Any person who expresses interest in receiving help for a cocaine problem has taken a courageous step and should be treated accordingly. The therapist, intake worker, or receptionist who has first contact with a prospective patient should do everything possible to facilitate entry into treatment. Staff should provide timely assistance and be flexible in scheduling, empathic when appropriate, and optimistic about the patient's ability to change. Some cocaine abusers may present for treatment with poor attitudes or seem demanding. It is important to expect such negative behavior and to label it as part of the problem. This will help the therapist or intake worker provide the friendly, respectful, and flexible treatment access required.
All initial contacts can be handled by a receptionist or clinician.
Conduct a preliminary screen to eliminate inappropriate applicants. For CRA + Vouchers, it is advisable to accept for treatment only those individuals who -
- Report cocaine abuse.
- Are aged 18 years or older.
- Reside within a reasonable distance of the clinic. This requirement is due to the intensive nature of the intervention. Patients are expected to attend the clinic a minimum of 3 days per week for urine monitoring and counseling during the first 12 weeks of treatment.
Once the applicant contacts the clinic to request treatment (either by telephone or by walking in), every effort should be made to conduct the intake interview as soon as possible. At least three studies show that scheduling intake appointments with minimal delay significantly reduces the attrition rate between initial contact and the intake appointment. Ideally, the intake would be done the same day; if that is not possible, then try to schedule it within 24 hours. The least accommodating schedule should be within 2 working days of contact, although occasionally this process may take longer.
Inform eligible applicants that the first appointment takes approximately 3 hours to complete and explain what is involved.
- Completion of various staff- and self-administered questionnaires
- A brief overview of the program
- An initial meeting with a therapist to begin developing a treatment plan
Be prepared to be flexible on timing and scheduling. If the applicant cannot stay for the complete intake, schedule another appointment as soon as possible to complete the process. However, a brief introductory meeting with a therapist is recommended at the end of the initial intake session even if the intake needs to be completed in a second session.
If applicants bring a spouse or partner to intake, it is important to make the partner feel comfortable. However, the assessment interview is conducted with the applicant only. Prior to and after the assessment, inform the partner about the assessment and treatment process. If appropriate, raise the possibility of relationship counseling and encourage it at this time.
The intake session is one of the most important elements of the treatment process. This may be the first treatment experience for many, and they may feel uncomfortable or ambivalent about being there. Some patients may have had an unpleasant treatment experience in the past and are wary of treatment in general. It is important that patients are made to feel as comfortable as possible during the intake process.
- Be aware of the patient's potential uneasiness and do everything possible to make the initial meeting a positive experience.
- Convey positive, can-do messages. The applicant should clearly hear that, by working together, the applicant and clinic staff can resolve problems that brought the individual to treatment.
- Accommodate the need for brief breaks, food or drink, or need to make a phone call.
It is important to collect detailed information on the severity of drug and alcohol use, treatment readiness, current psychiatric functioning, medical problems, employment, legal issues, and family and social problems. Following is a list of useful assessment instruments, in the order in which they are typically administered by the authors; your clinic may choose to use other instruments.
The questionnaires described in this section are completed by applicants prior to the interview. If there is any question about reading ability, take the applicants to a private office and have them read several questions aloud to see whether they can complete the forms without staff assistance. Persons deemed capable of completing the forms should be given approximately 45 minutes to finish the ones described below.
If staff assistance is required, read the questions aloud in a private setting, with care and positive regard for the discomfort poor readers may feel under such circumstances. Reassure applicants that providing such assistance is not unusual, because many individuals are unfamiliar with the words used in such medical questionnaires.
- Patient Information Form
A brief questionnaire should be used to obtain information on the demographic characteristics of the applicants as well as their current address and telephone number and the number of someone who will always know their whereabouts. This information can be used to contact patients who do not show up for treatment and to enhance followup efforts.
- Cocaine Dependency Self-Test and Cocaine-Related Consequences Questionnaire
Adaptations of these forms can be used to efficiently collect useful, specific information about the applicants' pattern of cocaine use and associated problems (Washton et al. 1988).
