Lifestyle Change Components

An essential part of the treatment for cocaine abuse involves helping patients change their lifestyles. To accomplish this, they may need new skills, new information, or steady prodding. The therapists' task is to identify, with patients and based on the initial assessments, the types and areas of assistance required. Then patients acquire the skills needed to mold themselves into the kinds of people they want to become. This chapter outlines a number of skills-training components in the areas most commonly addressed by cocaine abusers in treatment:

• Time management
• Social and recreational activities
• Problemsolving
• Vocational satisfaction
• Social skills
• HIV infection prevention

These components are provided as needed. Other types of skills training (e.g., anger management) should also be available.

The substantial lifestyle changes needed to achieve and maintain abstinence from cocaine require that patients make productive use of their time. They must learn to plan and schedule events and activities so they have little idle, high-risk time available. Many patients do not keep regular schedules, and some express resentment at the suggestion that this might be helpful. However, planning and scheduling activities increase the likelihood that patients will follow through with treatment goals and activities. Thus, time-management training is provided to most patients.

Therapists can introduce the idea of time management in the following manner.

"This part of your treatment involves learning to plan, schedule, and prioritize the events and activities in your life. Solving your cocaine problem requires making many substantial changes; it is important to develop efficient ways to do this. Some patients say they don't like to plan or they like to be spontaneous, but if they don't find a way to schedule and organize their lives, they eventually become overwhelmed and don't achieve their goals. It is important to spend time on this issue in treatment."

Develop Time-Management Skills

The importance of writing down and scheduling appointments and activities should be reviewed at each session. Therapists should inform patients that this practice can increase followthrough with plans and goals, reduce stress, help avoid missed appointments, increase awareness of accomplishments, and help organize and prioritize plans.

The first step is to make sure that patients have the appointment books provided during the first session. Since patients often lose these books, an effective alternative is to give them photocopies on a week-by-week basis. The next step is to show patients how to effectively use the appointment book. Therapists should stress the importance of establishing a regular pattern of using the book. Suggest that patients get their books out each morning at a regular time.

"Planning is usually done best first thing in the morning or at the end of the day. There are many advantages to planning in the morning when you are fresh. Having just thought about what you have to do, you can move easily to getting it done. With the day's priorities clearly in mind, you will be less likely to be sidetracked as you go along. Also, you can review any scheduled activities for the day."

Patients should make a list of what they would like to accomplish that day or before the next therapy session. Therapists should then point out how all the items on a list are not of equal importance and introduce the ABC system of prioritizing (Lakein 1973). In this system, therapists ask patients to write a capital "A" beside those items on the list that have a high value, a "B" for those with medium value, and a "C" for those with low value. Items marked A should be those that yield the most value.

"You will get the most out of your time by doing the A's first and saving the B's and C's for later. By taking account of the time of day and the urgency of the items, you can even break them down further so that A items become A-1, A-2, A-3, and so on. How detailed you get depends on you and the number of activities on your list."

After the prioritizing is complete, therapists should help patients make realistic plans and schedules and enter them in the appointment book. The priority given to each item guides where and when it is written. At first, patients may try to place more into their schedules than they can possibly accomplish. Also, some make poor choices about which activities to schedule when. Here, therapists need to guide and teach patients about efficient, realistic time-management planning.

Patients should be encouraged to make a separate "To Do" list each day. As they complete each activity, they should cross it off the list. Then, at the end of the day, they will be able to check on how many items have been completed. It is important that this list be on a single piece of paper rather than jotting down items on miscellaneous scraps of paper. Patients should be encouraged to keep the list in their appointment books so it is accessible and useful.

Apply Time Management

Therapists should ask patients to practice these time-management procedures (i.e., daily scheduling and keeping daily lists) during the coming week. Have them choose a specific time of day to do this. Patients should also be instructed to bring their appointment books and daily lists to each session.

Therapists should encourage daily and continuous use of these procedures throughout treatment and help problemsolve any difficulties that patients may have in completing the exercises. Emphasis is placed on making this a daily routine for the next few months and perhaps for many years to come.

If patients do not comply with these exercises between sessions, therapists should always try to have them use the appointment book and make daily lists while in session. This repeated in-session exercise may help reinforce between-session compliance.

