Topic 1: Coping With Craving
Tasks for Topic 1
- Understanding craving
- Describing craving
- Identifying triggers
- Avoiding cues
- Coping with craving
Because craving is such a difficult problem for so many cocaine abusers, this topic is introduced very early in treatment. Episodes of intense subjective craving for cocaine are often reported weeks and even months after the inception of abstinence. This experience can be both mystifying and disturbing to the abuser and can result in cocaine abuse if it is not understood and managed effectively.
The goals of the session are to -
- Understand the patient's experience of craving.
- Convey the nature of craving as a normal, time-limited experience.
- Identify craving cues and triggers.
- Impart and practice craving- and urge-control techniques.
It is important for patients to recognize that experiencing some craving is normal and quite common. Craving does not mean something is wrong or that the patient really wants to resume drug use.(Much of this material on key interventions used with episodes of craving was adapted from Kadden et al. 1992.)
Because of the frequency and the variety of circumstances in which cocaine is self-administered, a multitude of stimuli have been paired with cocaine abuse. These may act as conditioned cues or triggers for cocaine craving. Common triggers include being around people with whom one used cocaine, having money or getting paid, drinking alcohol, social situations, and certain affective states, such as anxiety, depression, or joy. Triggers for cocaine craving also are highly idiosyncratic, thus identification of cues should take place in an ongoing way throughout treatment.
To explain the ideas of conditioned cues, therapists might paraphrase Pavlov's classical conditioning paradigm by equating food to cocaine, the animal's salivation to cocaine craving, and the bell as the trigger. Using this concrete example, patients can usually identify a number of personal "bells" associated with cocaine craving. The example of Pavlov's experiments is often enough to demystify the experience of craving and help patients identify and tolerate conditioned craving when it occurs.
It is also important to convey the time-limited nature of cocaine craving, that is, conditioned craving usually peaks and dissipates in less than an hour, if not followed by cocaine use. Therapists should also explain the process of extinction of conditioned responses, again using concrete examples from Pavlov's experiments.
Next, it is essential to get a sense of the patients' experience of craving. This includes eliciting the following information.
- What is craving like for you?
Cravings or urges are experienced in a variety of ways by different patients. For some, the experience is primarily somatic; for example, "I just get a feeling in my stomach" or "My heart races" or "I start smelling it." For others, craving is experienced more cognitively; for example, "I need it now" or "I can't get it out of my head" or "It calls me." Or it may be experienced affectively; for example, "I get nervous" or "I'm bored." It is important for the therapist to get a clear idea of how craving is experienced by the patient.
- How bothered are you by craving?
There is tremendous variability in the level and intensity of craving reported by patients. For some, achieving and maintaining control over craving will be a principal treatment goal and take several weeks to achieve. Other patients deny they experience any craving. Gentle exploration with patients who deny any craving (especially those who continue to use cocaine) often reveals that they misinterpret a variety of experiences or simply ignore craving when it occurs until they suddenly find themselves using. Other, abstinent patients who deny they experience any craving often, when asked, admit to intense fears about relapsing.
- How long does craving last for you?
To make the point about the time-limited nature of craving, it is often important to point out to patients that they have rarely let themselves experience an episode of craving without giving in to it.
- How do you try to cope with it?
Getting a sense of the coping strategies used by patients will help the therapist identify their characteristic coping styles and select appropriate coping strategies.
Therapists should then work with patients to develop a comprehensive list of their own triggers. Some patients become overwhelmed when asked to identify cues (one patient reported that even breathing was associated with cocaine use for him). Again, it may be most helpful to concentrate on identifying the craving and cues that have been most problematic in recent weeks. This list should be started during the session; the practice exercise for this session should include self-monitoring of craving, so patients can begin to identify new, more subtle cues as they arise.
Keep in mind that the general strategy of "recognize, avoid, and cope" is particularly applicable to craving. After identifying the patients' most problematic cues, therapists should explore the degree to which some of these can be avoided. This may include breaking ties or reducing contact with individuals who use or supply cocaine, getting rid of paraphernalia, staying out of bars or other places where cocaine was used, or no longer carrying money, as in the following example:
"You've said that having money in your pocket is the toughest trigger for you right now. Let's spend some time thinking through ways that you might not have to be exposed to money as much. What do you think would work? Is there an amount of money you can carry with you that feels safe? You talked about giving your check to your mother earlier; do you think this would work? You've said that she's very angry about your cocaine use in the past; do you think she'd agree to do this? How would you negotiate her keeping your money for you? How could you arrange with her to get money you needed for living expenses? How long would this arrangement go on?"
Therapists should spend considerable time exploring the relationship between alcohol and cocaine with patients who use them together to such an extent that alcohol becomes a powerful cocaine cue. Specific strategies to reduce, or preferably, stop alcohol use should be explored.
Coping With Craving
The variety of strategies for coping with craving include the following.
- Talking about craving
- Going with the craving
- Recalling the negative consequences of cocaine abuse
- Using self-talk
Therapists may wish to point out that these strategies may not stop craving completely. However, with practice, they will reduce the frequency and intensity of craving and make it less disturbing and frustrating when it occurs.