- Michigan Alcoholism Screening Test (MAST)
This widely used, 25-item instrument lists common signs and symptoms of alcoholism (Selzer 1971). Considering that most patients entering treatment for cocaine dependence also use alcohol, and greater than 50 percent meet diagnostic criteria for alcohol dependence, the MAST is useful for flagging patients with alcohol problems.
- Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
This instrument provides information on applicants' perceptions of the severity of their drug abuse problem and their readiness to engage in behaviors that reduce use (Miller and Tonigan 1996). It provides a quantitative index of motivation to change, which may be an important indicator of applicants' willingness to comply with certain treatment goals. Three versions of the SOCRATES that refer to specific substances (i.e., cocaine, alcohol, and other drugs) are administered because the patient's motivation to reduce substance use is likely to be substance specific.
- Beck Depression Inventory (BDI)
The BDI may be used to screen for depressive symptomatology (Beck et al. 1961). It can be easily readministered on a regular basis to monitor progress with patients who score in the clinical range at intake. The mean BDI score of cocaine abusers entering treatment typically falls in the clinical range of that scale. For most patients, BDI scores drop precipitously after 1 or 2 weeks of cocaine abstinence. However, that is not true for all patients. Therefore, it is important to carefully assess and monitor depressive symptomatology and to intervene when symptoms do not remit.
This instrument may be used to screen for psychiatric symptoms to help determine whether a more indepth psychiatric evaluation is warranted. The SCL-90-R (Derogatis 1983) can be easily readministered to monitor progress or change in psychiatric status.
When the self-administered questionnaires have been completed, they are reviewed by the intake worker to make sure all questions have been answered. The information on the Patient Information Form is checked for completeness.
A brief description of the CRA + Vouchers program and its philosophy should be offered after completion of the self-administered questionnaires but before the structured interviews. The goals are to -
- Orient applicants to what will happen in treatment.
- Create an atmosphere of optimism about treatment outcome.
- Make applicants feel hopeful about improving their life situation.
The intake worker should also explain that -
- The program is confidential; everything discussed or written remains private.
- The program is specifically designed for persons who have problems with cocaine.
- The program lasts 24 weeks, with the first 12 weeks being fairly intensive and involving counseling sessions at least twice a week and urine testing three times a week.
- If progress is being made, the last 12 weeks become much less intensive. Counseling sessions focus on lifestyle changes designed to help patients make positive changes that will result in greater life satisfaction.
The following is an example of a short description of what might occur during counseling.
"If you are interested in finding a job, the therapist will help you with the job search, with developing a resume, and with transportation and phone support if necessary. If you would like to go back to school, we can help you obtain the applications, access funding and assistance, and even take you to an interview if you need transportation. If you are having problems in your relationship, relationship counseling is available. If you don't regularly participate in any fun activities, we have many suggestions and may even take you to some of these, like basketball, tennis, fishing, boating, and arts and crafts classes."
"We also provide coping skills training. If you have problems controlling anger, we can help with anger management. If you have money problems, we can assist you with financial management. If you have difficulty with behavior problems with your children, we can assist you directly or we can help you get some additional help. If you have trouble relaxing, we can work on relaxation skills and stress management."
The intake worker also provides a very brief description of the Voucher program.
"You will also participate in our incentive program. When you provide cocaine-free urine samples, you earn points that can be used to support your goals. You can accumulate points to pay for activities like going to the movies, joining a gym, taking a class, buying a fishing rod, and so forth. When you provide consecutive clean urines, you earn bonus points. Staying clean for 12 weeks can earn you the equivalent of nearly $1,000. Your therapist will tell you more about these things after our interview."
After this brief description of the program, the intake worker should give applicants an opportunity to ask questions. Keep this interaction brief; the therapist can provide more detailed information after the structured interview is completed. If applicants are still interested and wish to enroll in CRA + Vouchers, escort them to a specified location to complete the structured interview.
- Drug History
A structured drug history interview should be used to collect information on past and current substance use to determine the duration, severity, and pattern of the patients' cocaine and other drug use. The accuracy of the patients' reports of cocaine use (amount and frequency) is facilitated by the use of an effective technique for reviewing recent use called timeline followback (Sobell et al. 1988). Using a calendar as a prompt, individuals are asked to recall, on a day-by-day basis, when they used a particular substance in the past week and the amount used on each occasion. Grams are the best metric measurement for determining the amount of cocaine used. The same assessment is conducted for the previous 3 weeks and as far back as is needed for diagnostic purposes. This technique provides a good overview of the pattern of cocaine use during the past 30 days. The interviewer should ask for as much clarification as possible to help obtain an accurate assessment of the applicants' substance abuse history.