This component of CRA + Vouchers focuses on developing interest and participation in recreational and social activities that are pleasurable for the patient and do not involve cocaine or other drug use. The goal is to increase participation in social activities that may serve as alternatives to cocaine use.

Rationale

Therapists should provide a rationale for working on lifestyle changes in social and recreational areas.

"Many times, when cocaine or other drugs become a regular part of someone's life, they either stop doing many of the nondrug activities they used to enjoy, or they never start or develop any regular recreational activities. For example, many drug abusers, like anyone else, used to play sports, work out or exercise, go on hikes, go out to the movies, visit relatives, and so forth. But as drug use increases, it gradually replaces these other activities."

"Social and recreational activities are important in most people's lives. They provide -

• A source of enjoyment that can be looked forward to after a stressful day at work or taking care of the kids.
• A way to decrease boredom when you have free time.
• A way to feel physically healthy.
• An outlet for developing a skill that makes you feel good about yourself.
• A chance to be with people you like to develop friendships."

"These activities can play a very important part in becoming and staying drug free. When you give up using drugs, you have to do something else during the times you were using. If the things you do are not satisfying or enjoyable, or you don't do anything but sit around and feel lonely or bored, you are more likely to use drugs."

"Developing satisfying, regular social and recreational activities is difficult for many people who are trying to quit cocaine. Sometimes it is hard to -

• Find anyone to do things with who is not a drug user.
• Think of things you would like to do that are affordable.
• Fit activities into your schedule because of work or family responsibilities.
• Become motivated to start something new."

"This is why we have a specific treatment component to assist patients in developing a regular schedule of social and recreational activities."

List Activities and People

The first step in social/recreational counseling is to develop a list of potentially reinforcing activities that patients are interested in pursuing. Therapists should gather possibilities from patients by asking about -

• Current activities.
• Activities enjoyed in the past.
• Things patients have always wanted to do, but have never done.

Therapists could also use the Leisure Interests Checklist (Rosenthal and Rosenthal 1985) to assess the patients' interest in various activities. This checklist can be administered either in-session or as an assignment between sessions. As with any assignment, if the checklist is not completed as scheduled, it should be completed during the next session.

Once possible activities are identified, therapists and patients should attempt to categorize activities by amount of interest, cost, others' involvement, time commitment, likelihood of engaging in the activity, and whether it is physical or sedentary.

An important goal for most patients is to increase time spent with nondrug-using persons and discontinue interaction with drug abusers. Thus, the next step is to create a list of persons who might participate in activities with the patient. This can be very difficult, because patients will often report that they don't know anyone who is not a drug user or alcoholic; this is rarely true. With gentle prompting by therapists about extended family and old acquaintances, patients can usually name at least one safe person to target as a contact.

If patients are unable to identify anyone, therapists should move on and come back to this issue later. Finding safe people has high priority, since establishing a social network of nonusing friends or family members can play a substantial role in the achievement and maintenance of cocaine abstinence. As a last resort, clinic staff may accompany patients who are trying out a new activity as a way to establish interest and increase the probability that they will ask a nondrug-using friend to participate in the future.

Set Goals and Assess Progress

Therapists and patients should agree upon goals for directly participating in a particular activity, taking the necessary steps toward participation, or increasing the time spent with nondrug-using persons. Behavioral techniques for effectively setting goals and shaping behavior can be applied here. These goals should then be incorporated into the treatment plan and systematically worked on throughout the course of treatment. Progress should be assessed in each session and any problems or changes in goals dealt with at that time.

Facilitate Change

If patients express fears about doing certain activities or meeting people, therapists should assess the extent of the problem and offer to help with problemsolving, social skills training, behavioral rehearsal, or another appropriate procedure. If applicable, therapists should encourage the use of vouchers from the incentive program to pay for these activities. Also, if significant others are participating in treatment, they can help involve the patients in new activities.

Therapists can also help in this area by providing patients with listings of local activities, recreational facilities, continuing education classes, and other community resources and activities. In essence, the therapist or another staff member can function as a source of information about available social/recreational opportunities in the community. This means therapists will need to review local newspapers, bulletin boards, and radio advertisements and make contact with community agencies prior to sessions.

