want to need it.
With this understanding that it is not the physical withdrawal symptoms that are exclusively important, we can take our treatment concepts for addiction beyond only substances that cause withdrawal and look more globally at any behavior that someone wants to change but seems to be uncontrollable and compulsive. We can apply it to pornography, the internet, gambling, junk food, and losing our temper; the list is endless.
If it is not the physical withdrawal that makes the behavior uncontrollable, what is it?
The behavior usually doesn’t change until the individual decides that the consequence of continuing the behavior are too high. A person can do anything they want for some time, but after a while, they gravitate back to their state of most pleasure/least pain, whatever state that may be. So how, as a field, do we help psychologically dependent individuals change their uncontrollable, compulsive behavior?
Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse, provided the following insight into drug addiction. He stated, “The word addiction calls up many different images and strong emotions. But what are we reacting to? Too often, we focus on the wrong aspects of addiction, so our efforts to deal with this difficult issue can be badly misguided. Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitably moves to the question is it addicting. The conversation then shifts to the so-called types of addiction, whether the drug is physically or psychologically addicting. The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, which we in the field call physical dependence. The assumption then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be. Indeed, people always seem relieved to hear that a substance just produces psychological addiction or has only minimal physical withdrawal symptoms. Then they discount the dangers, and they are wrong.”
Twenty years of scientific research, coupled with even longer clinical experience, has taught us that focusing on this physical vs. psychological distinction is off the mark and a distraction from the real issue. From both clinical and policy perspectives, it does not matter entirely what physical withdrawal symptoms occur. Other aspects of addiction are far more important. Physical dependence, although a difficult issue, is not paramount because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications. Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances. Second, and more importantly, many of the most addicting and dangerous drugs do not even produce severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples. Both are highly addicting, but stopping their use produces very few physical withdrawal symptoms, certainly, nothing like the physical symptoms of alcohol or heroin withdrawal.
What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define addiction and how we all should use the term. It is only this expression of addiction and use of drugs that matters to the addict and his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.
Drug craving, which can be defined as an intense, urgent, or abnormal desire or longing and other compulsive behaviors, is extremely difficult to control, much more difficult than any physical dependence. We may be missing the mark on long-term success by our focus. For an addict, there is no motivation more powerful than drug craving.
Focusing on addiction as a compulsive, uncontrollable drug use disorder should help clarify the perception of the nature of addiction and potentially addicting drugs. For the addict, the clinician, and the substance abuse counselor, this more accurate definition forces the focus of treatment to a broader picture. Understanding that in some cases managing withdrawal symptoms is a medical necessity and this view of focusing on the essence of addiction is not to lessen the purpose and intent of managing specific withdrawal symptoms but rather to expand the focus to the more meaningful and powerful concept of uncontrollable drug seeking and use. The task of treatment is to regain control over drug cravings.
Rethinking addiction also affects which drugs we worry about, as well as the nature of our concerns. The message should be that in deciding which drugs are addicting and those that require societal attention, we should focus primarily on whether taking those drugs causes uncontrollable drug seeking and use. One important example is the use of opiates, like morphine, to treat cancer pain. In most circumstances, opiates are addicting. However, when administered for pain, although morphine treatment can produce physical dependence, which now can be easily managed after stopping use, it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here. This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.
Our national attitudes and the way we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction. We certainly will do a better job of serving everyone affected by addiction, addicts, their families, and their communities if we focus on what matters to them. As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.
Understanding the addiction process, as it applies to a specific client, will help the substance counselor, as well as the drug abuser, to better understand the why behind their involvement with drugs. It is important that counselors, as well as substance abusers, understand the cognitive, behavioral, and physical aspects of drug use. This enables the counselor to recognize the special needs of this sub-population and to be able to advocate counseling approaches and other treatment modalities aimed at their specific needs. The counselor should be able to address topics such as impulse control, distorted cognitive ability, and the consequences of poor decision-making.
If an individual has a flawed value/belief system, based upon his or her perceptions of events, teachings, and influences of his or her family, friends, peers, and others, it may lead to that individual having a distorted cognitive ability. That, in turn, enables an individual to continue to use and will ultimately result in the inability to manage the use.
An individual’s value/belief system reflects his/her perception of self and represents values, judgments, and myths that he/she believes to be true or false. A person’s initial value/belief system is fairly well established by age seven or eight and is refined and honed by life’s experiences to make them into whatever person they become at any given time in their life. It is their major control and decision-making guide and helps them to choose between right and wrong and the things they do versus things they don’t do. Most individuals have a value/belief system about:
- Alcohol and other drug use/abuse
- Peer pressure/social acceptance/social involvement
- Honesty/fair play/generosity
- Family roles/authority (parents, school administrators, police)
A counselor should explore a client’s value/belief system early in the treatment process to better understand what they believe about various topics and why they hold the views they hold. The topics generally addressed with an addiction client include:
Determine if their parents or caregivers had a permissive attitude toward tobacco, alcohol, and other drug use.
Determine the social norm with friends and family regarding the use of substances.
Determine if the client was exposed to limits or restrictions as a youth.
Determine if tobacco, alcohol, and other drugs were used in the home.
Determine if they drink, smoke, or used other drugs with your parents/relatives/caregiver.