- The Addiction Severity Index (ASI)
This structured clinical interview is designed to provide reliable, valid assessments of multiple problems common among substance abusers (McLellan et al. 1985). It gives a quantitative, time-based assessment of substance abuse as well as employment, medical, legal, family, social, and psychological functioning. The data obtained in this interview are useful for developing treatment plans that include lifestyle change goals. The ASI is also a useful instrument for assessing progress at followup points because it is time based and yields quantitative composite scores for each problem area. Interviewers must be trained on ASI administration to ensure that they conduct a reliable ASI interview.
- The DSM-III-R Checklist
Only the psychoactive substance use section of this semistructured interview is administered to facilitate accurate diagnoses of substance abuse and dependence (Hudziak et al. 1993). Special training in substance use diagnostics is required. Particular care must be taken to ensure accurate diagnoses, especially if a nonprofessional conducts the interview.
- Practical Needs Assessment
This form (exhibit 6) was developed to determine if the cocaine abuser has any basic needs that may interfere with engaging successfully in treatment (e.g., housing, legal, transportation, childcare, financial). The interviewer asks specific questions and collects detailed information on each area of potential need. These are needs that may require immediate attention and should be given priority in treatment planning, since many cocaine abusers enter treatment with their lives in chaos. The probability of engaging and keeping patients in treatment may be compromised if swift attention is not provided to basic life problems.
After the interviews are completed, the intake worker should inform the applicants that they will be meeting with their therapist in a few minutes, after a brief break (5 - 10 minutes). The intake worker should then complete an intake summary sheet (exhibit 7) and give it and all of the intake information to the therapist during a brief meeting to review the case. Patients are then introduced to their therapist.
Initial Treatment Session
The purpose of the initial treatment session is to ensure that patients leave the clinic feeling that treatment has begun and there is hope that they can improve their life situation. In many ways, this is an orientation session (exhibit 8). The session should be used to establish rapport with the patient and to provide a clear rationale for the CRA + Vouchers approach. By doing this, patients will develop clear expectations about how treatment works and about what is expected of them.
If the patient is pressed for time or tired from the intake procedures, this first meeting with the therapist can be shortened and any unfinished business completed in the next session. The most important goals of this meeting are to build rapport, enhance expectations, and orient patients to the treatment process.
Get to Know the Patient
Therapists should begin by introducing themselves and reviewing the purpose of the session.
"What I hope we can do is begin to get to know each other. I'd like to start by briefly discussing the problems that brought you here. I know you already discussed them in detail with the intake worker, but I'd like to hear about your problems from you firsthand so I can get a better feel for what's going on. Then I'd like to give you an idea of what to expect as far as your treatment goes. Please feel free to ask questions or express any concerns you may have about the treatment or anything else. Hopefully, by the time we're done, you will feel like we have a chance to really help you with your problems. How does that sound?"
Expressions of empathy and support from the therapist for the patient's situation are essential during this session. The intake information is used to guide questions and express concern. The therapist can ask for clarification of any information on the intake materials as a means of further understanding the patient's problems and clearing up any ambiguities.
Therapists start this process by inquiring about drug and alcohol use and associated problems.
"I can see by looking over your paperwork that you have come to the right place. It looks like problems with cocaine use and to some extent alcohol use are the primary problems. Is that right? . . . Can you tell me a little bit about your cocaine use and how it led you to seek help today? . . . I see you had some treatment in the past. Was it helpful? . . . What did it involve? . . . What do you expect to get out of treatment this time around? . . . Are you optimistic about your chances for success? . . . Do you have any thoughts about what it will take to get you to stay clean? . . . Tell me a little about the pros and cons of your cocaine use. What are the positive aspects of using? What are the negative aspects?"
Next the therapist moves to a similar mode of interviewing regarding other problem areas.
