Basic Principles of CBT
CBT is collaborative. The patient and therapist consider and decide together on the appropriate treatment goals, the type and timing of skills training, whether a significant other is brought into some of the sessions, the nature of outside practice tasks, and so on. Not only does this foster the development of a good working relationship and avoid an overly passive stance by the therapist, but it also assures that treatment will be most useful and relevant to the patient.
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.
People learn new skills by watching others and then trying it themselves. For example, children learn 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.
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. It is important that clinicians understand that any given individual uses cocaine for important and particular reasons.
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.
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 patients' 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 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 been 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 network 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 individual 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?
In identifying patients' determinants of drug abuse, it may be helpful for clinicians to focus their inquiries to cover 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 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).
Standardized instruments may also be useful in rounding out the therapist's understanding of the patient and identifying treatment goals. The following assessment tools have been helpful.
- Substance abuse and related problems
- The Addiction Severity Index (McLellan et al. 1992) 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 (DiClemente and Hughes 1990) assesses the patient's current position on readiness for change (e.g., precontemplation, contemplation, commitment), which may be an important predictor of response to substance abuse treatment (Prochaska et al. 1992).
- A record of daily substance use can be used to collect inform-ation on cocaine and other substance use day by day over a significant period.
- The Treatment Attitudes and Expectation form, a self-report instrument, has been adapted from the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin et al. 1985) and modified for use with cocaine abusers. Greater congruence between patients' expectations of treatment and beliefs about the causes of substance use and those of the treatment they receive may result in improved outcome, as compared to persons whose treatment expectations contrast with the treatment received (Hall et al. 1991).
- Psychiatric diagnosis and symptoms
- The Structured Clinical Interview for DSM-IV (SCID) and SCID-P (First et al. 1995) provides DSM-IV diagnoses (for Axis I and II psychiatric diagnoses). It can also be used to assess severity of cocaine dependence by the total number of dependence syndrome elements endorsed (from the DSM-III-R substance abuse criteria).
- The California Psychological Inventory Socialization Scale (CPI-So) has been found to be a valid continuous measure of sociopathy in alcoholics (Cooney et al. 1990) and an important variable for patient-treatment matching in alcoholics (Kadden et al. 1989).
- The self-report Beck Depression Inventory (BDI) (Beck et al. 1961) and a clinician-rated instrument, the Hamilton Depression Rating Scale (Hamilton 1960), assess depression. The Symptom Checklist (SCL-90) (Derogatis et al. 1973) assesses a broader range of symptoms.
- Baseline level of coping skills and self-efficacy
- The Cocaine Use Situations Inventory monitors changes in patients' self-efficacy and expectations of abstinence. This self-report form lists approximately 30 different types of high-risk situations and helps clinicians pinpoint specific situations that the patient does not cope with effectively. This instrument was derived from the self-efficacy instrument developed by Condiotte and Lichtenstein (1981) for use with alcoholics.
Learning serves as an important metaphor for the treatment process throughout CBT. Therapists tell patients that a 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 cocaine abuse, or for whom the consequences of cocaine abuse have been highly negative, are frequently surprised to consider cocaine abuse 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 cocaine (which often led to another set of licit or illicit skills), acquire cocaine without being arrested, use cocaine 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.
Learning Strategies Aimed at Cessation of Cocaine Use
In CBT, it is assumed that individuals essentially learn to become cocaine 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 are used several ways in CBT.
- Through a detailed examination of the antecedents and consequences of substance abuse, therapists attempt to understand why patients may be more likely to use 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 reinforcers 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 cocaine and other substance abuse is employed as a strategy to build or reinforce the patient's resolve to reduce or cease substance abuse.
Classical conditioning concepts also play an important role in CBT, particularly in interventions directed at reducing some forms of craving for cocaine. 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 own 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 craving 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 cocaine 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 craving (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 cocaine 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 manual describes a sequence of sessions to be delivered to patients; 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 cocaine-abusing patients coming into treatment.
Early sessions focus on the fundamental skills of addressing ambivalence and fostering motivation to stop cocaine abuse, helping the patient deal with issues of 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 cocaine 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 cocaine abuse.
Match Material to Patient Needs
CBT is highly individualized. Rather than viewing treatment as cookbook psychoeducation, the therapist should carefully match the content, timing, and nature of 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 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 treatment that is patient driven rather than manual driven) is to use, whenever possible, specific examples provided by the patients, either through their history or relating 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 cocaine 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 difficulty 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?"
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. It is important that therapists 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.
In fact, 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 out by asking about any episodes of cocaine use or craving, what preceded the episodes, and how the patient coped.
The idea of cocaine use in the context of its antecedents and consequences is inherent in most treatment sessions. For example, craving and thoughts about cocaine are common antecedents of cocaine 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 cocaine 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, 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. It is critical that patients 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 opportunities for practice, 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 basically 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 actually tries the exercise. Compliance with extra-session assignments is a problem for many patients. Several strategies are helpful in encouraging 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 really 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. It's very important that you give yourself a chance to try out new skills outside our sessions so we can identify and discuss any problems you might have putting them 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 because 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.
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 prob-lemsolving strategy to help 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, to 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.
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 actually 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 are 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 potential 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 own 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 own observations, will help guide the topic selection and pacing of future sessions.
Some patients literally 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' difficulty, therapists can help them work through it.
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.