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A Community Reinforcement Approach: Treating Cocaine Addiction |
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Lifestyle Change ComponentsAn 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:
These components are provided as needed. Other types of skills training (e.g., anger management) should also be available. Time ManagementThe 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. Social/Recreational CounselingThis 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 - "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 - "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 -
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. ProblemsolvingAchieving 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. "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 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.
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. Vocational CounselingSatisfying, 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 - 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:
For the patient who works "too many" hours or has an irregular schedule:
For the patient working in a "high risk for drug use" environment or the dissatisfied employee:
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.
Social-Skills TrainingSocial-skills training is provided to patients who report or demonstrate difficulties in -
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.
In summary:
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. HIV/AIDS PreventionAt 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.
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.
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 -
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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