For patients who seem unable to sample social activities, therapists might use scheduled sessions to initiate such behavior. For example, therapists could take patients bowling, shopping for crafts, to the YMCA, to play tennis or basketball, or to a museum.

Achieving cocaine abstinence and making substantial lifestyle changes involve finding solutions for many problems. Some patients may have so many problems that even minor problems seem overwhelming. For example, a straightforward goal like going to a job service center to meet a therapist and signing up for assistance may require solving a number of problems. The patient may not have readily available transportation, childcare may be needed, or the only available appointments may conflict with other important activities.

For many patients, their cocaine abuse has resulted in either avoidance of such problems or making impulsive decisions that are not in their best interest. Such poor problemsolving behavior usually results in negative consequences that increase the severity of existing problems or create additional problems. Thus, an important component of CRA + Vouchers is skills training in effective problemsolving. The method is similar to that used by Monti et al. (1989) in the treatment of alcohol dependence. The goal of this training is to teach patients to identify, analyze, and find solutions for the many problems they will face in their efforts to stop cocaine use and make lifestyle changes.

Rationale

Therapists should provide a rationale for this component.

"Persons trying to recover from cocaine problems often find themselves confronted by difficult situations. These situations become problematic if you do not have an effective response for them. Cocaine abusers are likely to encounter several types of problems.

• Finding themselves in situations where they have used cocaine and other drugs in the past
• Having to deal with social pressures
• Craving drugs or relapsing

  "Some common problems are encountered in making positive lifestyle changes.

• Having difficulty finding the time to participate in social activities or hobbies
• Lack of transportation
• Problems with childcare
• Job-related issues
• Family pressures
• Legal problems

"Effective problemsolving requires that you recognize the fact that you face a problem situation and resist the temptation either to respond to your first impulse or to do nothing. If you don't find good solutions, your problems can build up over time, and the pressure may eventually get to you and trigger cocaine use. We have a program for helping you become a better problem solver. To become good at this skill usually takes some time and a lot of practice."

Steps for Problemsolving

At this point, therapists should introduce the basic steps for prob-lemsolving.

• Recognize the problem
• Identify the problem
• Brainstorm
• Select the approach
• Evaluate its effectiveness

Recognize the Problem

Therapists should review several questions that patients can ask themselves to become more aware of problem situations. The following are some sources of clues that a problem exists.

• Your body (e.g., tension, craving)
• Your thoughts and feelings (e.g., worry, depression, loneliness,
• irritability)
• Your behavior (poor work performance, not meeting responsibilities in your family, with friends)
• Your reactions to other people (e.g., irritable, lack of interest, isolation)
• Others' reactions to you (e.g., avoidance, complaining)

Identify the Problem

Patients need to learn to clearly label or identify a problem once they realize that something is wrong. They should collect as much information and as many facts as possible to help clarify the problem. For example, if patients are upset about their current job and are considering quitting, the therapist could work with them to clearly identify what is problematic about the job. Questions such as the following could be asked.

"Do you get along with your coworkers?"

"How is your relationship with your supervisor?"

"Have you received any negative feedback or evaluations?"

"Is the pay high enough? Have you asked for a raise?"

More and more detailed questions should be posed as therapists focus on the problem.

Brainstorm

It is important to develop a number of solutions to a given problem, because the first one that comes to mind may not be the best. When brainstorming, list all possible solutions but do not evaluate them yet. Patients should be encouraged to list ridiculous as well as serious solutions, the most difficult as well as the easiest solutions, and the "worst" solutions as well as the "best" solutions.

Select Approach

The next step is to select the most promising approach. Therapists should help patients evaluate each potential solution and identify the most probable outcomes for each possible solution. Be sure to consider both positive and negative outcomes and both long- and short-term consequences. Also evaluate the difficulty of implementing each solution. The decision on which solution to try first is made after considering both the ease of implementing the solution and the potential for a positive outcome.

