce the notion of sleep hygiene and give a copy of the six rules (exhibit 34) to patients. These rules should be presented as important suggestions that, if followed, can help improve the sleep pattern. Therapists should be familiar with the rationales for these rules, as discussed by Lacks (1987) and Morin (1993). It is important for them to take the time necessary to explain the rationale for each rule and be able to respond to patients' questions and concerns.

Sleep Restriction and Stimulus Control

After the sleep-hygiene rules are reviewed and plans are made to practice them, therapists should discuss sleep-restriction and stimulus-control strategies (exhibit 35) and give patients a copy. Again, it is important that therapists be familiar with the rationales behind these recommendations and be able to explain them for each instruction and respond to all concerns expressed by patients.

A common concern of many patients is that these procedures (not going to bed until they feel drowsy, getting up at the same time every day, and no naps) will result in their not getting enough sleep and being unable to function at work or school. It is important for therapists to reassure them that this is the best method for determining how much sleep a person needs to function well. Although it may result in less sleep in the beginning, eventually the body will adjust and get on a regular schedule. Patients may not function at their optimal level during this adjustment period, but they will be able to cope. They have probably been coping with fairly little sleep in the recent past, and this can be used as an example of how they will be able to get through this difficult time.

Goals for practice and recordkeeping should be arranged for each relevant behavior change. The timeframe for implementing these strategies should be determined by patients and therapists together.

Practice

After reviewing the two handouts, therapists should reiterate the importance of following the sleep-hygiene and sleep-restriction and stimulus-control instructions every day.

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