Topic 2: Shoring Up Motivation and Commitment to Stop
Tasks for Topic 2
- Clarifying and prioritizing goals
- Addressing ambivalence
- Identifying and coping with thoughts about cocaine
By now, therapists and patients will have completed several functional analyses of cocaine use and high-risk situations, and patients have a clearer idea of the general approach to treatment. Most patients have also reduced their cocaine use significantly (or even stopped) at this point and can work toward a more realistic view of treatment goals than may have been possible in the first session. Patients are more aware of the role cocaine has played in their lives; they may be aware of recurrent thoughts about cocaine, and they may also be more ready to sort through some of their ambivalence about cocaine abuse and treatment.
While some patients intend to fully cease cocaine and other substance use, others may have slightly different goals.
- Reduction of cocaine use to "controlled" levels
- Cessation of cocaine use but continued high use of alcohol or other substances
- Remaining in treatment until the external pressures that precipitated treatment seeking (e.g., a spouse's ultimatum, pressure from an upcoming court case) have abated
While such goals tend to be quite unrealistic, it may be wise for therapists, particularly in the early weeks of treatment, to not directly challenge them until a therapeutic alliance is established that allows for a more informed reassessment. Allowing patients to recognize for themselves the impossibility of controlled cocaine use may be much more persuasive than a therapist's repeated warnings. For example, a young woman maintained she could not possibly cease both cocaine and marijuana simultaneously (because she attempted to use marijuana to cope with cocaine craving) until she discovered that her excursions to buy marijuana led to a variety of powerful cocaine cues and usually to extended cocaine binges.
The goals of this session are to -
- Revisit and clarify treatment goals.
- Acknowledge and address ambivalence about abstinence.
- Learn to identify and cope with thoughts about cocaine.
This is a good time to explore with patients their commitment to abstinence and other treatment goals. By now, even patients who were pressured into treatment usually have begun to sort out the consequences of continued cocaine use in relation to other goals. Thus, therapists should check the patients' current view of treatment and readiness to change.
"I noticed that, even though you haven't stopped completely, you've mentioned several times all the problems cocaine has caused you, like the job and the trouble with your probation officer, and some of the opportunities it has cost you, like spending more time with your kids as they were growing up. Do you have any thoughts about these problems? At the same time, I also hear that there are some things about using cocaine that you really miss right now. I thought we could spend some time this session talking more about your goals and how we might be able to help you get there. Do you feel ready for that? What are you thinking about your cocaine use at this point? Are there other problems you'd like to tackle while we work together?"
From this discussion, therapists should be able to get a clear idea of the following:
- The patients' current readiness for change
- Their current stance toward abstinence
- A sense of other target goals and problems
This should be an open-ended discussion, with therapists refraining from taking too active a role or supplying goals for patients. The techniques described by Miller et al. (1992) for strengthening commitment to change could be used here.
- Communicate free choice (e.g., "It's up to you what you want to do about this").
- Emphasize the benefits of abstinence as a goal.
- Provide information and advice around the kinds of problems and issues that should be addressed if the patient is to remain abstinent.
Patients might be encouraged to talk about their treatment goals any number of ways (e.g., "Have you thought about where you want to be 12 weeks from now? What about 12 months from now?"). This discussion usually elicits other target symptoms and problems, some of which may be closely related to cocaine use (e.g., medical, legal, family/social, psychiatric, employment/support, and other types of substance abuse or dependence). Others may be less closely related and thus less important to address during treatment. Because this is a brief treatment focused on helping patients achieve initial abstinence, therapists must balance the need to address problems that might pose barriers to abstinence with the need to keep treatment focused on achieving abstinence.
Therapists should work with patients to prioritize other target problems:
Address Ambivalence About Abstinence
Ambivalence is best addressed early to foster a therapeutic alliance that allows for open exploration of conflicts about cessation of cocaine use. Encourage patients to articulate the reasons they have used cocaine, help them "own" the decision to stop use through exploring what they stand to gain, and underscore the idea that cocaine abuse cannot be divorced from its consequences.
We frequently use a simplified version of the decision matrix described by Marlatt and Gordon (1985). In this exercise, therapists use an index card and record the patients' descriptions of all possible benefits of continued cocaine use, however subjective, on one side of the card. Some patients have initial difficulty acknowledging any positive consequences of continued cocaine abuse, but most are able to list several justifications like "There's nothing else as exciting in my life" or "I feel less anxious with people" or "I get most of my money from selling cocaine" or "Sex and coke go together."
Next, with open-ended questions, therapists encourage patients to explore each of these stated benefits (e.g., "Having money in your pocket sounds important; what else does selling do for you?"). Most often, patients indicate many of these are ultimately negative. For example, if the cocaine high was listed as an advantage, the nature of the high is explored, and patients are reminded of the crash and dysphoria that invariably follow and endure much longer than the euphoria. Patients who sell cocaine remind themselves that all of the profits are used to support cocaine use.