"I see you do construction work. Is that full time? . . . How do you like it? . . . Are you satisfied with that type of work as a way of making a living?. . . Are there other types of jobs you are considering? . . . Does your current job pose any risks for using cocaine or drinking? . . . Do you use drugs with your coworkers? . . . Are you interested in finding another job or getting any additional training? . . . Do you have a timeframe in mind for when you might do that? . . .
"I see that you are married and have two children. How old are they? How are they doing in school? . . . Any problems or concerns with either of them? . . . Does you wife agree with you about that problem? . . . Have you tried anything to help with that? . . . How did it work? . . . How are you and your wife getting along? . . .That's too bad. It's pretty common for us to hear about those types of problems in this clinic. Is she willing to work with you on your cocaine problem? . . . If she is, we'd love to have her come in. I'll tell you about how that might work in a few minutes."
This type of questioning will promote a discussion and provide an opportunity for therapists and patients to exchange information relevant to treatment planning. Therapists can also assess the patients' general level of functioning, gain an initial understanding of their history, and assess their attitudes toward treatment.
Provide Overview and Rationale
After reviewing the intake material and touching on the specific problem areas, the therapist should explain the philosophy and goals of CRA + Vouchers. The overview should be phrased in a positive, confident manner and draw on the empirical support for this approach in the treatment of cocaine dependence. The therapist should describe how the treatment experience gives patients an opportunity to move their lives forward in a positive and fulfilling direction. The therapist should be upbeat and optimistic when presenting the overview. The overview includes the following.
"I'd like to tell you a little bit about the treatment you will be receiving. This treatment can provide you with skills others have found useful for overcoming cocaine abuse. Our main emphasis will be on -
- Getting you involved in new social and recreational activities.
- Beginning new employment or educational opportunities if you want.
- Helping you obtain more satisfaction from relationships with family and friends.
"We have learned that, for people to stop cocaine abuse, they must make significant changes in their lifestyle. Cocaine and other drug use can develop a very powerful control over a person's life. To stop using drugs and alcohol, people must have something equally powerful to look forward to that will fill their time. That is why our focus will be on helping you increase the satisfaction you get from things in your life that have nothing to do with drugs or alcohol. We believe that nondrug-related activities can compete against the powerful effects of cocaine use and the activities associated with its use.
"Our program also provides incentives for you to abstain from cocaine. I'll explain how that works in a few minutes. We will also focus on teaching you effective ways to avoid relapse and to turn down drugs when they are offered to you. We know that slips can occur while you are in treatment, but that is no excuse for quitting treatment. Ups and downs can be expected. However, we are not giving you permission to use."
"One important factor to keep in mind is that there are usually multiple causes of cocaine abuse. Some people say it is genetic, others say one's family or the stress of our society is the cause, others say it is like a disease, while still others say it is a learned habit that can be unlearned with practice. It actually doesn't matter how the problem got started. Once it exists, we must look at what needs to be done in the here and now to solve the problem. Whatever the causes, it doesn't help to blame anything or anyone. We have to focus all our attention and energy on the lifestyle changes that need to happen for you to stop using cocaine."
"We will help you to the very best of our ability. It will be hard for all of us and I expect some tough times. We will be there for you during the good and bad times; we will help you understand your cocaine abuse and help you develop alternative activities. However, nobody can change your life for you. We can and will try to assist you in every way we can, but you will have to do the work of changing your life."
Introduce the Voucher Program
Describe Abstinence Contract
After describing the treatment program, the therapist should answer any questions the patients may have and then introduce them to the notion of therapeutic contracts via an abstinence contract. This involves a written contract in which patients explicitly agree to abstain from cocaine use and to conform to a regular schedule of urinalysis testing. The rationale for this contract is based on the primary treatment goal of eliminating cocaine use. Exhibit 9 is an example of a contract adapted from one reported by Crowley (1984).
Explain Urinalysis Monitoring
Urinalysis monitoring is used as an objective marker of progress in achieving the goal of abstinence from cocaine. It is imperative that patients clearly understand the rationale for this procedure, and it is the responsibility of clinic staff to ensure that they understand. Below is a list of reasons for using a urinalysis monitoring contract. These are shared with patients.
