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A Cognitive-Behavioral Approach: Treating Cocaine Addiction



Topic 7: Case Management

Tasks for Topic 7

  • Reviewing and applying problem solving skills to psychosocial problems that present a barrier to treatment
  • Developing a concrete support plan for addressing psychosocial problems
  • Monitoring and supporting patients' efforts to carry out the plan

Session Goals

Most patients will present for treatment with a range of concurrent psychosocial problems in addition to cocaine abuse. Some problems are best assessed and addressed after patients have achieved a period of stable abstinence, while other problems, if unaddressed, are likely to present barriers to treatment and undermine the patients' efforts to become abstinent. Thus, to deal with these issues, therapists may engage in modified "case management."

In this approach, therapists do not serve as advocates for patients outside of sessions. Rather, therapists use problem solving strategies within treatment to help patients contact and make use of the social service system. The intent is to build patients' self-efficacy in recognizing and coping with concurrent problems and in successfully using the network of available social service agencies.

To be effective, therapists should be knowledgeable about the community's service system, with current information on the type of services provided by each organization, the types of patients served by the organization, eligibility requirements, sources for alternative serv-ices, and reasonable timeframes for various types of service delivery. Therapists should help patients transform their goals into a service plan and help them articulate the steps needed to attain these goals.

The goals of this topic are to -

  • Review and apply problem solving skills to psychosocial problems that present a barrier to treatment.
  • Develop a concrete support plan for addressing psychosocial problems.
  • Monitor and support patients' efforts to carry out the plan.

Key Interventions

Problem Identification

Early in treatment, therapists should have identified problems that would be barriers to abstinence. Information useful in identifying relevant psychosocial problems may also come from pretreatment assessments, particularly the Addiction Severity Index.

Goal Setting

Therapists and patients together should identify and prioritize the three or four major problems they will focus on during treatment and specify concrete goals for each (e.g., have a stable place to live by the end of the month, enter a job training program by the end of August). As needed, therapists should also review the basic steps in problem solving, since that model is used to work through these target problems.

Resource Identification

With the goals clarified, therapists and patients then brainstorm solutions and the resources needed to resolve each of the target problems.

Specifying a Plan

Once problems are identified and goals set, therapists and patients should begin to work on the support plan, which is simply a concrete strategy that outlines how patients will follow through on reaching their goals. The support plan should include, for each goal, specification of who or which agency is to be contacted, when the contact is to be made, what services or support are to be requested, and the outcome of the contact. The support plan thus serves as a kind of log, or organizing force, in patients' efforts to obtain needed services. It will also provide a record of their efforts and successes in this area and, thus, bolster their self-efficacy.

Monitoring Progress

Although patients are to take primary responsibility in following the support plan and obtaining needed services, it is essential that therapists closely monitor their efforts to follow through. This should take place at every subsequent session; thus, therapists should spend time during the initial phase of the next sessions (e.g., the first 20 minutes of a 20/20/20 session) monitoring patients' success in implementing their plans. Similarly, a portion of the closing of each session should be devoted to reviewing the steps for implementing the support plan during the coming week.

Therapists should affirm patients and praise their efforts in carrying out their plans enthusiastically and genuinely. Even small steps should be seen as significant and be met with praise. Therapists should convey confidence that patients can, and will, successfully complete the support plans and obtain needed services. In this strengths-based approach, therapists assume that patients have the resources and skills to obtain needed services, both within treatment and after treatment ends.

Therapist: "I'm really impressed that you were able to arrange a place for yourself at Transitional Housing. I know you had real questions about whether you could handle all the admission steps on your own, but it sounds like you hung in there, were persistent when Mrs. X put you on hold several times, and kept rescheduling those interviews until you got it. It sounds like it wasn't easy, but you really made it happen. How do you feel about how you handled it?"
Patient: "Like you said, it wasn't easy, and once or twice I felt like telling them off, but I just kept telling myself I really needed a safe place to live and that I could do it."
Therapist: "You know, you sound and look like you're really proud of yourself, and your pride is well deserved. Knowing how to work the social service system is an important skill, and one I see you getting better and better at. Have you thought about your next step?"

Practice Exercise

The practice exercise for this week includes following through on the support plan (exhibit 11)and reporting back on the successes or problems the patients experienced in carrying out the plan. Remind patients that treatment will end soon, and they will be using these skills on their own.

 

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