Early Counseling Sessions

Sessions One and Two should take place as soon after the intake meeting as possible. It is essential to complete the assessment/orientation and start treatment while patients are motivated. Therapists should be flexible and willing to schedule these early sessions at any time that is compatible with the patient's schedule. Prior to these two sessions, as with all sessions, therapists should prepare by completing a therapy session checklist.

Prior to Session One, therapists should begin to develop a tentative treatment plan (exhibit 12) using the information collected during intake. The final working version of this plan, however, should represent active collaboration between the therapist and patient. It is important that patients be involved in this process and that they agree to the goals and methods.

Achieving cocaine abstinence is always the primary focus of the treatment plan. Thus, the plan should target areas for change that are directly related to cocaine use, are likely to decrease cocaine use, or will reduce the probability of relapse. Areas for change typically fall into the following categories: other drug use, vocation, family relations, social relations, and recreational activities. Psychiatric, legal, medical, financial, or housing problems deemed likely to interfere with achieving or maintaining cocaine abstinence should also be considered.

The following steps are useful in this task.

• Develop a list of lifestyle changes that are reasonable targets for the patient.
• List reasons for those changes that can be readily discussed with the patient.
• Prioritize targets for lifestyle change based on what is most urgent for achieving initial cocaine abstinence. It is important to decide on the order in which such changes should be attempted.
• Determine methods for achieving change in each of the targeted areas. For example, if the goal is to find satisfying employment, the method might be employment counseling, resume building, and social skills training. If the goal is to enhance patients' relationship satisfaction, the method would be relationship counseling and communications training. If the goal is to increase prosocial recreational activities with nondrug-using peers, the method might be social/recreational counseling, and social skills, relaxation, and time-management training.

Our research and that of others indicate that alcohol use and abuse are often major obstacles to achieving cocaine abstinence. Hence, we routinely recommend a period of disulfiram therapy for all patients who meet diagnostic criteria for alcohol abuse or dependence or who report that drinking is related to their cocaine use.

Therapists have a great many tasks to accomplish in Session One as well as getting to know the patient better and developing rapport. It is unlikely that all of these tasks can be completed in one session. Those that are not should be carried over into Session Two.

• Review the patient's urinalysis results since the last meeting.
• Complete anything not accomplished in the intake assessment session and review the rationale for behavioral treatment.
• Introduce the concept of functional analysis of cocaine use and stimulus control procedures to help with initial abstinence.
• Assist the patient with practical needs.
• Use the patient's appointment book to organize, plan, and schedule activities.
• Initiate or continue with disulfiram or relationship counseling procedures.
• Begin to develop the treatment plan.

Urinalysis Results

Therapists should review the urinalysis results with the patient and provide appropriate feedback. (The voucher should have been supplied by the staff person who reports the results to the patient.) Any problems in the area of drug abstinence should be discussed.

Complete Intake and Treatment Orientation

Patients should complete any unfinished assessment instruments or interviews. If this is all the patients have time for, they should still meet with their therapist. If time is limited, therapists should answer any new questions that the patients have and offer some optimistic remarks about treatment outcome.

Introduce Functional Analysis and Stimulus Control

In the early stage of treatment, it is important to teach patients to identify the antecedents of their cocaine use so that they can actively prepare to deal with situations that place them at high risk for drug use. We refer to this as functional analysis.

The therapist should provide an overview of functional analysis and stimulus control procedures to help the patient understand how these can be used to avoid or actively cope with risky environments. In this context, the notion of craving should be addressed. The following points should be made.

• Having the urge or craving to use cocaine is normal for persons in treatment for cocaine dependence.
• These urges can be triggered by external environmental events or internal states. Examples of external events are seeing a friend you have previously used with, passing a certain bar, watching a TV show about cocaine, or attending a party. Examples of internal states may be memories of past use episodes, feelings of depression, nervousness or tension, or remembering the good effects of past uses.
• Urges to use are time limited; they only last a few minutes or at most a few hours. They usually become less frequent and less intense as you learn how to cope with them.
• Functional analysis is the procedure by which you learn to identify triggers for craving and cocaine use so you can develop strategies to avoid or prevent them from occurring and cope with urges if they occur.

Therapists will probably not have time in Session One to fully introduce and explain functional analysis. Before this session ends, however, therapists should discuss potential triggers (e.g., high-risk situations) that may occur before the next session and help patients develop strategies for dealing with those situations. Concrete plans should be made to deal with these high-risk situations before patients leave the clinic.

Assist With Practical Needs

If practical needs such as housing or transportation are issues for treatment attendance, these needs should be a primary focus of the first session. Therapists should do everything possible to assist patients in finding solutions to these problems.

Use the Appointment Book

Have patients use the appointment book provided by your agency to schedule alternative activities or strategies for coping with high-risk periods or situations. The next session should also be scheduled, and patients should record the day and time in the book.

