The Structure and Format of Sessions
CBT is highly structured and is more didactic than many other treatments. Thus, CBT therapists assume a more directive and active stance than therapists conducting some other forms of substance abuse treatment.
A great deal of work is done during each session, including reviewing practice exercises, debriefing problems that may have occurred since the last session, skills training, feedback on skills training, in-session practice, and planning for the next week. This active stance must be balanced with adequate time for understanding and engaging with the patient.
To achieve a good integration of manual-driven and patient-driven material in each session, we have developed the "20/20/20 Rule" for the flow of a typical 60-minute CBT session (exhibit 1). During the first 20 minutes, therapists focus on getting a clear understanding of patients' current concerns, level of general functioning, and substance use and craving during the past week, as well as their experiences with the practice exercise. This part of the session tends to be characterized by patients doing most of the talking, although therapists guide with questions and reflection as they get a sense of the patients' current status.
The second 20 minutes is devoted to introduction and discussion of a particular skill. Therapists typically talk more than patients during this part of the session, although it is critical that therapists personalize the didactic material and check back with patients frequently for examples and understanding.
The final 20 minutes reverts to being more patient dominated, as patients and therapists agree on a practice exercise for the next week and anticipate and plan for any difficulties the patients might encounter before the next session.
Exhibit 1: Session Flow in CBT, The 20/20/20 Rule
First 20 minutes
- Assess substance abuse, craving, and high-risk situations since last session.
- Listen for/elicit patients' concerns
- Review and discuss the practice exercise
Second 20 minutes
- Introduce and discuss the session topic
- Relate the session topic to current concerns
Third 20 minutes
- Explore the patient's understanding of and reactions to the topic.
- Assign a practice exercise for the next week
- Review plans for the week and anticipate potential high-risk situations.
First Third of Session
Assess Patient Status
Therapists greet the patients and typically start the session by asking them how they are doing. Most patients respond by spontaneously reporting whether they used cocaine or had cravings during the last week. If patients do not report substance use, therapists should ask about this directly. Particularly in the beginning of treatment, therapists should obtain detailed, day-by-day descriptions of how much cocaine was used.
For each episode of use, therapists should spend several minutes doing a functional analysis (what happened before the episode, when was the patient first aware of the desire or urge to use, what was the feeling, how and where did the patient acquire the cocaine, what was the high like, what happened afterward). If patients report no cocaine use, therapists should probe for any high-risk situations or cravings they may have experienced and debrief these as well. The therapists' goal is to get a detailed sense of the patients' current level of functioning, motivation, and cocaine use.
Objective feedback on patients' clinical status and progress through urine toxicology screens is an important part of this and any other drug treatment program. Urine specimens should be collected by therapists at every clinical contact (and at least weekly). The early part of the session is a good opportunity to review the results of the most recent urine toxicology report with patients. Ideally, the clinic would have access to a dipstick method where urine can be tested on the spot, and drug abuse within the past 3 days can be detected.
While discussing urine test results is straightforward when patients report being drug-free and the laboratory results confirm this, it is somewhat more complicated when patients deny cocaine use but the urine screen is positive. While patients often present excuses or creative explanations for why the toxicology screen was in error, it is best to point out that laboratory errors are quite unusual, that patients have little to gain from not being honest about substance abuse, and in fact, have much to lose, since treatment will be less helpful if patients are not open about the kinds of problems they are having.
Confronting patients about discrepancies in self versus laboratory reports of substance use is very important; done well, this can advance the therapeutic relationship and the process of treatment significantly. However, pointing out these discrepancies should not be done in a confrontational style. Rather, therapists might point out discrepancies between the patients' stated treatment goals and the urine results ("You've said things are all going great, but the urine results make me wonder if it's all been as easy as you say. What do you make of this?"). Therapists might also point out some reasons why patients are often reluctant to admit to ongoing drug abuse (fear of being terminated from treatment, wanting to please the therapist, testing the therapist), explore these with the patients, and process these as appropriate.
"It sounds like you're afraid that treatment is not working for you as quickly as you, and especially your wife, would like, and admitting you used last week might mean you wouldn't continue in treatment. I want you to understand that as long as you keep coming, working hard, and trying to stop use, I'll keep working with you. The only way that would change is if your cocaine use increased to a level where it was clear that outpatient treatment just wasn't enough to help you stop. In that case, we'd talk about increasing the frequency of sessions or other options, like having you enter an inpatient unit. How does that sound?"
* * *
Therapist: "I know the cocaine level from last week's lab test wasn't high, but it does indicate some recent cocaine abuse. Is it possible you used even a small amount last week?"
Patient: "Well, I did use a dime, but I didn't think that counted."
