Topic 3: Refusal Skills/Assertiveness
Tasks for Topic 3
- Assessing cocaine availability and the steps needed to reduce it
- Exploring strategies for breaking contacts with individuals who supply cocaine
- Learning and practicing cocaine refusal skills
- Reviewing the difference between passive, aggressive, and assertive responding
A major issue for many cocaine abusers is reducing availability of cocaine and effectively refusing offers of cocaine. Patients who remain ambivalent about reducing their cocaine use often have particular difficulty when offered cocaine directly. Many cocaine users' social networks have so narrowed that they associate with few people who do not use cocaine, and cutting off contact may mean social isolation. Also, many individuals have become involved in distribution, and extricating themselves from the distribution network is difficult. Many patients lack the basic assertiveness skills to effectively refuse offers of cocaine or prevent future offers of cocaine. Thus, this session includes sections on reducing availability, refusal skills, and a review of general assertiveness skills.
Therapists should carefully direct questions to ferret out covert indicators of ambivalence and resistance to change and the social forces working against change. Failure of patients to take initial steps toward removing triggers and avoiding cocaine may reveal a number of clinically significant issues.
- Ambivalence toward stopping cocaine use (e.g., the individual who resists breaking ties with dealers or telling family and friends of his decision to stop use)
- Failure to appreciate the relationship between cocaine availability and use (e.g., the abuser who sells cocaine but maintains that he will be able to stop using while still dealing)
- Marked limitations in personal or psychosocial resources (e.g., the unemployed single parent living in a neighborhood where cocaine is readily available)
- Important indications of how actively patients will take part in treatment. If patients have taken no independent steps toward limiting cocaine availability, they may be expecting mere exposure to treatment to magically produce abstinence with little or no effort on their part.
The goals for this session are to -
- Assess cocaine availability and the steps needed to reduce it.
- Explore strategies for breaking contacts with individuals who supply cocaine.
- Learn and practice cocaine refusal skills.
- Review the difference between passive, aggressive, and assertive responding.
Assess Cocaine Availability
Therapists and patients together should assess the current availability of cocaine and formulate strategies to limit that availability. In particular, therapists should examine whether patients are involved in selling cocaine, the nature of their cocaine sources, and whether other individuals in their home or workplace use cocaine. Determining the steps patients have already taken toward reducing cocaine availability may be an invaluable index of their internal and external resources. For example, have patients informed cocaine-using associates of their intention to stop using? Have patients who sell cocaine attempted to extricate themselves from the distribution network? It is virtually impossible for an individual to continue to sell cocaine and not use it. Therapists can make some useful inquiries.
"If you wanted to use cocaine, how long would it take to get some? Is there any in your house? Are you still holding onto pipes?"
"The last few times you used, you said Tommy came to your house and suggested you take a drive. Have you thought about talking to Tommy about your decision to stop?"
In spite of its illicit nature, cocaine may be offered by a range of individuals - friends, coworkers, dealers, and even family members. Because such individuals frequently have financial or other incentives (e.g., maintaining the status quo in a relationship) to keep abusers in the distribution network, extricating oneself is often challenging. Therapists should review the patients' suppliers and explore strategies for reducing contact with them. In some cases, a clear and assertive refusal, followed by a statement that the patient has decided to stop and a request that cocaine no longer be offered, can be surprisingly effective. In other cases, patients can arrange to avoid any contact with particular users or suppliers.
When patients are in a close, intimate relationship with someone who uses and supplies cocaine, the problem is more difficult. For example, it may not be easy for a woman to abstain when her partner supplies cocaine or continues to use, and she may not be ready to break off the relationship. Furthermore, sometimes only limited change in a patient's stance toward such a relationship can be effectively undertaken in 12 weeks of treatment. Rather than seeing this as either-or ("I can either stop cocaine use or get out of the relationship"), therapists should explore the extent to which exposure to cocaine can be renegotiated and limits set.
"I hear you say that you feel like you want to stay with Bob for now, but he's not willing to stop using cocaine. Being there is pretty risky for you, but maybe we can think of some ways to reduce the risk. Have you thought about asking him not to bring cocaine into the house or use it in the house? You've said you know there's a lot of risk to you while he continues to do that, both in terms of your staying abstinent as well as having drugs around your kids."
Cocaine Refusal Skills
There are several basic principles in effective refusal of cocaine and other substances.
- Respond rapidly (not hemming and hawing, not hesitating).
- Have good eye contact.
- Respond with a clear and firm "no" that does not leave the door open to future offers of cocaine.
Many patients feel uncomfortable or guilty about saying no and think they need to make excuses for not using, which allows for the possibility of future refusals. Inform patients that "no" can be followed by changing the subject, suggesting alternative activities, and clearly requesting that the individual not offer cocaine again in the future. ("Listen, I've decided to stop and I'd like you not to ask me to use with you anymore. If you can't do that, I think you should stop coming over to my house.")
After reviewing the basic refusal skills, patients should practice them through role-playing, and problems in assertive refusals should be identified and discussed. Since this is the first session that includes a formal role-play, it is important for therapists to set it up in a way that helps patients feel comfortable.
- Pick a concrete situation that occurred recently for the patients.
- Ask patients to provide some background on the target person.
- For the first role-play, have patients play the target individual, so they can convey a clear picture of the style of the person who offers cocaine and the therapist can model effective refusal skills. Then reverse the roles for subsequent role-plays.
Role-plays should be thoroughly discussed afterward. Therapists should praise any effective behaviors shown by patients and also offer clear, constructive criticism:
"That was good; how did it feel to you? I noticed that you looked me right in the eye and spoke right up; that was great. I also noticed that you left the door open to future offers by saying you had stopped cocaine 'for a while.' Let's try it again, but this time, try to do it in a way that makes it clear you don't want Joe to ever offer you drugs again."
Passive, Aggressive, And Assertive Responding
Quite often, the role-plays will reveal deficits in understanding and feeling comfortable with assertive responding. For such individuals, therapists should devote another session to reviewing and practicing assertive responding. An excellent guide to this topic is given in Monti et al. (1989).
Key areas to review include defining assertiveness, reviewing the differences between response styles (passive, aggressive, passive- aggressive, and assertive), body language and nonverbal cues, and anticipating negative consequences.
Remind Patients of Termination
Beginning about the sixth week of treatment, therapists should start reminding patients of the time-limited nature of the treatment, and in some cases, begin each session thereafter by pointing out "we have xx weeks to work together." It may be helpful to discuss or reframe termination as a potential high-risk situation. Reemergence of slips and other symptoms is common in the last weeks of treatment and may be interpreted in this context (so might emergence of new problem areas).
As termination approaches, therapists might also ask patients to imagine every high-risk situation they might encounter after they leave treatment. After such relapse fantasies are elicited and explored, specific coping strategies can be developed in the weeks approaching termination. This often makes patients feel more comfortable and confident about their ability to end treatment.
The practice exercises for this session include mapping cocaine availability and strategies to reduce availability (exhibit 6) and anticipating and rehearsing refusals (exhibit 7) to a range of individuals who might offer cocaine.