Integrating CBT and Medication
CBT is highly compatible with pharmacotherapy. When used in combination with medication, the range of CBT interventions expands to include a focus on enhancing medication compliance. Generally, medication response and compliance are monitored during the early part of each session (i.e., the first third of a 20/20/20 session). The following specific strategies (Adapted from Carroll and O'Malley 1996.) have been found useful:
- Inquire as to patients' previous experience with medication.
- Therapists should ask patients about their prior history with pharmacotherapy for any psychiatric disorder or condition.
- Why was it prescribed?
- Was it helpful?
- Under what conditions was it terminated?
- Did they take the medication as prescribed?
Previous noncompliance should alert therapists to the need to establish the patients' view of why they did not comply previously and to attempt to address those issues proactively.
- Address patients' concerns about medication.
During all sessions, therapists should listen carefully for any concerns, misunderstandings, or prejudices about taking medication and address these rapidly and assertively. These may include misconceptions about expected medication effects, time needed to experience the effect, side effects, dosing, and interactions with cocaine and other substances. Therapists should provide clarification in clear, familiar terms and frequently check back with patients to be sure they understand.
When medication effects may not be immediately apparent, it is impor-tant to inform patients that it may take several weeks before therapeutic effects emerge; thus, patients should be encouraged to expect gradual rather than all-or-nothing change. Explaining the gradual emergence of medication effects provides an opportunity for the therapist to emphasize that patients should not expect to benefit from an entirely passive stance regarding CBT treatment simply because they are taking medication. Mastery and implementation of coping skills remain an essential and important part of treatment; medication may be an additional, useful adjunct or tool.
- Assess medication compliance since last session.
Close, consistent, and careful monitoring is one of the most effective strategies for enhancing compliance with medications. Thus, a portion of each session should be devoted to evaluating medication compliance and working through any difficulties that might arise. In general, until the patients' compliance pattern is clearly established, therapists should, at each meeting, inquire about medication compliance, day by day, since the last session. This should include asking when patients take the medication, how they take the medication, and a thorough discussion of any deviation from the prescribed dose and schedule.
Fawcett et al. (1987) noted that compliance and retention are most difficult to achieve early and late in treatment - early if the patient is not receiving obvious benefit, and later if the patient, after obtaining a partial or full therapeutic response, does not appreciate the need to continue treatment. Thus, therapists should be particularly attentive to compliance and motivation issues during early and late sessions.
- Praise medication compliance.
Therapists should also convey confidence in the medication and inform patients of the likely benefits. Therapists should be strongly on the side of compliance and praise patients' compliance enthusiastically and genuinely.
"I see you have taken your medication every day since our last meeting. That's really great. I know you had your doubts about whether the medication would work for you, and I'm glad you were willing to give it a try. Have you noticed any positive changes you think might be related to the medication?"
- Relate patients' clinical improvement to compliance and lack of improvement to noncompliance.
A crucial role of the therapist is to establish and stress the connection between medication compliance, psychotherapy sessions, and improvement. Therapists should make explicit causal links between patients' compliance and improvement in cocaine abuse and other appropriate target symptoms. Conversely, therapists might tie poor compliance to failure to improve.
"Since you've been taking the medication, I can see a lot of positive changes in your life....you've cut way down on your cocaine use and you say you've been feeling a lot better. I think the changes indicate that the medication is helping you. What do you think?"
"I know you're discouraged about how you've been feeling, but since we've begun to work together, you've also told me you haven't been taking the medication every day. As we've discussed, I don't think you'll notice a real change until you take the medication more consistently. How about giving it a try?"
- Use a problem solving strategy for noncompliance.
When patients are not compliant with medication, therapists should take a practical, objective approach. They should try to help patients clarify reasons or obstacles to compliance and generate practical solutions. For example, patients may report difficulty remembering to take the medication. Practical strategies to cue the patient (e.g., notes on the bathroom mirror, taking the medication at a regular mealtime, enlisting family support and reminders) should be generated and followed up on in the next session. In all of these discussions, therapists should be nonjudgmental and nonconfrontational. Efforts should be made to help patients feel ownership of the plan. This can be done by having them take the primary role in developing the plan, rather than having therapists telling them what to do.