Determine at what age they began to smoke or drink alcoholic beverages.
Determine if there was a permissive attitude toward social activities in your home/neighborhood.
Did parents involve themselves with the client’s friends?
Did parents monitor activities?
This background information will help the counselor to assess the risk and protective factors (those associated with tobacco, alcohol, and other drugs) that the individual was exposed to during his or her early life. Generally, if a person was exposed to a permissive attitude/environment it will provide early opportunities to experiment with alcohol, tobacco, and other drugs. This liberal, permissive environment may also provide a framework for the client to form a distorted mental picture of specific activity (such as its okay to use drugs). To give an example of how our beliefs/values work in the life of a drug user, let’s suppose a person forms a concept of a problem user as one who drops out of school and/or who is a poor student (low academic achiever). Now, let’s suppose this individual is a drug user but does not meet his or her pre-programmed characteristics of how they perceive a problem used to be or acts. In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem. The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use. It should also be noted that an individual’s belief system about drug use might change in response to his or her own experiences and influences from an effective treatment program. The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.
A flawed value/belief system may result in a distorted cognitive ability that, in turn, results in illogical and impaired thinking; consequently, the affected individual continues to make high-risk decisions concerning the use of drugs. It follows that if an individual is unable to comprehend the reality, consequences, or truth about events/actions/activities, they are generally referred to as being in denial. The most common forms of denial are:
Rationalizing: Making excuses for drug use.
Example: All of my friends use more than I do.
Minimizing: Indicating his/her use is less serious than it is.
Example: Sure I use it, but not that much; I only use it on weekends, real users use it every day.
Blaming: The user admits involvement but the responsibility for it lies with someone else.
Example: I use it because all of my friends use it.
It is difficult for most compulsive users to break through denial and accept the reality of their situation; consequently, one of the greatest challenges in counseling with the addicted individual is to help them through this process. This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adopt new coping strategies and new ways to divert himself or herself away from his or her former lifestyle. Learning new concepts is usually met with resistance, as most individuals don’t want to change and will only change in response to pain or another strong motivator. Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist.
A user who finds himself in a dilemma can gain insight into their preconception (thinking) regarding excessive use by answering and analyzing the following types of questions:
What is your most frequently used form of denial (rationalizing, minimizing, blaming, or others)?
What is your most frequently processed impaired thought (I can quit any time I want to; drugs don’t bother me).
Why do you think you are not a problem user (I have a normal life; drugs don’t bother me).
If an individual becomes emotionally stressed when asked these types of questions, it’s a strong indication that he or she is in denial regarding their involvement with drugs and they need professional help. The key to any cognitive change is that the individual is open and honest and willing to accept that change is needed. If they have a good attitude, it is easier for them to accept the perils associated with compulsive use. The net is that people can change but in most cases, the change must be initiated at the cognitive level. If one is in denial regarding the existence of a problem, there is very little that anyone else can do to help that individual.
The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This ongoing activity results in addiction (again, compulsive, uncontrolled drug craving, seeking, and use). This lifestyle is problematic and typically follows a well-established pattern. At this phase of use, his or her drug-related choices begin to disrupt normal activities with family, work, school, social, and community. His or her use is increasing in importance to where it is masking most other activities/relationships. It generally results in behavioral problems or the inability to manage of one’s life.
As the use intensifies, the individual begins to encounter the negative consequences of his/her choices. In general, the consequences cause pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help. The hypothesis is that deeply embedded in human nature is the tendency to resist all change until we finally experience pain and then we may stop to look at the cause of the pain. This process may manifest itself in any of the following:
- Physical (health problems, increased risk-taking, aggression)
- Social problems (family, work, school, community)
- Emotional (feelings of guilt, shame, or depression)
- Spiritual (low self-esteem, feeling empty, isolated)
- Financial (heavy debt load; inability to manage financial matters)
- Job loss
- Antisocial behaviors such isolation, aggression, spousal abuse, legal/financial problems, bullying, and fear.
- An individual should attempt to identify the negative consequences associated with his/her drug use (the old axiom states: when a person decides to use drugs they accept the consequences resulting from that use). This exercise is generally done over several counseling sessions and will help the individual to better understand the consequences of their decisions.
It is important to emphasize that addiction can be treated, both behaviorally and, in some cases, with medications, but it is not simple. There is a range of effective treatments and the industry continues to invest in research, to improve existing treatments and develop new approaches to help people deal with their compulsive drug use. Research has demonstrated that treatment can help addicted patients to stop using drugs, avoid relapse, and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment program. It cannot be overemphasized that drug addiction is a complex illness characterized by intense and, at times, uncontrollable drug cravings, along with compulsive drug seeking and use that persist even in the face of devastating consequences. While the path to drug addiction begins with the voluntary act of taking drugs, over time a person’s ability to choose not to do so becomes compromised, and seeking and consuming the drug becomes compulsive. This behavior results largely from the effects of prolonged drug exposure on brain functioning. Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior.
Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.
Too often, addiction goes untreated: According to SAMHSA’s National Survey on Drug Use and Health (NSDUH), 23.2 million persons (9.4 percent of the U.S. population) aged 12 or older needed treatment for an illicit drug or alcohol use problem. Of these individuals, 2.4 million (10.4 percent of those who needed treatment) received treatment at a specialty facility (i.e., hospital, drug or alcohol rehabilitation, or mental health center). Thus, 20.8 million persons (8.4 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive it.
