Program Overview

Cocaine dependence is a life-threatening problem characterized by behavior patterns that make treatment entry, compliance, and lifestyle change very difficult. Therefore, CRA + Vouchers providers are expected to make every effort to facilitate treatment initiation, ongoing attendance, and behavior change that will support a drug-free lifestyle. The general approach taken to achieving this goal is perhaps best described as individualized, empirically based, and behavioral.

Although patients are expected to be extremely active participants in the treatment process, therapists should expect difficulties and noncompliance with therapeutic activities. These problems should be defined for what they are, problem behaviors in need of therapy, not as a reason to discharge patients from treatment.

Lifestyle Changes

Increasing cocaine abstinence is the primary goal of CRA + Vouchers. To achieve and maintain abstinence, patients need to make major lifestyle changes, particularly in four areas:

• Family relationships
• Recreational activities
• Social networks
• Vocation

High levels of satisfaction in a cocaine-free lifestyle are needed to compete with the reinforcement derived from drug use and the drug-using lifestyle. Therefore, increasing satisfaction in these areas is a major goal for reducing the probability of continuing or resuming cocaine use.

Patients are assessed at intake in each of these areas, and individual treatment goals are developed by the therapist and patient together. Specific types of counseling and skills training are provided on an as-needed basis, depending on each patient's lifestyle change goals and the skills needed to achieve those goals. Therapists are expected to facilitate achievement of targeted goals through extensive outreach whenever necessary.

Urinalysis testing is used to measure the patient's progress in achieving cocaine abstinence, which is the basis for receiving positive reinforcement (social and material) to further increase abstinence. Cocaine abstinence is difficult to achieve and may not result in sufficient, immediate natural rewards, particularly in its early stages. The treatment program provides prompt reinforcement to keep the abstinence going as well as additional motivation to abstain by using vouchers. The points accumulated under this system can be spent for anything that contributes to the patient's treatment goals. Purchases are made by staff with the approval of the therapist.

Cocaine abusers frequently abuse multiple substances, and more than half use alcohol and marijuana excessively or in conjunction with cocaine. CRA + Vouchers routinely initiates interventions to decrease other drug use, including disulfiram therapy when appropriate to help patients increase alcohol abstinence. The subject of other drug abuse is introduced at intake, and therapy is started immediately, if appropriate.

Patients are always counseled that abstinence from all other drugs of abuse, including alcohol, is the most direct and surest way to increase their chance of success in dealing with their cocaine dependence. However, it is quite common for cocaine abusers to not consider their alcohol or other drug use a problem. The treatment philosophy of CRA + Vouchers in this regard is to first and foremost provide patients with treatment for the problem for which they sought help - cocaine dependence.

Schedule

CRA + Vouchers is designed as a 24-week treatment program. During weeks 1 - 12, the therapist schedules two 60-minute individual counseling sessions each week. Additional patient contacts in the form of brief phone calls or in-person sessions are employed as needed. During weeks 13 - 24, the therapist schedules one 60-minute counseling session each week, depending on the patient's needs. Urinalysis monitoring is scheduled for three times a week (e.g., Monday, Wednesday, Friday) during weeks 1 - 12 and twice a week (Monday, Thursday) during weeks 13 - 24.

Components

CRA + Vouchers includes a variety of skills-training components (exhibit 1), but not all patients need or receive all components. Training is tailored to the needs of the individual and is focused on achieving and maintaining cocaine abstinence. Patients are taught to identify their pattern of cocaine use and to develop drug-refusal skills and strategies for avoiding or coping with situations that are high risk for cocaine use (i.e., functional analysis and self-management planning). Skills training in other areas (e.g., assertiveness, communication, relaxation) is also provided as needed to help patients abstain from cocaine and other substance abuse.

The order in which these components are delivered may vary depending on the needs and priorities of the individual patient. For example, functional analysis training is usually scheduled for sessions two through four. However, if a patient has important practical needs (e.g., housing) that must be addressed during these sessions, the therapist may assist in solving those problems first.

The number of sessions used to address each problem is also flexible. For example, one patient may receive four sessions of social skills training, while another may receive only two sessions. Individualized treatment plans are developed for patients based on their particular needs. The therapist and patient come to a collaborative decision concerning which components will be implemented during the program and the order in which they will be delivered.

Structure

Treatment is delivered through individual counseling. Although each patient's treatment sessions will be somewhat different in content and focus of behavior change interventions, all sessions follow the same basic structure.

In general, sessions focus on the areas for change listed in the individual's treatment plan. During each session, the therapist and patient discuss progress and problems in each targeted area. The specific goals are evaluated, and plans of action are initiated. Sessions also focus on the development of behavioral skills important for gaining and maintaining abstinence. Behavioral rehearsal and role-playing are regular in-session activities when skills training is scheduled.