Therapist: "One line in the last week is a lot less than you were using just a few weeks ago and that's really great. But before we get into how you were able to cut down your use that much, I was wondering why you think that one line 'doesn't count,' since there's probably a lot we can learn about even that small amount of use."
It is not unusual for patients, particularly those who have not been in treatment before, to come late to appointments or miss appointments without calling. In such cases, therapists may apply a problem solving strategy. This entails some inquiry about why the patient was late, brainstorming solutions to lateness, and working through how plans to attend sessions promptly might be implemented.
Listen for Current Concerns
In reporting on substance abuse and major life events since the last session, patients are likely to reveal a great deal about their general level of functioning and the types of issues and problems of most current concern. Therapists should listen carefully and assess patients in a number of domains.
- Has the patient made some progress in reducing drug abuse?
- What is the patient's current level of motivation?
- Is a reasonable level of support available in efforts to remain abstinent?
- What's bothering this person most right now?
Therapists should listen intently, clarify when necessary, and where appropriate, relate current concerns to substance abuse.
"It seems like you're really worried about the guys at work getting you in trouble with your boss. Are these the same guys you used with?"
"It sounds like you were really lonely and bored this weekend, and maybe you've been feeling this way for a long time. Is that something you'd like to work on in here?"
During this part of the session, while getting a clear sense of patients' current concerns, therapists should be planning for the rest of the session, particularly in terms of how the planned session topic relates specifically to a problem or issue the patient has experienced recently.
"Talking about how bored you felt over the weekend makes me wonder if you weren't having a lot of craving for cocaine as well. If you think that's true, I'd like to spend time in this session talking about understanding craving and learning to deal with it."
When done well, this approach builds strong working relationships and heightens the relevance of CBT tremendously, because patients get the sense that the therapist is responding to their struggles with useful, timely techniques and strategies.
Discuss the Practice Exercise
The early part of each session should also include detailed review of the patients' experience with and reactions to the practice exercise. The primary focus should be on what the patients learned about themselves in carrying out the exercise.
- Was it easier or harder than expected?
- What coping strategies worked best?
- What did not work as well?
- Did the patients come up with any new strategies?
If therapists spend considerable time engaged in a detailed review of the patients' experience with the implementation of extra-session tasks, not only will the therapists convey the importance of practice, but both therapists and patients will learn a great deal about the patient. Therapists should not diminish the importance of practice by doing any of the following.
- Merely asking patients whether they completed the task or accepting a one word (yes/no) response without further probing.
- Collecting the patients' practice exercise as if it were a homework assignment. Instead, patients should be encouraged to keep a notebook or journal with their practice exercises, since they may find this a useful reference long after they leave treatment.
- Using an aggressive or confrontational style when patients do not attempt new skills or do so in a perfunctory way.
Again, therapists should move patients toward practicing skills outside of sessions by giving a clear rationale, getting a commitment from the patients, anticipating and working through obstacles, monitoring task completion closely, making good use of the data, exploring resistance, and praising approximations.
Second Third of Session
Introduce the Topic
After getting a clear sense of the patients' general functioning, current concerns, and progress with task implementation, therapists should move toward a transition to the session topic for that week. This may be either introducing a new topic or finishing up or reviewing an old one. In any case, an agenda for the remainder of the sessions should be set or reviewed at this time.
"Since you had that problem with Jerry last week, I think it might be a good idea to talk more about how you can avoid or refuse offers of cocaine and to practice a few more times so you feel more confident the next time that comes up. Then we can spend some time figuring out how you can have another clean week. How does that sound?"
Relate Topic to Current Concerns
Therapists should explicitly point out the relevance of the session topic to the patients' current cocaine-related concerns and introduce the topic by using concrete examples from the patients' recent experience.
"I think this is a good time to talk about what to do when you find yourself in a really tough high-risk situation, like what happened at the park on Tuesday. You coped with it really well by getting out of there quickly, but maybe there are some other things we can come up with if you find yourself in that kind of situation again."
Therapists should never assume that patients fully understand the session material or that it feels timely and useful to them. While going through the material, therapists should repeatedly check the patients' understanding.
- Ask for concrete examples from the patients.
"Can you think of a time last week when this happened to you?"
- Elicit the patients' views on how they might use particular skills.
"Now that we've talked about craving and talked about urge surfing, distraction, and talking it out, what do you think would work best for you? Which of these techniques have you used in the past? Is there any other way you've tried to cope with craving?"
- Ask for direct feedback from patients.
"Does this seem like it's an important issue for us to be working on right now, or do you have something else in mind?"
- Ask patients to describe the topic or skill in their own words.
"We've talked a lot about building an emergency plan. Just to make sure you're confident about what you want to do, can you tell me what you're planning the next time you get into an emergency situation?"
- Role-play or practice the skill within the session.