Principals of Effective Treatment
- Addiction is a multifaceted disease and demands a triad of treatment modalities.
- It affects brain function and alters various behaviors.
- Addiction is a treatable disease; however, no single treatment program is effective for all individuals.
- Effective treatment addresses the needs of the whole person (including treatment for psychological and behavioral disorders).
- Treatment needs to be readily available.
- Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
- Remaining in treatment for an adequate period is critical.
- Counseling individuals and/or groups and other behavioral therapies are the most commonly used forms of drug abuse treatment.
- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
- An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
- Many drug-addicted individuals also have other mental disorders.
- Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.
- Treatment does not need to be voluntary to be effective
- Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
- Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.
Medications can be used to help with different aspects of the treatment process. For example, medications are used during withdrawal to help suppress symptoms during detoxification. However, medically assisted detoxification is not in itself “treatment” it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.
Medications can also be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, there are medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction, and are developing for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Most people with severe addiction problems, however, are poly drug users (users of more than one drug) and will require treatment for all of the substances that they abuse. The following medications are currently used frequently:
Opioids: Methadone, buprenorphine, and, for some individuals, naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues, naltrexone is not as widely used as the other medications. All medications help patients disengage from drug-seeking and related criminal behavior and become more receptive to behavioral treatments.
Tobacco: A variety of formulations of nicotine replacement therapies now exist including the patch, spray, gum, and lozenges that are available over the counter. In addition, two prescription medications have been FDA approved for tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral treatments, including group and individual therapies, as well as telephone quitlines.
Alcohol: Three medications have been FDA approved for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some but not all patients, this is likely related to genetic differences. Acamprosate is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Compliance can be a problem, but among highly motivated patients, disulfiram can be very effective.
Behavioral treatments help patients engage in the treatment process, modify their attitudes and involvements related to drug abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches. Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling and 12-step support programs. Some programs also offer other forms of behavioral treatment such as:
Cognitive behavioral therapy seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.
Multidimensional family therapy, which was developed for adolescents with drug abuse problems as well as their families addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.
Motivational interviewing capitalizes on the readiness of individuals to change their behavior and enter treatment.
Motivational incentives (contingency management), use positive reinforcement to encourage abstinence from drugs.
Contingency management uses positive reinforcement to change behaviors. It is founded on the principle that if positive behavior is rewarded, it is more likely to be repeated in the future. Examples of rewards for positive behaviors in drug and alcohol rehab include day passes with family members or extra recreational activities.
Rational Emotive Behavioral Therapy is used to help clients identify self-defeating, unhealthy thoughts, consider the validity of those thoughts, and then learn to replace them with healthier ones. As a result, clients learn how to manage negative emotions, modify their thought processes, and develop healthier relationships with others.
Individual and Group counseling help clients through talk therapy and support groups.
There are also many treatment environments such as residential treatment programs that can be very effective, especially for those with more severe problems. Therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community treatment staff and those in recovery as key agents of change to influence patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities, and seriously impaired social functioning. TCS is now also being designed to accommodate the needs of women who are pregnant or have children. The focus of the TC is on the re-socialization of the patient to a drug-free, crime-free lifestyle. Treatment in a criminal justice setting can succeed in preventing an offender’s return to criminal behavior, particularly when treatment continues as the person transitions back into the community. Studies show that treatment does not need to be voluntary to be effective.
Benefits of Behavioral Therapy in Addiction Treatment
Provides incentives for maintaining abstinence
Modifies negative behaviors and attitudes
Improves life skills
Enhances ability to handle stressful situations and triggers
A truly holistic approach to treatment will include a variety of complementary therapies that are used in conjunction with traditional behavioral therapies. Complementary therapies may include:
- Art therapy, pet therapy, or music therapy – Helps synthesize experiences in different ways as well as reduce stress and bolster coping skills
- Biofeedback – Trains the client to reduce the body’s response to stress on command, such as lowering the heart rate and blood pressure, by engaging in activities like progressive relaxation or deep breathing
- Neurofeedback – Trains the client to interact with the brain waves and alter their frequencies to help reduce triggers like insomnia, anger, and stress
- Meditation and other mindfulness practices – Help the client become more keenly aware of thoughts and emotions to help better regulate mood, cope with triggers like cravings and stress, and improve the functioning of the immune system
Let’s explore a few of the mentioned behavioral therapies.
Individual counseling focuses on the symptoms of drug addiction and related areas of impaired functioning and the content and structure of the patient’s ongoing recovery program. Most importantly, helping the client decide what they want and why. Once they make this decision then help them follow through with how. This model of counseling is time limited and emphasizes behavioral change. It gives the patient coping strategies and tools for recovery and promotes a 12-step ideology and participation. The primary goal of addiction counseling is to assist the addict in achieving and maintaining abstinence from addictive chemicals and behaviors. The secondary goal is to help the addict recover from the damage the addiction has caused in his or her life.
Addiction counseling works by first helping the patient recognize the existence of a problem and the associated irrational thinking. Next, the patient is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills and spiritual development to continue in recovery as a lifelong process.