- Urinalysis monitoring contracts have been used successfully to help decrease many forms of drug use, including cocaine, opioid, and benzodiazepine use.
- Urinalysis monitoring will help us stay focused on the primary problem that brought you into treatment. We are not trying to catch you being bad, but rather to catch you being good (i.e., not using cocaine). In this way, we as well as others in your life can reinforce this desired behavior. We can provide incentives, praise, and other forms of positive support when you don't use drugs. In addition, urinalysis monitoring will assist us in helping you learn more about the relationship between cocaine and other drug abuse and certain consequences.
- If you use cocaine during treatment, the urinalysis test will provide us with that information and an opportunity to work on ways to help you get back on track and prevent further use from occurring. Many times, patients do not want to share the fact that they used cocaine because of embarrassment, pride, or some other reason; however, such information is important for helping you learn more about how to meet your goal of stopping cocaine use.
- Many times, drug abusers have lost credibility with friends, relatives, and other persons in their lives by the time they arrive in treatment. Urinalysis monitoring can provide a way to prove that you are doing well. This may be important, because once you start doing well, any bad days or irritability may be perceived by others as an indication of relapse. Urinalysis monitoring can provide reassurance to those around you that you are continuing to do well. Thus, monitoring can assist you in regaining credibility with family and friends.
Explain Voucher Program
It is imperative that the therapist take adequate time to discuss the rationale and procedures related to the voucher system in the introductory session. The following issues should be covered.
"The purpose of this incentive system is to give you a positive reward for staying in treatment and achieving your goal of not using cocaine. It is also a way to increase your motivation to work hard on this goal and to support you as you work toward making some of the lifestyle changes important for increasing your life satisfaction and maintaining cocaine abstinence."
- Examples of how to use earnings.
"The points you earn can be used to pay for things like taking a person who does not use drugs to the movies or dinner but not to a bar or party. The points can be used to take classes or get training in some area that you would like to pursue as a career or hobby. The points can be used to pay to develop regular hobbies or activities like joining a gym, the YMCA, or dues for a photography or hiking club. They can also be used for family activities like taking a child for swimming lessons, to a State park, or to an amusement park. With the approval of your therapist, any activities that promote healthy behavior rather than drug use can be considered."
- How the points accumulate.
"The point system is designed to help you maintain periods of continuous cocaine abstinence. The points increase each time you provide a cocaine-free urine specimen. For example, the first clean urine specimen you provide is worth $2.50 in points, the second $3.75, and for each week with three consecutive cocaine-free samples, you will receive bonus points worth $10.00. Thus, if you were clean for 6 consecutive weeks, one clean sample provided during Week 7 would be worth $25.00. All in all, if you stay clean every week for your first 12 weeks in treatment and provide all urine specimens as scheduled, you will have $997.50 worth of points that can be spent.
"In this system, however, one cocaine use during the middle of treatment can cost you quite a few points/dollars. For example, if you are clean for 8 weeks and then, during Week 9, you use cocaine, instead of getting $32.50 for the next clean urine sample, you get only $2.50. And instead of the next clean urine sample being worth $33.75, it is only worth $3.75. You can see the system is designed to help you stay clean for long continuous periods. However, because we recognize that cocaine use during treatment may occur, there is also a procedure to encourage you to stop using if you do slip. If, following a slip, you provide five clean samples in a row, the value of your vouchers returns to the level of points you would have achieved before the slip."
Review Abstinence Contract
After answering any questions about urinalysis and vouchers, therapists can hand patients an abstinence contract and ask them to follow along as they read it aloud. Questions should be elicited from the patients, and therapists should provide as much explanation as necessary. It is essential that patients completely understand this contract, including the urine sample collection schedule, reinforcement schedule, and process of voucher spending.
After reviewing the abstinence contract, all patients are provided with two movie tickets or passes to some community recreational facility such as the YMCA or YWCA. These incentives serve as a start toward having the patient engage in lifestyle changes deemed important for treatment success. These passes are not contingent on a cocaine-negative urine specimen.
This procedure is called priming. It should be explained as an example of what can be done with the vouchers earned for cocaine abstinence. Therapists should also use this as an opportunity to have patients begin the process of planning and scheduling cocaine-free activities by discussing when and with whom they plan to use the passes.