Evaluate Effectiveness

Once a solution is chosen, therapists should discuss the next step, evaluating its effectiveness. Here, emphasis is placed on the need to evaluate and try again if the solution is not effective. Also, it is important that therapists help patients determine how they will know if it is effective. Determining this ahead of time helps patients be more realistic and perhaps optimistic about finding effective solutions to problems.

Practice

Therapists next provide several problemsolving worksheets (exhibit 17) and, together with the patients, follow the steps outlined above for effective problemsolving. Patients work through the problem recognition stage to identify problems they would like to work on. Then therapists have patients describe a problem as accurately as possible, brainstorm solutions, assess alternative solutions, select a solution, and make plans for carrying out the solution.

Satisfying, gainful employment or career activities can play an important role in achieving and maintaining abstinence from cocaine and other drugs of abuse. Therefore, vocational counseling is an important component of CRA + Vouchers. The procedures are based on those outlined in Azrin and Besalel's "Job Club Counselor's Manual" (1980). We have adapted it for use in individual rather than group settings. Counselors providing this vocational component will benefit from familiarizing themselves with the Job Club manual.

A job counselor is available to work with patients throughout the week, and therapists use Job Club procedures in individual counseling sessions when appropriate. This counseling focuses on helping unemployed patients locate work and on improving the employment situation of patients who consider their jobs unsatisfactory or have jobs that place them at high risk for continued drug use.

Rationale

The rationale for making positive changes in this area is straightforward. Therapists initiate a discussion about the role of a satisfying vocation in the short- and long-term maintenance of drug abstinence.

"In drug abuse treatment, one of the predictors of long-term success is stable, satisfying employment. This relationship between abstinence and employment satisfaction exists because -

• When you work at a job you like, you are unlikely to use cocaine while working.
• You are less likely to jeopardize that job by coming in late or missing work because of late-night partying.
• The job makes you take pride in and feel good about yourself.
• The job provides you with the financial means to access other
• positive things, such as social and recreational activities, and desirable housing and transportation.
• Sometimes the job also provides a source of social support, friendship, and social activities that are unrelated to drug use."

Set Goals

The primary goal of vocational counseling is to assist patients in finding satisfying employment or in taking steps toward the development of a meaningful career. Similar to other components of CRA + Vouchers, therapists first conduct a thorough assessment and then collaborate with patients to set behavior-change goals. For example, many patients have difficulty initiating job-seeking behavior. Thus, in the spirit of the Community Reinforcement Approach, therapists can take patients to fill out applications or provide job leads for those patients who do not take the initiative. The goals of vocational counseling vary depending on the individual patient's situation. Below are examples of goals that are typically set in the vocational counseling component.

For the unemployed patient:

• Make eight job contacts per week.
• Develop a resume
• Send out two resumes with a cover letter each day.
• Go to the job service twice a week.
• Enroll in a job training program.
• Enroll in a vocational exploration program.
• Take a job-skills-related class.
• Collect and consider information on educational possibilities.

For the patient who works "too many" hours or has an irregular schedule:

• Keep work to 35 - 50 hours each week.
• Establish a more regular schedule.
• Explore alternative work schedules.

For the patient working in a "high risk for drug use" environment or the dissatisfied employee:

• Consider a job change.
• Submit applications for alternative employment while continuing to work.
• Modify the work environment to reduce risk of drug use or improve working conditions.
• Enroll in a career exploration class.
• Enroll in job-skill or alternative career-related educational classes.

By the end of the first session of vocational counseling, therapists and patients should have set a long-term goal (e.g., full-time employment as a secretary) and specific, short-term attainable goals (e.g., five job contacts per week, employment with a temporary agency, enrollment in a computer skills class). These goals should be monitored and changed, as needed, until patients achieve their long-term goal. In this respect, vocational counseling is typically an ongoing component throughout treatment.

Treatment Components

The following vocational counseling services are provided to patients by either the Job Club counselor or the therapist.