Within this counseling model, the patient is the effective agent of change. It is the patient who must take responsibility for working on and succeeding with a program of recovery. Although recovery is ultimately the patient’s responsibility, the patient is encouraged to get a great deal of support from others, including counselors and other treatment staff, one’s sponsor, and drug-free or recovering peers and family members.
Overall, drug use is a maladaptive way of coping with life’s problems. It sometimes becomes compulsive and leads to a progressive deterioration in one’s life circumstances. Compulsive drug abuse is addiction, which is defined as a disease. It damages the addict physically, mentally, and spiritually.
The goals and objectives of individual counseling generally center around the symptoms of the drug addiction and areas of impaired functioning that are related to it and the content and structure of the patient’s ongoing recovery program. Throughout counseling, the addiction counselor should:
- Help the patient to accept that he or she suffers from the disease of chemical addiction.
- Point out the signs and symptoms of addiction that are relevant to the patient’s experience.
- Teach the addict to recognize and re-channel urges to use drugs.
- Encourage and motivate the patient to achieve and sustain abstinence.
- Monitor and encourage abstinence by using objective measures, such as urinalysis and Breathalyzer tests.
- Hold the chemically addicted person accountable for and discuss any episodes of use and strongly discourage further use.
- Assist the patient in identifying situations where drugs were used to cope with life’s problems and in understanding that using drugs to cope with or solve problems does not work.
- Help the addict to develop new, more effective problem-solving strategies.
- Introduce the patient to the 12-step philosophy and strongly encourage participation in NA, AA, and/or CA.
- Encourage the chemically addicted person to develop and continue with a recovery plan as a lifelong process.
- Help the addict to recognize and change problematic attitudes and behaviors that may stimulate a relapse.
- Encourage the patient to improve self-esteem by practicing newly acquired coping skills and problem-solving strategies at home and in the community.
The drug counseling sessions have a clear structure. However, within the framework of that structure, the content of the discussion is largely up to the patient. We make an effort to address effectively the patient’s individual needs at any point in treatment while also recognizing the commonality of many issues in addiction and recovery. People are indeed unique; however, the facets of a human problem like cocaine addiction usually follow familiar patterns. The validity of both realities should be respected.
Group Counseling is a special form of therapy in which people meet together under the guidance of a substance abuse counselor to help themselves and one another. Group counseling helps people learn about themselves
and improve their interpersonal relationships. It addresses feelings of isolation, depression, or anxiety and it helps people make significant changes so they feel better about the quality of their lives.
Fundamental to group counseling is the idea that the group therapy experience can be a carrier of change for individuals and be an effective influence over precipitating that change. In a group, the counselor observes the interactions rather than hearing about the interactions from the individual. In a group therapy situation, the client learns that she or he is not alone in his or her feelings.
Cognitive Behavioral Therapy is the therapy of choice for many clinicians who work with addiction clients. It is collaborative therapy that focuses on the strong interaction between the patient and therapist. They jointly consider and decide on the appropriate treatment goals, the types of skills and coping training needed, and when and if others should be brought into the sessions, and so on. Not only does this foster the development of a good working relationship it also assures a buy-in by the client to the treatment modalities. CBT is based on social learning theory. It is assumed that an important factor in how individuals begin to use and abuse substances is that they learn to do so. The several ways individuals may learn to use drugs include modeling, operant conditioning, and classical conditioning.
Modeling: With modeling, individuals learn skills/behaviors by watching others and then trying them themselves. For example, children learn a language by listening to and copying their parents. The same may be true for many substance abusers. By seeing their parents use alcohol, individuals may learn to cope with problems by drinking. Teenagers often begin smoking after watching their friends use cigarettes. So, too, may some cocaine abusers begin to use after watching their friends or family members use cocaine or other drugs.
Operant Conditioning: Laboratory animals will work to obtain the same substances that many humans abuse (cocaine, opiates, and alcohol) because they find exposure to the substance pleasurable, that is, reinforcing. Drug use can also be seen as behavior that is reinforced by its consequences. Cocaine may be used because it changes the way a person feels (e.g., powerful, energetic, euphoric, stimulated, less depressed), thinks (I can do anything, I can only get through this if I am high), or behaves (less inhibited, more confident).
The perceived positive (and negative) consequences of cocaine use vary widely from individual to individual. People with family histories of substance abuse, a high need for sensation seeking, or those with a concurrent psychiatric disorder may find cocaine particularly reinforcing. Clinicians must understand that any given individual uses cocaine for important and particular reasons.
Classical Conditioning: Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the presentation of food) could elicit a reliable response (e.g., a dog salivating). Over time, cocaine abuse may become paired with money or cocaine paraphernalia, particular places (bars, places to buy drugs), particular people (drug-using associates, dealers), times of day or week (after work, weekends), feeling states (lonely, bored), and so on. Eventually, exposure to those cues alone is sufficient to elicit very intense cravings or urges that are often followed by cocaine abuse.
Functional Analysis: The first step in CBT is helping patients recognize why they are using cocaine and determining what they need to do to either avoid or cope with whatever triggers their use. This requires a careful analysis of the circumstances of each episode and the skills and resources available to patients. These issues can often be assessed in the first few sessions through an open-ended exploration of the patient’s substance abuse history, their view of what brought them to treatment, and their goals for treatment. Therapists should try to learn the answers to the following questions.