Therapists should make sure patients receive the passes before leaving the clinic.
Next, therapists can switch the topic to the development of a treatment plan. The problem list (exhibit 10 and exhibit 11) can help organize the areas that will be worked on during treatment. Therapists should explain that the list focuses on seven areas of life functioning:
- Drug and alcohol use
- Employment and support status
- Family relationships
- Social and recreational functioning
- Psychological status
- Legal status
- Medical status
Data from the intake assessment can be used as a guide during this discussion. (If the ASI is used, it assesses each of these areas.) Therapists can elicit from patients the problems that they are experiencing in each area. After this discussion, most of the important problems should be identified. This information can then be used in developing the patients' treatment plans.
Practical Needs Assessment
Therapists should also review the information on the patients' Practical Needs Assessment forms, which focus on such areas as housing, childcare services, and transportation needs. Reviewing these areas with patients will follow naturally from the data on the problem list. Any significant problems that might impede treatment compliance or success should be targeted for intervention as soon as possible. For example, helping homeless patients find at least temporary shelter would be an immediate priority. If they do not have transportation or a ride to the treatment facility, transportation issues should be discussed.
Hopefully, therapists can initiate some problem solving and action as soon as these types of issues are identified.
"You say you live about 5 miles from the clinic and don't have a driver's license. Is there a bus route that goes near your home? . . . No . . . Can your wife drive you here regularly? . . . She doesn't have a license either. . . . Do you have friends or relatives who drive who are not active drug users? . . . Your sister? Can she give you a ride? Why don't we call her up and check it out? . . . It's possible that if she can drive 2 days a week, maybe we can help you with a ride on the other day. What do you need to do to get back your driver's license? Have you filled out the reinstatement application? . . . Why don't we call the DMV now and have them send us an application? If we can figure out how to come up with $50.00, we could get you back your license as soon as next week."
Assisting patients very early with problems like these can help tremendously with treatment compliance in general. This type of aid also gives therapists credibility as people who understand patients' basic needs and can help make things happen to change their lives.
Patients should be given a pocket-sized daily appointment book, and the importance of scheduling activities and appointments should be discussed. The rationale provided to the patient is that the goal of the program is to develop new habits that include regularly scheduled activities that are not related to drugs. Planning and scheduling those activities is the best way to develop new habits.
Therapists should also stress the importance of bringing the appointment book to the clinic for each therapy session. It can be a valuable tool in helping patients stay focused on the behavior changes that are the core of CRA + Vouchers. Therapists should continually emphasize this point and prompt patients to bring it to all sessions.
If patients are involved in a relationship with a partner, discuss the possibility of relationship counseling and its potential benefits. A brief description of the content and structure of the counseling should be provided. If patients agree, schedule an appointment for the first relationship counseling session. If partners have come to the clinic for this initial session, therapists should discuss with them their potential role in treatment and the benefits of participation.
Disulfiram Procedures (if applicable)
Those patients who show evidence of alcohol abuse or dependence, or who report that alcohol use interferes with cocaine abstinence, should be offered disulfiram therapy. For example:
"You have indicated a few times today that your drinking causes you problems and that you always use cocaine when you drink. This is a fairly common experience among our patients. Because of this relationship between cocaine and alcohol, we feel that it is very useful and sometimes necessary for people with cocaine problems to stop drinking. Staying free from alcohol allows you to have a clear head, which you will need to resolve the difficult problems of stopping cocaine use. Many times, if someone doesn't stop drinking, they find that even though they have good intentions of staying clean from cocaine, they fail. Once they have a few drinks, their plans go right out the window and they use cocaine."
"We have found that an effective way to help people stop drinking is by using a medication called disulfiram. Have you heard of it? . . . We find that those patients who take disulfiram are much more likely to achieve their goal of cocaine abstinence."
Try to get patients who need this medication started on disulfiram in a timely manner.
The therapist should make sure that a urine sample has been collected before the patient leaves the clinic.
Schedule the Next Session
Before the patient leaves the clinic, the therapist should schedule the next session. Every effort should be made to hold the meeting as soon as possible. The next day is preferable.