1. The therapist encourages patients to treat the job search as a full-time job. The suggested timeframe for this is to spend half of each workday looking for job leads and setting up interviews and the other half going to interviews. Patients are to continue with this schedule each day until they find a job.
2. The therapist advises patients to systematically contact friends, relatives, and acquaintances for job leads.
3. The therapist provides standard scripts and forms to follow when making contacts with potential employers, for writing letters, for making telephone calls, and for keeping records.
4. The therapist provides the supplies and services necessary for a job search. Patients should have access to a work area, telephone, computer, photocopier, postage, and newspapers.
5. The therapist encourages patients to seek job interviews and applications for jobs that are not advertised. For example, the patient could call all the manufacturing plants, all the car dealerships, or all the haircutting establishments in the yellow pages.
6. Patients are encouraged and taught to use the telephone as the primary means for obtaining job leads. This is a more efficient method than letters or visits.
7. The yellow pages section of the telephone book is used to make lists of potential employers.
8. The therapist helps patients learn how to promote strengths other than work skills (i.e., social and personal skills). These skills can be highlighted in a resume when making job contacts as well as during interviews. In addition, the therapist helps patients identify and list marketable work-related skills that were not necessarily acquired during previous employment.
9. The therapist helps patients learn how to make the most of unsuccessful job contacts, that is, learn how to ask that source for other job leads.
10. Patients learn to recontact a potential job source following an interview. This can help demonstrate their interest and enthusiasm for the job to the employer. Also, after an unsuccessful contact with a very desirable job source, patients learn to call that employer back after a period of time in search of future opportunities.
11. The therapist helps patients learn how to arrange transportation to job sites that are difficult to get to for whatever reason.
12. Patients are encouraged to contact previous employers for jobs or job leads.
13. Patients are encouraged to get open letters of recommendation from multiple sources. These can be used when submitting applications or when interviewing to expedite the employer's decision.
14. The therapist helps patients build an effective resume.
15. The therapist provides advice and instruction on how to effectively fill out an application (e.g., emphasize personal skills).
16. The therapist provides training on how to effectively present yourself at interviews.
17. The therapist provides a list of effective behaviors that should occur during an interview. After each interview, the list is reviewed and feedback provided.
18. Patients who cannot find a job in a reasonable amount of time should be encouraged to place a job-wanted ad in the newspaper. This ad emphasizes personal skills and the type of work the patient is seeking.
19. The therapist encourages patients to create a structured job-seeking schedule. A datebook or form is used to schedule each day's activities.
20. Patients engage in recordkeeping using such things as job lead lists, call-backs, and progress notes.
21. The therapist encourages patients to contact job supervisors rather than personnel staff. Sometimes the supervisor has an important role in making hiring decisions.
22. The therapist instructs patients in how to discuss handicaps (e.g., physical limitation, prison record) with a potential employer and how to turn them into strengths.
23. The therapist encourages patients to consider a variety of jobs so they do not restrict themselves to the extent that they do not find employment.
24. The therapist provides continued assistance until a job is obtained.

Social-skills training is provided to patients who report or demonstrate difficulties in -

• Meeting nondrug-using peers.
• Interacting with coworkers or roommates.
• Attending social activities because they feel uncomfortable in social settings.
• Expressing their feelings or asserting themselves in an appropriate way.

The goal is to help patients learn how to better handle interpersonal situations so they can experience more positive reinforcement and fewer negative, aversive effects from social interactions. The particular skill area to be addressed depends on the patient's needs (e.g., anger management, anxiety in social situations, initiating pleasant conversation). Effective procedures for social-skills training with alcoholics and drug abusers have been outlined by Chaney (1989) and Monti and colleagues (1989).

This chapter provides a detailed protocol for assertiveness training to illustrate the structure of a skills-training protocol. Most patients will benefit from help in this area, since studies have shown a relationship between lack of assertiveness and drug use.

Assertiveness Training

Assertiveness training is appropriate for patients who tend to be either too passive or too aggressive in social situations. Because of these tendencies, these patients are unable to effectively obtain what they want in certain situations. As cocaine abusers try to make positive lifestyle changes, their ability to effectively communicate their needs becomes important in developing alternative, nondrug reinforcements. Assertiveness training is one method for increasing positive experiences and decreasing negative experiences in social settings. Our procedures for implementing assertiveness training are based on those outlined by Alberti and Emmons (1982) and McCrady (1986).

Rationale

Therapists should tailor the rationale for assertiveness training to the needs of the patient.