Deficiencies and Obstacles:
- Have the patients been able to recognize the need to reduce the availability of cocaine?
- Have they been able to recognize important cocaine cues?
- Have they been able to achieve even brief periods of abstinence?
- Have they recognized events that have led to relapse?
- Have the patients being able to tolerate periods of cocaine craving or emotional distress without resorting to drug use?
- Do they recognize the relationship of their other substance abuse (especially alcohol) in maintaining cocaine dependence?
- Do the patients have concurrent psychiatric disorders or other problems that might confound efforts to change behavior?
Skills and Strengths:
- What skills or strengths have they demonstrated during any previous periods of abstinence?
- Have they been able to maintain a job or positive relationships while abusing drugs?
- Are there people in the patients’ social networks who do not use or supply drugs?
- Are there social supports and resources to bolster the patients’ efforts to become abstinent?
- How do the patients spend time when not using drugs or recovering from their effects?
- What was their highest level of functioning before using drugs?
- What brought them to treatment now?
- How motivated are the patients?
Determinants of Cocaine Use
- What is their pattern of use (weekends only, every day, binge use)?
- What triggers their cocaine use?
- Do they use cocaine alone or with other people?
- Where do they buy and use cocaine?
- Where and how do they acquire the money to buy drugs?
- What has happened to (or within) the patients before the most recent episodes of abuse?
- What circumstances were at play when cocaine abuse began or became problematic?
- How do they describe cocaine and its effects on them?
- What are the roles, both positive and negative, that cocaine plays in their lives?
Relevant Domains: In identifying patients’ determinants of drug abuse, it may be helpful for clinicians to focus their inquiries covering at least five general domains:
Social: With whom do they spend most of their time? With whom do they use drugs? Do they have relationships with those individuals that do not involve substance abuse? Do they live with someone who is a substance abuser? How has their social network changed since drug abuse began or escalated?
Environmental: What are the particular environmental cues for their drug abuse (e.g., money, alcohol use, particular times of the day, certain neighborhoods)? What is the level of their day-to-day exposure to these cues? Can some of these cues be easily avoided?
Emotional: Research has shown that feeling states commonly precede substance abuse or craving. These include both negative (depression, anxiety, boredom, anger) and positive (excitement, joy) affect states. Because many patients initially have difficulty linking particular emotional states to their substance abuse (or do so, but only at a surface level), affective antecedents of substance abuse typically are more difficult to identify in the initial stages of treatment.
Cognitive: Particular sets of thought or cognition frequently precede cocaine use (I need to escape, I can’t deal with this unless I’m high, with what I am going through I deserve to get high). These thoughts are often charged and have a sense of urgency.
Physical: Desire for relief from uncomfortable physical states such as withdrawal has been implicated as a frequent antecedent of drug abuse. While the controversy surrounding the nature of physical withdrawal symptoms from cocaine dependence continues, anecdotally, cocaine abusers frequently report particular physical sensations as precursors to substance abuse (e.g., tingling in their stomachs, fatigue or difficulty concentrating, thinking they smell cocaine).
Assessment Tools: Standardized instruments may also be useful in rounding out the therapist’s understanding of the patient and identifying treatment goals. The following assessment tools are two examples, of many that can be used:
- The Addiction Severity Index assesses the frequency and severity of substance abuse as well as the type and severity of psychosocial problems that typically accompany substance abuse (e.g., medical, legal, family/ social, employment, psychiatric).
- The Change Assessment Scale assesses the patient’s current position on readiness for change (e.g., pre-contemplation, contemplation, commitment), which may be an important predictor of response to substance abuse treatment).
Learning serves as an important metaphor for the treatment process throughout CBT. Therapists tell patients that the goal of the treatment is to help them “unlearn” old, ineffective behaviors and “learn” new ones. Patients, particularly those who are demoralized by their failure to cease their substance abuse, or for whom the consequences of the use and abuse have been highly negative, are frequently surprised to consider using alcohol or drugs as a type of skill, as something they have learned to do over time. After all, they are surprised when they think of themselves as having learned a complex set of skills that enabled them to acquire the money needed to buy the substance (which often led to another set of licit or illicit skills), acquired it without being arrested, use and avoid detection, and so on. Patients who can reframe their self-appraisals in terms of being skilled in this way often see that they also have the capacity to learn a new set of skills that will help them remain abstinent. In CBT, it is assumed that individuals essentially learn to become substance abusers through complex interplays of modeling, classical conditioning, or operant conditioning. Each of these principles is used to help the patient stop abusing cocaine.
Modeling is used to help the patient learn new behaviors by having the patient participate in role-plays with the therapist during treatment. The patient learns to respond in new, unfamiliar ways by first watching the therapist model those new strategies and then practicing those strategies within the supportive context of the therapy hour. New behaviors may include how to refuse an offer of drugs or how to break off or limit a relationship with a drug-using associate.
Operant conditioning concepts specific to substance abuse are evaluated through a detailed examination of the antecedents and consequences of this abuse, therapists attempt to understand why patients may be more likely to use it in a given situation and to understand the role that cocaine plays in their lives. This functional analysis of substance abuse is used to identify the high-risk situations in which they are likely to abuse drugs and, thus, to provide the basis for learning more effective coping behaviors in those situations.
