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A Cognitive-Behavioral Approach: Treating Cocaine Addiction |
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Session 1: Introduction to Treatment and CBTTasks for Session 1
Session GoalsThe first session is the most important and often the most difficult because the therapist must address several areas.
Because of the complexity of the tasks involved in the first session, the therapist should allow 90 minutes, rather than rely on the typical 1-hour session. Key InterventionsHistory and Relationship Building Therapists should spend a considerable amount of time during the first session getting to know the patients, obtaining histories of them and their substance use, getting a sense of their level of motivation, and determining what led them to seek treatment. This can occur through a series of open-ended questions that should cover at least the following areas. Reasons for seeking treatment and treatment history
History and current pattern of cocaine abuse
Other problems and resources
If patients have been through an extensive pretreatment assessment battery, therapists should attempt to be sensitive to further questions. "I know you've already spent several hours answering questions, but now as we're beginning treatment, I hope you can answer a few more questions that should help you and me plan where we go from here." Enhance Motivation As patients respond to the above questions, the therapist should listen closely for and, where possible, elicit statements or comments from them concerning their reasons for seeking treatment or reducing cocaine use. Some of the general strategies recommended by Miller and colleagues (1992) for enhancing motivation and avoiding resistance are extremely useful. These are summarized below.
Negotiate Treatment Goals CBT for cocaine dependence is an abstinence-oriented treatment for many reasons. Cocaine use, even in small amounts, is associated with a variety of serious medical and psychiatric risks. Furthermore, unlike alcohol where some cognitive-behaviorally oriented treatments advocate a moderate drinking goal, cocaine is an illicit drug with considerable legal risks. Clinically, better outcomes are usually seen for patients who are abstinent. However, relatively few patients come to treatment completely committed to abstinence. Many seek treatment because of some external persuasion or coercion; others want to cut down to a point where the negative consequences are eliminated, but cocaine use might go on. For highly ambivalent patients, clinicians must recognize that commitment to abstinence is a process that often takes several weeks to work through. Moreover, in most patients, abstinence takes several weeks to achieve and does not occur all at once. Therapists should explicitly state that the goal of treatment is abstinence. However, for highly ambivalent patients, this should be done in a manner that acknowledges their uncertainty. "I know you're not sure about stopping cocaine use completely, and we'll spend some time over the next few sessions talking about what you want to decide. However, there are some good reasons to consider abstinence from cocaine, as well as abstinence from other drugs and alcohol. For example, by trying to stop completely while you're here, you'll learn a lot about yourself and some of the factors that might be pushing you to continue using. You might also find it easier to understand the circumstances that make it more likely that you will use and some things you can do to stop using. You'll also avoid substituting other substances for cocaine. After a period of abstinence, you can get a clear idea of how you will feel without cocaine in the picture and can get a sense of whether that's what you really want to do. You can always change your mind later. What do you think?" While this is a short-term treatment focused on cessation of cocaine use, patients often have a number of coexisting problems and concerns. Some are related to cocaine dependence, but some are not. While the primary focus of treatment should be stopping cocaine abuse, it is important to recognize and help patients sort through other problems and symptoms. Therapists should also ask whether patients have other goals, as well as how stopping substance use might help them reach those goals (e.g., regain custody of their children, go back to work). In the case of problems that may be closely related to cocaine dependence (e.g., depressive symptoms, marital conflict, legal problems), it is critical for therapists to acknowledge these, work with patients to prioritize goals in relation to cocaine use, negotiate reasonable treatment goals and how the goals of treatment will be addressed, and monitor these other target symptoms and problems as treatment proceeds. "I know you've been feeling down and want to try Prozac again, but you've been abusing cocaine for a long time, and it's going to be hard to sort out how much of how you're feeling is related to cocaine abuse and how much might be a depressive problem that's separate from your cocaine abuse. The best way to tell is after a period of abstinence from cocaine. Generally, we find that depressed feelings which last more than a month after the last use indicate the need to address drug abuse and depression separately, possibly with medication for the depression. What do you think about being abstinent for a month, and then considering a referral to a psychiatrist for a medication evaluation? In the meantime, it also sounds like we should spend some time talking about feeling down and how that might be related to your cocaine use." * * * "It sounds like there have been some problems with Billy for a long time, and he's asked you to leave, but you think things might get better if you stop using cocaine. One thing we can do in our work is to invite Billy to attend a session or two so he can ask questions and learn more about this treatment program, and the two of you can talk about where to go from here. After we complete this first 12 weeks, we might also think about a referral to family services. How does that sound?" Present the CBT Model Next, therapists should provide an explanation and rationale for the treatment. This should cover the following points.
Establish Treatment Ground Rules In addition to treatment goals and tasks, it is important to establish clear expectations for the patient in terms of treatment, your obligations, and the patient's responsibilities. The following areas should be reviewed and discussed.
Introduce Functional Analysis Therapists should work through a recent episode of cocaine use with patients, conducting a full functional analysis. "To get an idea of how all this works, let's go through an example. Tell me all you can about the last time you used cocaine. Where were you and what were you doing? What happened before? How were you feeling? When was the first time you were aware of wanting to use? What was the high like at the beginning? What was it like later? Can you think of anything positive that happened as a result of using? What about negative consequences?" Practice ExerciseThe practice exercise (exhibit 2) asks patients to do a functional analysis of at least three recent episodes of cocaine use. It follows closely the format of the functional analysis conducted by the therapist within the session. Therapists may want to use the sheet as a within-session example.
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