"Your functional analysis showed that at least one of your triggers is your inability to handle certain situations. Your positive consequences from cocaine use included feeling free to express yourself, more relaxed, less depressed, and more powerful. If you can learn to deal with these unpleasant situations and to create these positive feelings without cocaine, you will have a much better chance of remaining drug free."

"Learning how to be assertive will enable you to act in your own best interest, to stand up for yourself without experiencing excessive anxiety, to express your feelings honestly and comfortably, and to exercise your personal rights without denying the rights of others."

Define Interpersonal Style

Learning and practicing assertiveness skills typically take two to four sessions. Therapists should begin by defining assertiveness for the patient: what it is, what it is not, and the results of assertiveness and its alternatives. Descriptions and consequences of passive, aggressive, and assertive behaviors should be discussed with patients. Help patients recognize which styles they tend to use, when they use them, how they affect them, and how they can act assertively in more of these situations. Point out that assertive people can also choose to be passive or aggressive if the situation requires it.

The following points about each interpersonal style should be integrated into the discussion.

• Passive behavior causes you to -
  • Deny yourself or your rights.
  • Avoid expressing feelings.
  • Feel hurt and anxious.
  • Allow others to choose for you.
  • Fail to achieve your desired goals.
• Aggressive behavior causes you to -
  • Accomplish goals at the expense of generating hatred and resentment in others.
  • Express feelings and promote self-enhancement, but usually hurt others in the process.
  • Minimize others' worth and put them down.
  • Make choices for others, and deny them their rights.
• Assertive behavior enables you to -
  • Express your feelings honestly.
  • Achieve your personal goals.
  • Respect the feelings of others.
  • Improve how you feel about yourself.

In summary:

• Passive: You are hurt by not getting what you want.
• Aggressive: The other person is hurt and may seek revenge.
• Assertive: Neither person is hurt, and both get what they want.

Assertiveness Skills

Therapists should give patients the Being Assertive handout (exhibit 18) and encourage a discussion of each point.

Practice

Therapists and patients now choose two situations from the patients' Functional Analysis in which patients would benefit from being assertive. Behavior rehearsal and role-play are used to practice assertive responses in the two situations. Therapists should give feedback after each attempt and have the patients practice two or three times.

Set Goals and Assess Progress

After patients have made significant progress during rehearsal, therapists and patients collaborate in setting a between-session goal for either rehearsing assertive responses or actually attempting assertiveness in a specific situation.

At the next session, progress is reviewed. Problems are discussed, and feedback and social reinforcement are given by the therapist. Additional role-playing and rehearsal of either the same targeted situation or a new situation occur in this session. Again, appropriate between-session goals are set for practicing assertive behavior. This process of goal-setting, evaluation, and practice continues until the patients meet their goals.

At least one or two sessions during the early stages of treatment should be devoted to HIV/AIDS education and, if warranted, counseling on the needs and risk behavior of the patients.

The following tasks should be accomplished in this component.

• Patients complete an AIDS knowledge test (pretest).
• Patients watch and then discuss a video on HIV and AIDS.
• Patients are given copies of HIV/AIDS pamphlets and condoms (if desired).
• Patients complete an AIDS knowledge test (posttest).
• Patients are given information about being tested for HIV antibodies
• and hepatitis B and C.

Rationale

The rationale for HIV infection counseling can be provided to patients by the therapist as follows.

"We will take time during your treatment to provide education on HIV, the AIDS virus, and other diseases commonly associated with drug abuse, like hepatitis B and C. The most common way these diseases are spread among drug users is needle sharing. Injection drug users are more likely to contract HIV or hepatitis B or C than are intranasal users or smokers of cocaine. However, even users who do not inject are at increased risk because these diseases are also spread by sexual activity. If you associate with other drug users and have intimate contact with one who injects or has had sexual contact with an injection user, you are placing yourself at risk for getting these diseases. It is important for you to have the knowledge you need so you can protect your health as well as the health of other people you love or associate with."