Therapists attempt to help patients develop meaningful alternative reinforces to drug abuse, that is, other activities and involvements (relationships, work, hobbies) that serve as viable alternatives to cocaine abuse and help them remain abstinent.
A detailed examination of the consequences, both long- and short-term, of substance abuse, is employed as a strategy to build or reinforce the patient’s resolve to reduce or cease use.
Classical conditioning concepts also play an important role in CBT, particularly in interventions directed at reducing some forms of craving for alcohol and other drugs. Just as Pavlov demonstrated that repeated pairings of a conditioned stimulus with an unconditioned stimulus could elicit a conditioned response, he also demonstrated that repeated exposure to the conditioned stimulus without the unconditioned stimulus would, over time, extinguish the conditioned response. Thus, the therapist attempts to help patients understand and recognize conditioned craving, identify their idiosyncratic array of conditioned cues for craving, avoid exposure to those cues, and cope effectively with craving when it does occur so that conditioned craving is reduced.
Since CBT treatment is brief, only a few specific skills can be introduced to most patients. Typically, these are skills designed to help the patient gain initial control over cocaine and other substance abuse, such as coping with cravings and managing thoughts about drug abuse. However, the therapist should make it clear to the patient that any of these skills can be applied to a variety of problems, not just substance abuse.
The therapist should explain that CBT is an approach that seeks to teach skills and strategies that the patient can use long after treatment. For example, the skills involved in coping with cravings (recognizing and avoiding cues, modifying behavior through urge-control techniques, and so on) can be used to deal with a variety of strong emotional states that may also be related to abuse. Similarly, the session on problem-solving skills can be applied to nearly any problem the patient faces, whether drug abuse-related or not.
Basic Skills First: This course describes a sequence of sessions to be delivered to clients; each focuses on a single or related set of skills (e.g., craving, coping with emergencies). The order of presentation of these skills has evolved with experience with the types of problems most often presented by substance-abusing clients coming into treatment.
Early sessions focus on the fundamental skills of addressing ambivalence and fostering motivation to stop substance abuse, helping the patient deal with issues of alcohol and other drug availability and craving, and other skills intended to help the patient achieve initial abstinence or control over use. Later sessions build on these basic skills to help the patient achieve stronger control over abuse by working on more complex topics and skills (problem-solving, addressing subtle emotional or cognitive states). For example, the skills patients learn in achieving control over craving (urge control) serve as a model for helping them manage and tolerate other emotional states that may lead to abuse.
Match Material to Patient Needs: CBT is highly individualized. Rather than viewing treatment as cookbook psycho-education, the therapist should carefully match the content, timing, and nature of the presentation of the material to the patient. The therapist attempts to provide skills training at the moment the patient is most in need of the skill. The therapist does not belabor topics, such as breaking ties with cocaine suppliers, with a patient who is highly motivated and has been abstinent for several weeks. Similarly, the therapist does not rush through the material in an attempt to cover all of it in a few weeks; for some patients, it may take several weeks to truly master a basic skill. It is more effective to slow down and work at a pace that is comfortable and productive for a particular individual than to risk the therapeutic alliance by using a pace that is too aggressive.
Similarly, therapists should be careful to use language that is compatible with the patient’s level of understanding and sophistication. For example, while some patients can readily understand concepts of conditioned craving in terms of Pavlov’s experiments on classical conditioning, others require simpler, more concrete examples, using familiar language and terms.
Therapists should frequently check with patients to be sure they understand a concept and that the material feels relevant to them. The therapist should also be alert to signals from patients who think the material is not well suited to them. These signals include loss of eye contact and other forms of drifting away, overly brief responses, failure to come up with examples, failure to do homework, and so on.
An important strategy in matching material to patient needs (and providing patient-driven treatment rather than manual-driven) is to use, whenever possible, specific examples provided by the patients, either through their history or related events of the week. For example, rather than focusing on an abstract recitation of “Seemingly Irrelevant Decisions,” the therapist should emphasize a recent, specific example of a decision made by the patient that ended in an episode of use or craving. Similarly, to make sure the patient understands a concept, the therapist should ask the patient to think of a specific experience or example that occurred in the past week that illustrates the concept or idea.
“It sounds like you had a lot of difficulties this week and wound up in some risky situations without quite knowing how you got there. That’s exactly what I’d like to talk about this week, how by not paying attention to the little decisions we make all the time, we can land in some rough spots. Now, you started out talking about how you had nothing to do on Saturday and decided to hang out in the park, and 2 hours later you were driving into the city to score with Teddy. If we look carefully at what happened Saturday, I bet we can come up with a whole chain of decisions you made that seemed pretty innocent at the time, but eventually led to you being in the city. For example, how did it happen that you felt you had nothing to do on Saturday?”
Use Repetition: Learning new skills and effective skill-building requires time and repetition. By the time they seek treatment, cocaine users’ habits related to their drug abuse tend to be deeply ingrained. Any given patient’s routine around acquiring, using, and recovering from cocaine use is well established and tends to feel comfortable to the patient, despite the negative consequences of cocaine abuse. Therapists must recognize how difficult, uncomfortable, and even threatening it is to change these established habits and try new behaviors. For most patients, mastering a new approach to old situations takes several attempts.