In many cases, an effective strategy for coping with conditioned craving for cocaine is distraction, especially doing something physical. It is useful to prepare a list of reliable distracting activities in conjunction with patients in anticipation of future craving. Such activities might include taking a walk, playing basketball, and doing relaxation exercises. Preparation of such a list may reduce the likelihood that patients will use substances, particularly alcohol and marijuana, in ill-fated attempts to deal with craving. Leaving the situation and going somewhere safe is one of the most effective ways of dealing with craving when it occurs.
Talking About Craving
When patients have supportive, abstinent friends and family members, talking about craving when it occurs is a very effective strategy and can help reduce the feelings of anxiety and vulnerability that often accompany it. It can also help patients identify specific cues.
Close family members may become distressed when they hear patients talk about craving because they expect it to lead to use. Therapists might spend some time identifying who patients would feel comfortable talking with about craving, how that person would be likely to react, and whether it makes sense to ask that person in advance for support.
"It sounds like you think talking to your wife might help, but you've also said that she's very nervous about what would happen if you relapsed. Do you think she'd be able to listen if you talked with her the next time you felt like using? Maybe you could talk to her about this before the next time you feel craving, so the two of you can figure out how you'll handle it when it comes up."
Socially isolated patients, or those who have few nonusing friends, will find it difficult to nominate a supportive other who can assist with craving, thoughts about cocaine, and other problems. This should alert therapists to the need to consider addressing social isolation during treatment. For example, therapists and patients can brainstorm ways of meeting new, nonusing others, reconnecting with friends and family members, and so on. To help patients "own" these strategies and be more likely to initiate positive social contact, therapists might suggest applying the problem solving strategies discussed in topic 7.
Going With The Craving
The idea behind this technique is to let cravings occur, peak, and pass; in other words, to experience them without either fighting or giving into them. Giving patients the imagery of a wave or walking over a hill may help convey this concept, as does judo, that is, gaining control by avoiding resistance.
Ito and colleagues (1984) identified the steps involved; these should be practiced within sessions or at home before craving occurs. Also, patients should be told that the purpose is not to make the cravings disappear, but to experience them in a different way that makes them feel less anxiety provoking and dangerous and thus easier to ride out. The steps are summarized below.
- Pay attention to the craving. This usually involves, first, finding someplace safe to let oneself experience craving (e.g., a comfortable and quiet place at home). Next, relax and focus on the experience of craving itself - where it occurs in the body or mind and how intense it is.
- Focus on the area where the craving occurs. This involves paying attention to all the somatic and affective signals and trying to put them into words. What is the feeling like? Where is it? How strong is it? Does it move or change? Where else does it occur? After concentrating in this way, many patients find the craving goes away entirely. In fact, the patient may find it useful to rate the intensity of craving before and after the exercise to demonstrate the effectiveness of the technique.
Recalling Negative Consequences
When experiencing craving, many people have a tendency to remember only the positive effects of cocaine; they often forget the negative consequences. Thus, when experiencing craving, it is often effective for them to remind themselves of the benefits of abstinence and the negative consequences of continuing to use. This way, patients can remind themselves that they really will not feel better if they use.
To this end, it may be useful to ask patients to list on a 3 x 5 card the reasons they want to be abstinent and the negative consequences of use and to keep the card in their wallet or another obvious place. A glimpse of the card when confronted by intense craving for cocaine or a high-risk situation can remind them of the negative consequences of cocaine use at a time when they are likely to recall only the euphoria.
For many patients, a variety of automatic thoughts accompany craving but are so deeply established that patients are not aware of them. Automatic thoughts associated with craving often have a sense of urgency and exaggerated dire consequences (e.g., "I have to use now," "I'll die if I don't use," or "I can't do anything else until I use").
In coping with craving, it is important both to recognize the automatic thoughts and to counter them effectively. To help patients recognize their automatic thoughts, therapists can point out cognitive distortions that occur during sessions (e.g.,"A few times today you've said you feel like you have to use. Are you aware of those thoughts when you have them?"). Another strategy is to help patients "slow down the tape" to recognize cognitions.
"When you decided to go out last night, you said that you really weren't aware of thinking about using cocaine. But I bet if we go back and try to remember what the night was like, sort of play it back like a movie in slow motion, we could find a couple of examples of things you said to yourself, maybe without even realizing it, that led to cocaine use. Can you sort of play last night back for us now?"
Once automatic thoughts are identified, it becomes much easier to counter or confront them, using positive rather than negative self-talk. This includes cognitions such as challenging the thought (e.g.,"I won't really die if I don't have cocaine"), and normalizing craving (e.g., "Craving is uncomfortable, but a lot of people have it and it's something I can deal with without using").,/p>
Depending on how serious a problem craving is for a patient, this topic can be delivered in one or two sessions. When presented in two sessions, the first session focuses on recognizing craving and identifying triggers, and the extra-session task includes making a more elaborate list of craving triggers through self-monitoring (exhibit 3). The second session then focuses on learning and practicing coping strategies, and the extra-session tasks involve continuing to self-monitor and also observing the coping behaviors used when craving occurs.