Therapists then ask patients to list all possible reasons to stop cocaine abuse and write these on the other side of the card. These are typically numerous and reflect negative consequences such as "I want to keep my job" or "Fewer fights with my parents" or "More money for things I want." Patients are instructed to keep the card in their wallet, preferably near their money. 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 abuse when they are likely to recall only the euphoria associated with the high.
The power of this concrete reminder was illustrated by a cocaine abuser who removed the card from his wallet before he went out one evening when he intended to use cocaine; he felt the card had literally "stopped me from using" on several previous occasions.
Identifying and Coping With Thoughts About Cocaine
Ambivalence is often manifested in thoughts about cocaine and using that are difficult to manage. Cocaine was an important, even dominant, factor in patients' lives, and thoughts, both positive and negative, about cocaine are normal and likely to linger for some time. Again, the strategy here is to "recognize, avoid, and cope."
Thoughts associated with cocaine that can lead to resumption of use vary widely across individuals and their cognitive styles. Therapists should help patients identify their own cognitive distortions and ration-alizations ("I've noticed that you talk about your cocaine self and your straight self; can you tell me more about your cocaine self?"). It is important that therapists also clearly define automatic thoughts (e.g., either a thought or visual image that you may not be very aware of unless you focus your attention on it) and cognitions (e.g., things you say to yourself).
Common thoughts associated with cocaine include the following.
Testing control: "I can go to parties (see friends who are users, drink or smoke marijuana) without using."
Life will never be the same: "I love being high."
Failure: "Previous treatments haven't worked; there's no hope for me."
Diminished pleasure: "The world is boring without cocaine."
Entitlement: "I deserve a reward."
Feeling uncomfortable: "I don't know how to be with people if I'm not high."
What the hell: "I screwed up again, I might as well get high."
Escape: "My life is so bad, I just need a break for a few hours."
Avoiding thoughts associated with cocaine is not always possible, but individuals who tend to be focused on positive goals seem to be less troubled by them. Asking patients to articulate and record their short- and long-term goals often helps them see beyond the immediate tempt-ations more readily than individuals who lack a clear focus on the future.
For an in-session exercise, have patients record their immediate (next week), short-term (next 12 weeks), and long-term (the next year) goals. These should be as concrete as possible (e.g., instead of "have a lot of money," "have a job paying $12 an hour by October").
There are a number of strategies for coping with thoughts about cocaine.<$FThese strategies are adapted from Monti et al. 1989.>
- Thinking through the high. While patients are beset with craving or positive thoughts about cocaine, it is often difficult to remember the downside of a cocaine binge. Therapists can ask patients to relate an instance and come up with an image of the end of a particularly unpleasant cocaine binge. For example, one patient's image of waking up naked, robbed, and beaten in someone else's car in a town he did not know, was powerful enough to counter a range of nostalgic thoughts about cocaine.
- Challenge the thoughts. For each negative, cocaine-related thought, patients can be encouraged to generate and practice positive beliefs to counter them: "I've dealt with craving in the past, and I can do it again" or "Keeping my family together is more important than getting high" or "I used to have relationships where cocaine wasn't a part of the picture." These should be individualized and tailored to each patient's cognitive style. Humor and reframing are particularly effective ways of countering thoughts about cocaine for some patients.
- Review negative consequences. Reviewing a 3 x 5 card or piece of paper that lists the patient's own view of the negative consequences of cocaine use is a powerful strategy to counter craving or thoughts about cocaine. Making one's own card is one of the practice exercises for this topic.
- Distraction. Just as cravings peak and go away if resisted, so do thoughts about cocaine. Thoughts about cocaine will become less strong, less frequent, and less upsetting if one does not give in to them. Just as distraction is an effective means of coping with craving, having a list of activities that are pleasant (something enjoyable or stimulating), available (that could be engaged in day or night, in good or poor weather), and realistic (not expensive or always dependent on the availability of others) is an effective way of coping with thoughts for patients who have trouble relying on other cognitive strategies.
- Talking. Just as talking to a supportive friend or significant other can be an effective means of pinpointing, understanding, and working through an episode of craving, talking through cocaine thoughts is often an effective way of dispelling them. Thoughts that seem compelling and dire (I can't live without cocaine) often lose their potency when expressed to others. Therapists should work with patients to identify appropriate others with whom they can discuss and work through thoughts about cocaine when they occur.
When done as two sessions, the first session exercise includes having patients complete the 3 x 5 card of positive and negative consequences of using and the goal worksheet (exhibit 4). The second session's exercise includes monitoring of thoughts, plus recording of coping skills (exhibit 5), similar to the craving session.