Moreover, many patients come to treatment only after long periods of chronic use, which may affect their attention, concentration, and memory and thus their ability to comprehend new material. Others seek treatment at a point of extreme crisis (e.g., learning they are HIV positive, after losing a job); these patients may be so preoccupied with their current problems that they find it difficult to focus on the therapist’s thoughts and suggestions. Thus, in the early weeks of treatment, repetition is often necessary if a patient is to be able to understand or retain a concept or idea.
The basic concepts of this treatment are repeated throughout the CBT process. For example, the idea of a functional analysis of cocaine abuse occurs formally in the first session as part of the rationale for treatment, when the therapist describes understanding cocaine abuse in terms of antecedents and consequences. Next, patients are asked to practice conducting a functional analysis as part of the homework assignment for the first session. The concept of a functional analysis then recurs in each session; the therapist starts by asking about any episodes of cocaine use or craving, what preceded the episodes, and how the patient coped.
The idea of substance use in the context of its antecedents and consequences is inherent in most treatment sessions. For example, cravings and thoughts about alcohol and other drugs are common antecedents of abuse and are the focus of two early sessions. These sessions encourage patients to identify their own obvious and more subtle determinants of cocaine abuse, with a slightly different focus each time. Similarly, each session ends with a review of the possible pitfalls and high-risk situations that may occur before the next session, to again stimulate patients to become aware of and change their habits related to use and abuse.
While key concepts are repeated throughout the manual, therapists should recognize that repetition of whole sessions, or parts of sessions may be necessary for patients who do not readily grasp these concepts because of cognitive impairment or other problems. Therapists should feel free to repeat session material as many times and in as many different ways as needed with particular patients.
Practice Mastering Skills: We do not master complex new skills by merely reading about them or watching others do them. We learn by trying out new skills ourselves, making mistakes, identifying those mistakes, and trying again. In CBT, the practice of new skills is a central, essential component of treatment. The degree to which the treatment is skills training over merely skills exposure has to do with the amount of practice. Patients must have the opportunity to try out new skills within the supportive context of treatment. Through firsthand experience, patients can learn what new approaches work or do not work for them, where they have difficulty or problems, and so on.
CBT offers many practice opportunities, both within sessions and outside of them. Each session includes opportunities for patients to rehearse and review ideas, raise concerns, and get feedback from the therapist. Practice exercises are suggested for each session; these are homework assignments that provide a structured way of helping patients test unfamiliar behaviors or try familiar behaviors in new situations.
However, practice is only useful if the patient sees its value and tries the exercise. Compliance with extra-session assignments is a problem for many patients. Several strategies help encourage patients to do homework.
Give a Clear Rationale: Therapists should not expect a patient to practice a skill or do a homework assignment without understanding why it might be helpful. Thus, as part of the first session, therapists should stress the importance of extra-session practice.
“It will be important for us to talk about and work on new coping skills in our sessions, but it is even more important to put these skills into use in your daily life. You are the expert on what works and doesn’t work for you, and the best way to find out what works for you is to try it out. You must give yourself a chance to try out new skills outside our sessions so we can identify and discuss any problems you might have put into practice. We’ve found, too, that people who try to practice these things tend to do better in treatment. The practice exercises I’ll be giving you at the end of each session will help you try out these skills. We’ll go over how well they worked for you, what you thought of the exercises, and what you learned about yourself and your coping style at the beginning of each session.”
Get a Commitment: We are all much more likely to do things we have told other people we would do. Rather than assume that patients will follow through on a task, CBT therapists should be direct and ask patients whether they are willing to practice skills outside of sessions and whether they think it will be helpful to do so. A clear “yes” conveys the message that the patient understands the importance of the task and its usefulness. Moreover, it sets up a discussion of discrepancy if the patient fails to follow through.
On the other hand, hesitation or refusal may be a critical signal of clinical issues that are important to explore with the patient. Patients may refuse to do homework. They do not see the value of the task, because they are ambivalent about treatment or renouncing cocaine abuse because they do not understand the task, or for various other reasons.
Anticipate Obstacles: It is essential to leave enough time at the end of each session to develop or go over the upcoming week’s practice exercise in detail. Patients should be given ample opportunity to ask questions and raise concerns about the task. Therapists should ask patients to anticipate any difficulties they might have in carrying out the assignment and apply a problem-solving strategy to help them work through these obstacles. Patients should be active participants in this process and have the opportunity to change or develop the task with the therapist, plan how the skill will be put into practice, and so on. Working through obstacles may include a different approach to the task (e.g., using a tape recorder for self-monitoring instead of writing), thinking through when the task will be done, whether someone else will be asked to help, and so on. The goal of this discussion should be the patient’s expressed commitment to do the exercise.
Monitor Closely: Following up on assignments is critical to improving compliance and enhancing the effectiveness of these tasks. Checking on task completion underscores the importance of practicing coping skills outside of sessions. It also provides an opportunity to discuss the patient’s experience with the tasks so that any problems can be addressed in treatment.
In general, patients who do homework tend to have therapists who value homework, spend a lot of time talking about homework, and expect their patients to do the homework. The early part of each session must include at least 5 minutes for reviewing the practice exercise in detail; it should not be limited to asking patients whether they did it. If patients expect the therapist to ask about the practice exercise, they are more likely to attempt it than patients whose therapist does not follow through.
