Session 1: Introduction to Treatment and CBT
Tasks for Session 1
- Take history and establish relationship
- Enhance motivation
- Present the CBT model
- Introduce functional analysis
- Negotiate treatment goals and treatment contract
- Provide a rationale for extra-session tasks
The first session is the most important and often the most difficult because the therapist must address several areas.
- Begin to establish a relationship with the patient
- Assess the nature of the patient's substance use and other problems that may be important factors in treatment
- Provide a rationale for the treatment
- Establish the structure for the remaining sessions
- Initiate skills training
Because of the complexity of the tasks involved in the first session, the therapist should allow 90 minutes, rather than rely on the typical 1-hour session.
History and Relationship Building
Therapists should spend a considerable amount of time during the first session getting to know the patients, obtaining histories of them and their substance use, getting a sense of their level of motivation, and determining what led them to seek treatment. This can occur through a series of open-ended questions that should cover at least the following areas. Reasons for seeking treatment and treatment history
- What brought you here today?
- Have you ever been in treatment for cocaine abuse before?
- If yes, when was that? How long did you stay there? What was it like? What did you like or not like about the program? Why did you leave?
- Have you ever been in treatment for abuse of other substances, like heroin, alcohol, or benzodiazepines?
History and current pattern of cocaine abuse
- What is your cocaine use right now? How do you use it?
- How often do you use cocaine? How much do you use?
- What is your longest period of abstinence from cocaine? When did it start? Stop?
- What is the longest period of abstinence you've had in the last 3 months? How did that start and end?
- What have you tried to do to cut down on your cocaine use?
- How do you get cocaine?
- How much alcohol do you drink? How does drinking affect your cocaine use?
- How long have you been able to not drink?
- What other types of drugs are you using?
- How do you feel after using cocaine?
- How did your cocaine use get started?
Other problems and resources
- Where do you live? Does anyone you live with use cocaine?
- Who among the people you spend the most time with use drugs? Who doesn't use?
- Are you working now? How has your cocaine use affected your employment?
- Does your family know about your cocaine use?
- When was your last physical? Do you have any medical problems or worries?
- Do you have any legal problems? Is probation or parole involved with your decision to seek treatment?
- How do you feel most of the time? Have you been depressed or down? Have you ever thought about hurting yourself? Have you ever done so? Does that happen only when you use cocaine?
- Have you ever become paranoid or thought someone was after you while using? What was that like?
If patients have been through an extensive pretreatment assessment battery, therapists should attempt to be sensitive to further questions.
"I know you've already spent several hours answering questions, but now as we're beginning treatment, I hope you can answer a few more questions that should help you and me plan where we go from here."
As patients respond to the above questions, the therapist should listen closely for and, where possible, elicit statements or comments from them concerning their reasons for seeking treatment or reducing cocaine use. Some of the general strategies recommended by Miller and colleagues (1992) for enhancing motivation and avoiding resistance are extremely useful. These are summarized below.
Negotiate Treatment Goals
CBT for cocaine dependence is an abstinence-oriented treatment for many reasons. Cocaine use, even in small amounts, is associated with a variety of serious medical and psychiatric risks. Furthermore, unlike alcohol where some cognitive-behaviorally oriented treatments advocate a moderate drinking goal, cocaine is an illicit drug with considerable legal risks. Clinically, better outcomes are usually seen for patients who are abstinent.
However, relatively few patients come to treatment completely committed to abstinence. Many seek treatment because of some external persuasion or coercion; others want to cut down to a point where the negative consequences are eliminated, but cocaine use might go on. For highly ambivalent patients, clinicians must recognize that commitment to abstinence is a process that often takes several weeks to work through. Moreover, in most patients, abstinence takes several weeks to achieve and does not occur all at once.
Therapists should explicitly state that the goal of treatment is abstinence. However, for highly ambivalent patients, this should be done in a manner that acknowledges their uncertainty.
"I know you're not sure about stopping cocaine use completely, and we'll spend some time over the next few sessions talking about what you want to decide. However, there are some good reasons to consider abstinence from cocaine, as well as abstinence from other drugs and alcohol. For example, by trying to stop completely while you're here, you'll learn a lot about yourself and some of the factors that might be pushing you to continue using. You might also find it easier to understand the circumstances that make it more likely that you will use and some things you can do to stop using. You'll also avoid substituting other substances for cocaine. After a period of abstinence, you can get a clear idea of how you will feel without cocaine in the picture and can get a sense of whether that's what you really want to do. You can always change your mind later. What do you think?"
While this is a short-term treatment focused on cessation of cocaine use, patients often have a number of coexisting problems and concerns. Some are related to cocaine dependence, but some are not. While the primary focus of treatment should be stopping cocaine abuse, it is important to recognize and help patients sort through other problems and symptoms.
Therapists should also ask whether patients have other goals, as well as how stopping substance use might help them reach those goals (e.g., regain custody of their children, go back to work). In the case of problems that may be closely related to cocaine dependence (e.g., depressive symptoms, marital conflict, legal problems), it is critical for therapists to acknowledge these, work with patients to prioritize goals in relation to cocaine use, negotiate reasonable treatment goals and how the goals of treatment will be addressed, and monitor these other target symptoms and problems as treatment proceeds.