"It sounds like you're ready to practice this. Why don't we try that situation you were telling me about when your father got angry when you asked for a ride over here?"
- Pay attention to the patients' verbal and nonverbal cues.
"I notice that you keep looking out the window and I was wondering what your thoughts are on what we're talking about today."
In many cases, patients feel that a particular topic is not really relevant. For example, patients may deny experiencing any craving for cocaine. While using their clinical judgment in determining the salience of particular material for particular patients, therapists might work through a particular topic by pointing out that some problems may come up in the future, and having a particular skill in the patients' repertoire may be quite useful.
"I know you're not feeling bothered by craving now and don't think you'll experience any in the near future, but it may come up in a few weeks or even after you leave treatment. In any case, it might be helpful to spend a little more time talking about it, so if it does come up, you'll be prepared. What do you think?"
Final Third of Session
The last third of the session is, like the first third, likely to be characterized by patients talking more, with therapists guiding the discussion by asking questions and obtaining clarification.
Assign a Practice Exercise
As part of the winddown of the session, therapists and patients should discuss the practice exercise for the next week. It is critical that patients understand clearly what is required. Early in treatment for most patients, and throughout treatment for others, therapists may find it useful to model the assignment during the session. Therapists should also ask for a commitment from patients to try out the skill and to work through obstacles to implementing the skill by planning when and where they will complete the task.
A suggested practice exercise accompanies each session. An advantage of using these sheets is that they also summarize key points about each topic and thus can be useful reminders to patients of the material discussed each week. However, the extra-session practice of skills is most useful to patients if it is individualized. Thus, rather than being bound by the suggested exercises, therapists and patients are encouraged to use these as starting points for discussing the best way to implement the skill and come up with variations or new assignments. Similarly, not all assignments must be written; a number of patients may have limited literacy, and they may tape their thoughts about the practice exercise.
Anticipate High-Risk Situations
The final part of each session should include a detailed discussion of the patients' plans for the upcoming week and anticipation of high-risk situations.
"Before we stop, why don't we spend some time thinking about what the next few days are going to be like for you. What are your plans after you leave here today? What's the hardest situation you think you'll have to deal with before we meet on Friday?"
Therapists should try to model the idea that patients can literally plan themselves out of using cocaine. For each anticipated high-risk situation, therapists and patients should identify appropriate and viable coping skills. Early in treatment, this may be as concrete as asking a trustworthy friend or significant other to handle a patient's money.
Anticipating and planning for high-risk situations may be difficult in the beginning of treatment, particularly for patients who are not used to planning or thinking through their activities, or whose lives are highly chaotic. This models an important skill that is the focus of the session on "Seemingly Irrelevant Decisions," that is, learning to modify behavior by looking ahead.
For patients whose lives are chaotic, this may also help reduce their sense of lack of control. Similarly, patients who have been deeply involved with drug abuse for a long time will discover through this process that they have few activities to fill their time or serve as alternatives to drug abuse, especially if they have been unemployed or have few social supports unrelated to their substance abuse. This provides an opportunity to discuss strategies to rebuild a social network or begin to think about going back to work.
Eight skill topics are covered in CBT for cocaine dependence plus a termination session and elective sessions that involve significant others. The sequence in which the topics are presented should be based on the clinical judgment of therapists and the needs of the patients. They are given here in the sequence most often used with cocaine abusers. The most critical behavioral skills for patients just entering treatment are introduced first, followed by more general skills.
Since CBT is usually delivered in 12-16 sessions over 12 weeks, there are fewer skills-training topics than sessions. This provides some flexibility for therapists to allow for greater practice and mastery of a small but critical set of skills as well as repetition of session material as needed. It is intended to prevent patients from being overwhelmed with material.
Several skill guidelines are given for each session, many more than can be reasonably introduced. When delivered as a single session, therapists should carefully select skills to match the patients and not attempt to cover them all. A therapist might pick one or two coping skills the patient has used in the past and introduce one or two more that are consistent with the patient's coping style.
When delivered in more than one session, therapists should split up the guidelines, discussing and practicing the most basic and familiar skills in the first session and more challenging ones in the second. Moreover, the two-session format allows patients to be introduced to a skill in the first session, practice it in the interval before the next session, and discuss and work through any difficulties during the second session. Practice exercises should be given for both sessions, with the exercise for the second session being a variant of the first (e.g., trying out a skill not used the week before, increasing the difficulty or complexity of the task).
Some patients, particularly less severe users, may move through the skills very quickly. When this occurs, excellent elective session material can be found in Treating Alcohol Dependence: A Coping Skills Training Guide in the Treatment of Alcoholism (Monti et al. 1989). Since this material tends to focus on broad, interpersonal skills, such as coping with criticism or anger, it is comparatively straightforward to adapt for use with cocaine abusers.