Similarly, if any other task is discussed during a session (e.g., implementation of a specific plan to avoid a potentially high-risk situation), be sure to bring it up in the following session. For example, “Were you able to talk to your brother about not coming over after he gets high?”
Use the Data: The work patients do in implementing a practice exercise and their thoughts about the task convey a wealth of important information about the patients, their coping style and resources, and their strengths and weaknesses. It should be valued by the therapist and put to use during the sessions.
A simple self-monitoring assignment, for example, can quickly reveal patients’ understanding of the task or basic concepts of CBT, level of cognitive flexibility, insight into their behavior, level of motivation, coping style, level of impulsivity, verbal skills, usual emotional state, and much more. Rather than simply checking homework, the CBT therapist should explore with the patients what they learned about themselves in carrying out the task. This, along with the therapist’s observations, will help guide the topic selection and pacing of future sessions.
Explore Resistance: Some patients do the practice exercise in the waiting room before a session, while others do not even think about their practice exercises. Failure to implement coping skills outside of sessions may have a variety of meanings: patients feel hopeless and do not think it is worth trying to change behavior; they expect change to occur through willpower alone, without making specific changes in particular problem areas; the patients’ life is chaotic and crisis-ridden, and they are too disorganized to carry out the tasks; and so on. By exploring the specific nature of patients’ difficulties, therapists can help them work through them.
Praise Approximations: Just as most patients do not immediately become fully abstinent on treatment entry, many are not fully compliant with practice exercises. Therapists should try to shape the patients’ behavior by praising even small attempts at working on assignments, highlighting anything they reveal was helpful or interesting in carrying out the assignment, reiterating the importance of practice, and developing a plan for completion of the next session’s homework assignment.
Stages of Addiction
Maintenance of Abstinence
As with other stage theories of development, the stage theory of addiction recovery is only a model. Individuals pass through the stages at their own pace, the stages are overlapping rather than discreet, and individuals may slip back at points and need to rework issues from previous stages. This theory does not, however, discount the considerable use of having a model of the typical process in mind so that the patient’s place in his or her recovery than e compared with the model for a better understanding of the patient’s process and the steps needed to be taken to proceed.
Appropriate treatment for chemical addiction varies and is sensitive and responsive to the changing needs of the patient throughout his or her recovery. The addiction counselor should understand that addiction treatment must be progressive, just as the patient’s recovery process is progressive. To provide optimal counseling, the counselor must be sensitive to the patient’s evolving needs in treatment. To ensure a progressive approach to addiction treatment, the counselor must be prepared to address different topics in recovery, use different kinds of interventions, and hold the patient to a different level of responsibility as he or she works toward recovery.
The counselor should prepare for each session by checking the patient’s recent urine results and recalling the major themes or issues from the previous session. The counselor must understand the progressive nature of treatment and be familiar with the topics that are appropriate to the patient’s current phase in recovery. In summary:
- Check urine test results.
- Recall history from previous sessions.
- Discuss topics appropriate to the patient’s phase of treatment.
During each session, the counselor should inquire how things have been going since the last session and whether the patient has used any drugs. Reported drug use should be noted. If the patient relapses, the patient and counselor should analyze the relapse, determine what precipitated it, and develop alternatives that can be used to avoid relapsing again. This process will probably require a full session.
If the patient presents with an urgent, addiction-related problem like family arguments or financial problems as a result of the addiction, the counselor should address these problems in the session. Emphasis should be on how these problems are related to addictive behavior. The counselor’s goal is to help the patient develop strategies for dealing with the problems without turning to drugs. For example, the loss of one’s job, the serious illness of a loved one, or severe relationship problems will require acknowledgment and some attention in the counseling session. However, the main purpose of the session is the promotion of recovery from addiction, not the resolution of the patient’s other life problems.
The counselor should always give the patient feedback regarding the most recent drug screen results. If the urine test was positive for cocaine, the counselor should confront the patient with this information. Even if the patient has admitted to recent use, the counselor should discuss the urinalysis result, so the patient is reassured that the counselor is monitoring his or her efforts to abstain. If, however, the patient denies any use even though the urine sample is positive for cocaine (which is not uncommon), the counselor should view this behavior as most likely indicative of denial, underlying which might be feelings of shame. The counselor will probably want to use themes of shame or denial in addressing this disparity.
A useful approach is discussing how the patient would feel and what it would mean if he or she were using drugs. If the patient continues to insist that there has been no cocaine use, the counselor probably should just drop the matter and agree to disagree for the present. Continuing to confront without moving the counseling anywhere probably is unwise because the counselor risks severing the therapeutic connection. If the patient insists that there is some type of laboratory error, the counselor may be able to split the urine and have half analyzed with a different test, or use a different screening procedure, such as a saliva test.
If nothing urgent must be addressed in the session, the counselor and patient should discuss the addiction-related topic(s) most relevant to the patient’s current needs in recovery. The topics central to recovery from cocaine addiction, and the stage of recovery they are particularly associated with, are described in the next section. No more than two new topics should be introduced to the patient in a session. However, any topics that have already been introduced to the patient can be reviewed, if appropriate.