"I know you've been feeling down and want to try Prozac again, but you've been abusing cocaine for a long time, and it's going to be hard to sort out how much of how you're feeling is related to cocaine abuse and how much might be a depressive problem that's separate from your cocaine abuse. The best way to tell is after a period of abstinence from cocaine. Generally, we find that depressed feelings which last more than a month after the last use indicate the need to address drug abuse and depression separately, possibly with medication for the depression. What do you think about being abstinent for a month, and then considering a referral to a psychiatrist for a medication evaluation? In the meantime, it also sounds like we should spend some time talking about feeling down and how that might be related to your cocaine use."
* * *
"It sounds like there have been some problems with Billy for a long time, and he's asked you to leave, but you think things might get better if you stop using cocaine. One thing we can do in our work is to invite Billy to attend a session or two so he can ask questions and learn more about this treatment program, and the two of you can talk about where to go from here. After we complete this first 12 weeks, we might also think about a referral to family services. How does that sound?"
Present the CBT Model
Next, therapists should provide an explanation and rationale for the treatment. This should cover the following points.
- Cocaine use can be seen as learned behavior.
"One way of looking at cocaine use is that it's something people learn to do over time. They learn from watching other people use it; they learn ways to get and use it; they learn that cocaine has certain effects that may make them feel more energetic or attractive or social. As you've been talking, it seems like you've been doing a lot of learning over the years, too."
- Over time, cocaine use affects how people think, how they feel, and what they do.
"This learning process affects a lot of things about a person over time. People start developing certain beliefs about cocaine - like it's hard for them to function without it. You've probably developed your own set of beliefs about cocaine abuse. By looking at these beliefs, we'll be able to understand them better and that will help you learn ways to stop. Cocaine also affects how people feel. Some people find it makes them feel better for a short period of time, others talk about using cocaine to try to stop feeling so bad. Over time, those feelings become associated with cocaine, and it's important to try to look at and understand these reactions. Finally, cocaine affects what people do.You've already talked about how cocaine is such a habit for you, that it's something you do without even thinking."
- By understanding this process, individuals find it easier to learn to stop using cocaine and other drugs.
"You've said there's a lot about cocaine that's pretty automatic for you, like how you don't even remember going to New York last week. What we'll do is spend a lot of time slowing that process down. We will look at what happens long before you use, what you're thinking and feeling and where you are using. We will look at what use is like for you, and we'll look at what happens after you use. By understanding what seems so automatic now, your cocaine abuse will be a lot easier to control."
- New, more effective skills can replace old habits that lead to cocaine use.
"It's not just understanding these automatic processes, it's also doing something different that helps people stop using. You've talked about how just stopping the cocaine and not changing anything else doesn't really work for you. Really stopping cocaine means learning to do things differently. That's where coping skills come in. Instead of responding to old cues and problems with cocaine, we'll be talking about, and practicing, new, more effective ways of coping. This isn't always easy, because you've learned your cocaine coping style over a long period of time.What we'll do is help you unlearn some old, less effective strategies and learn some new, more effective ones. It'll take some time and a lot of practice to learn some new skills, but I bet if we look at the time you were abstinent for 4 months last year, we'll find you used some pretty effective coping mechanisms."
- Practice is essential.
"It takes practice trying out new ways of responding to old situations. One thing that might help is to remember that it took a lot of time for you to learn how to be such an effective cocaine abuser - how to get the money, buy cocaine, use it, and not get caught. That's a highly developed skill for you. Since you've been doing it for so long, a lot of other kinds of skills that you might have aren't being practiced and won't be natural for you at first. That's where practice of new skills comes in. We'll practice during sessions, but each week we'll also talk about how you can practice new skills outside our sessions. This kind of practice is really important. It won't seem natural or easy at first. By sticking it out and practicing outside of our meetings though, you'll learn a lot about yourself and what works and doesn't work for you. You can always bring problems in and talk about new ways of coping. Can you see yourself doing some practice outside of sessions?"
Establish Treatment Ground Rules
In addition to treatment goals and tasks, it is important to establish clear expectations for the patient in terms of treatment, your obligations, and the patient's responsibilities. The following areas should be reviewed and discussed.
- Scheduling of sessions and length of treatment
- Importance of regular attendance
- Calling in advance if the patient will miss the session or be late
- Collection of a urine specimen at each session
- The need to come to sessions free of cocaine, alcohol, or other drugs
Introduce Functional Analysis
Therapists should work through a recent episode of cocaine use with patients, conducting a full functional analysis.
"To get an idea of how all this works, let's go through an example. Tell me all you can about the last time you used cocaine. Where were you and what were you doing? What happened before? How were you feeling? When was the first time you were aware of wanting to use? What was the high like at the beginning? What was it like later? Can you think of anything positive that happened as a result of using? What about negative consequences?"
The practice exercise (exhibit 2) asks patients to do a functional analysis of at least three recent episodes of cocaine use. It follows closely the format of the functional analysis conducted by the therapist within the session. Therapists may want to use the sheet as a within-session example.