Start To Develop the Treatment Plan

It is unlikely that a comprehensive treatment plan with specific goals and methods can be completed in Session One. Nonetheless, the topic should be introduced at the first opportunity. The therapist might say something like the following.

"A treatment plan will allow us to write down the things you and I think are important to accomplish and how we plan to go about trying to accomplish them. We will use the plan to keep us focused on the task at hand, that is, making lifestyle changes that will help you stop using cocaine and other drugs and also increase your satisfaction with other important areas of your life. The treatment plan will be developed through a cooperative effort between you and me. It is important that you think the goals we set are important and will help you achieve what you want in life. My job in this process is to assist you in coming up with meaningful, effective goals and to offer advice based on my knowledge and experience with treating persons with cocaine and other drug problems."

Discuss Areas for Change

Therapists should then present their ideas about which areas of the patients' lives need changes. For each suggested change, it is important that the therapist provide a rationale that draws from the information collected from the patient as well as from research findings and clinical experience. An open discussion and exchange of ideas should then follow.

If patients are reluctant to participate, the therapist should prompt them for their thoughts on each issue. To facilitate patient input, the therapist should use phrases such as: What do you think? Do you have any thoughts on this? Does this make sense to you? Do you think this is important? Is this type of change possible?

It is important for therapists and patients to agree on which areas of life present problems and should be changed. If patients disagree with the therapist's opinion, those areas should be dropped for now and discussed later in treatment if they continue to pose problems.

After the areas for change are agreed upon, the therapist and patient should discuss each one. Therapists should use active listening skills - reflection and empathy - and try to keep the focus on the specific areas. Therapists should inform patients that they will focus on these problem areas in each session. Progress and problems will be openly discussed, and additions or deletions to the plan will be decided together.

Prioritize Problems

Next, therapists and patients together decide the order in which these problem areas should be addressed, always remembering that increasing cocaine abstinence is the primary goal. Mutual agreement is important, and the therapist may need to compromise to achieve such agreement.

Set Specific Target Goals

Specific goals should then be set for each problem area. It is important that therapists provide the rationale for setting specific goals.

"Setting specific goals is important. They will help us stay focused on the primary changes which we agreed are important for stopping drug use and achieving a more satisfying life without drugs. Specific goals also provide a way to measure progress. This can be very important, because many times progress can be slow. You may feel you are getting nowhere. In reality, you may be progressing and making changes, but you don't feel much different. Information about specific goals will help us both see more clearly whether we are heading in the right direction, even if the progress is slow."

"This information could also show when you are not progressing as we planned. This information could lead us to either reconsider the goal or find other ways to meet the goal. Keeping track of progress on specific goals also provides us with a reminder to reward or praise you for the hard work you are doing. Lifestyle changes are often difficult to make. We would like you to learn to pat yourself on the back and take credit if you are doing well."

These goals should be quantifiable so progress can be graphed. Targets for change should be set in the priority areas listed in the treatment plan and categorized as primary or secondary behavior change goals.

The primary behavior goal in most cases will be one that emphasizes change in the highest priority area. Examples of typical goals might be -

• Five job contacts per week or making an appointment with vocational rehabilitation if the patient is unemployed.
• Engaging in three recreational activities each week during high-risk times.
• Spending 4 hours each week engaging in fun activities with a family member or close friend.
• Attending class one night each week.
• Doing 2 hours of homework toward obtaining a GED.
• Planning and following through with activities with a nondrug user on nights cocaine is typically used.

Secondary behavior goals might include similar behavioral changes, but they would not have the highest priority for achieving and maintaining abstinence for that particular patient. A maximum of three secondary behavior changes should be targeted.

Therapists and patients should mutually decide on these goals. Basic principles of effective goal-setting should be followed.

• Set goals relatively low at first so the patient can experience success early in treatment.
• Thoroughly analyze all possible barriers to achieving selected goals so that unrealistic goals are not chosen.
• Make sure the patient understands how a goal relates to the overall treatment plan.

It is essential to maximize the probability that patients will carry through and achieve the desired behavior change. The therapists' responsibility is to use the appropriate counseling style and behavioral procedures to increase the probability of compliance with a targeted behavior. The graphs of patient behavior are especially useful because they visually demonstrate progress or lack of progress.

Follow Through

The tentative treatment plan should be reviewed in the next clinical supervision meeting to obtain input from staff and supervisors. Suggested changes to the plan may occur at that point, and therapists can discuss these new ideas with patients during their next session.

Therapists should also prepare a therapy session checklist to help focus subsequent sessions. This should be updated regularly, because treatment planning is a process of constant reevaluation, assessment, and change, based on objective indices of progress. Patients and therapists together should review, discuss, and assess the treatment plan frequently as goals are achieved or interventions fail, or as new information becomes available. These changes should also be reviewed at the regular staff supervision meetings.

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