Topic 4: Seemingly Irrelevant Decisions
Tasks for Topic 4
- Understanding Seemingly Irrelevant Decisions and their relationships to high-risk situations
- Identifying examples of Seemingly Irrelevant Decisions
- Practicing safe decisionmaking
As treatment progresses, patients will invariably encounter high-risk situations related to cocaine, even with the best efforts. Certain exposures are beyond the abuser's control, for example, living in an area where cocaine abounds but lacking the resources to relocate.
Another class of exposures, however, that patients often experience as beyond their control actually involves behaviors determined by the patients. Seemingly Irrelevant Decisions (Marlatt and Gordon 1985) refer to those decisions, rationalizations, and minimizations of risk that move patients closer to or even into high-risk situations, although they may seem unrelated to cocaine use.
Working with these Seemingly Irrelevant Decisions emphasizes the cognitive aspects of treatment. Those who benefit most from this process tend to possess intact cognitive functions and some ability to reflect upon their cognitive and emotional lives. This session is also particularly helpful to individuals who have trouble thinking through their behavior and its consequences, such as patients with residual attention-deficit/hyperactivity disorder, antisocial traits, or difficulty with impulse control. For such individuals, the material in this session (as well as the session on problem solving) often takes some time to be understood and assimilated, but it is usually valued highly.
The goals of this session are to -
- Understand Seemingly Irrelevant Decisions and their relationships to high-risk situations.
- Identify examples of Seemingly Irrelevant Decisions.
- Practice safe decisionmaking.
Understand Seemingly Irrelevant Decisions
A critical task for therapists is to teach patients how to recognize and interrupt Seemingly Irrelevant Decision chains before the onset of actual use. While it is possible to interrupt such a chain at any point prior to use, it is more difficult toward the end of the chain when patients may already be in situations where cocaine is available and conditioned cues abound. Thus, it is desirable to teach patients how to detect the decisions that commonly occur toward the beginning of the chain, where risk, craving, and availability of cocaine are relatively low.
This may involve patients' learning to detect subtle but painful affect states that they frequently try to counter with cocaine, such as boredom or loneliness. It often involves familiarizing patients with their distortions of thinking (e.g., rationalizations, denial) so these may be detected and used as signals for greater vigilance.
Certain distortions are fairly common, such as the thought, "I could handle going to a bar." Others, however, are more reflective of the patient's cognitive style. For instance, one patient tended to project his thoughts onto others. In describing a relapse, during which the patient had encountered a friend who had cocaine, the patient stated, "I caught him with his guard down." Another patient, recounting a slip, described the various thoughts he experienced prior to winding up in an area of town where his former dealer resided and where the patient eventually used cocaine. He stated that earlier he thought "I have to go to the bakery" which "happened" to be in a high-risk area, but he had not linked this with a desire to use. The therapist pointed out that his use of "I have to..." sounded very much like craving. Here, again, the patient could now catch himself "having" to do certain things which led to high-risk activities or locations.
Another variation of this phenomenon occurs in treatment when patients tell therapists that they "have" to take "this vacation," "attend that party," "spend time" with particular drug-using friends, and so on. These provide therapists with the opportunity to relate the patients' urgency to engage in such activities with the urge to use cocaine.
Seemingly Irrelevant Decisions are dealt with by applying recognize, avoid, and cope - recognizing Seemingly Irrelevant Decisions and the thoughts that go with them, avoiding risky decisions, and coping with high-risk situations.
"I'm going to tell you a story about a person who made several Seemingly Irrelevant Decisions that led to a high-risk situation and, eventually, a relapse. As I tell you the story, try to pick out the decisions that he made along the way that, taken together, made him more vulnerable to using cocaine. Here is the story:
"Joe, who had been abstinent for several weeks, drove home from work on a night his wife was going to be away. On the way, he turned left rather than right at an intersection so he could enjoy the 'scenic route.' On this route, he drove past a bar he had frequented in the past and where he had bought and used cocaine. Because the weather that day was hot, he decided to stop in for a glass of cola. Once in the bar, however, he decided that since his problem was with cocaine, it would be fine to have a beer. After two beers, he ran into a friend who 'happened' to have a gram of cocaine and a relapse ensued.
"When did you think Joe first got into trouble, or 'thought' about using cocaine? One of the things about these chains of decisions that lead to cocaine use is that they are far easier to stop in the beginning of the chain. Being farther away from cocaine, it is easier to stop the decisionmaking process than when you're closer to cocaine use and craving kicks in.
"What do you think Joe was saying to himself at the point he took the scenic route home? We often find that people making Seemingly Irrelevant Decisions can catch themselves by the way they think - thoughts like 'I have to do this' or 'I really should go home this way' or 'I need to see so-and-so because...' These end up being rationalizations, or ways of talking oneself into cocaine use without seeming to do so. I've noticed sometimes that you talk yourself into high-risk situations by telling yourself a situation is safe, when it really may not be, like when you told yourself last week that it was safe for you to go hang out in the park with your friends. Can you think of other examples of ways you might have talked yourself into a risky situation?"
Identify Personal Examples
Therapists should encourage patients to relate a recent example of a chain of Seemingly Irrelevant Decisions.
"Can you think of your own relapse story?
"Now, let's go through it and try to pinpoint the places where you made risky decisions, what you were telling yourself, and how you could have interrupted the chain before you wound up in the park with nothing to do."
Practice Safe Decisionmaking
Therapists need to stress the notion of safe decisionmaking.
"Another important thing to know about Seemingly Irrelevant Decisions is that if you can get yourself into the practice of recognizing all the small decisions you make every day, and thinking through safe versus risky consequences for those decisions, you will be less vulnerable to high-risk situations."
"Returning to the story of Joe, what were the Seemingly Irrelevant Decisions he made and what would have been safer decisions for him?"
"Let's go through a few things that have happened to you in the last few weeks and try to work through safe versus risky decisions."
Some Seemingly Irrelevant Decisions are common among cocaine abusers.
- Using any alcohol, marijuana, or other drugs
- Keeping alcohol in the house
- Not destroying cocaine or crack paraphernalia
- Going to parties where alcohol or cocaine might be available
- Interacting with people who are cocaine abusers
- Keeping past cocaine abuse a secret from family members
- Not telling cocaine-abusing associates of the decision to stop
- Not planning to fill free time
- Having a lot of unscheduled time on nights or weekends that can lead to boredom
- Getting overtired or stressed
The practice exercise for this session includes self-monitoring of decisions over the course of several days and, for each one, identifying safe versus risky decisions (exhibit 8). Remind patients that treatment will end soon, and they will be using these skills on their own.