AIDS Knowledge Pretest

Next, patients are given an AIDS knowledge test to complete in session. A sample test is shown in exhibit 19. The purpose of assessing knowledge of HIV transmission is to assure that there is no confusion about how one can contract the virus and, more importantly, to ensure that patients recognize the behaviors that place them at risk for transmitting or becoming infected with the virus.

When patients have finished the questionnaire, therapists should review each item and answer any questions the patients may raise. Therapists should ensure that ample time is given to the discussion of incorrect answers and that any misconceptions the patients have are clarified. Supervisors should ensure that therapists themselves have the correct information.

Video and Discussion

After the pretest, patients should be shown an AIDS education video. In the discussion after the video presentation, therapists should add or emphasize the following information.

• Explain that HIV infection is now growing fastest among injection drug users and their sexual partners. Although gay men were the first to become infected in this country, the virus has now spread to the entire community. Almost 25 percent of AIDS cases have involved injection drug users, their sexual partners, or babies born to these individuals. Moreover, more than half the women with AIDS in the United States are injection drug users or sexual partners of such users.
• Make certain patients understand that HIV infection leads to AIDS, and that AIDS is a fatal disease in which the body can no longer fight off infections and malignancies (hence the name, acquired immunodeficiency syndrome).
• Review the three ways that HIV can be transmitted: (1) through sexual contact with an infected person, (2) through blood (as in needle sharing), and (3) from infected mothers to their babies. Explain that HIV is transmitted most efficiently through blood, and that sharing needles and other drug paraphernalia that might be bloody is an easy way for the virus to get from one person's system into another's.
• Emphasize that people who are HIV infected do not necessarily look sick and may not know they are infected. You cannot tell by looking at people whether they have the virus. People can carry the virus and not get sick for several years, but they can still infect others.
• If patients are currently injection drug users, point out that the only totally safe thing to do is to stop injecting drugs. If they continue to inject drugs, they should use new needles or clean them after each use. Explain the steps for appropriate syringe cleaning and provide them with a handout reviewing prevention tactics (exhibit 20).
• Unprotected sexual intercourse with the exchange of body fluids (blood, vaginal fluids, semen, pre-ejaculatory fluid) is also an efficient means of giving or receiving the virus. Sex can be made safer (if the partner's HIV status is unknown) by using latex condoms and a spermicide that contains the ingredient nonoxynol-9 with every sexual encounter, whether it is oral, vaginal, or anal.
• Point out that alcohol and other drug use contribute to risk because they can suppress the immune system, and they impair judgment in ways that can lead to increased risk taking, such as injection drug use and unsafe sex.

Pamphlets and Condoms

After viewing the video and discussing HIV infection, therapists should give patients currently available pamphlets on HIV/AIDS.

Therapists should then tell patients that condoms are given away free by the clinic and where to find them (some agencies leave them in the restrooms). If patients are hesitant about asking their partners to use them, this will need to be worked out in session. Role-playing these uncomfortable situations will be especially useful.

AIDS Knowledge Posttest

At the beginning of the session following the AIDS video and discussion, patients should retake an AIDS knowledge test in session to ensure that they fully understand and remember what they were taught. Again, the completed test should be reviewed and discussed.

HIV Antibody and Hepatitis B Testing

Patients manifest varying degrees of acceptance of HIV counseling and tests. Some patients are highly motivated to learn their serostatus, while others may be wary or suspicious. Still others may not perceive themselves to be at risk for HIV infection and consider the test unnecessary. The therapist's role is to -

• Improve the patient's self-perception of risk.
• Support behavior change already attempted.
• Negotiate a risk-reduction plan.
• Support decisionmaking about the antibody test.
• Help patients who test positive to deal with the results.

Provide Information

If patients express interest in being tested, provide them with the names of one or more testing facilities and their addresses, telephone numbers, and hours of operation. Also explain the agency's testing procedures, including confidentiality or anonymity policies, and the procedures for and time involved in getting the test results.

Discuss Results

Therapists should volunteer to meet patients at a place of their choosing (a parking lot, a park, the mall) to discuss the test results. If the results are positive, contact tracing can be done if patients so choose. These persons will be informed that someone (the patient will not be identified) they have had sex with or shared needles with during the recent past has tested positive for HIV. They will be given information about what this means for them and how to get tested themselves.

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