Chapter 1 - Introduction
This manual is intended as a guide for the individual treatment of cocaine addiction by addiction counselors. The counseling model described here was developed originally for use in the Collaborative Cocaine Treatment Study (Mercer and Woody 1992) sponsored by the National Institute on Drug Abuse. This model was based on the counseling in the outpatient, drug-free program in the Addiction Recovery Unit and in the methadone maintenance program (Woody et al. 1977), which are both part of the Veterans Affairs Medical Center. Twelve-step philosophy and participation is a central component of the model. Additionally, we have drawn upon the ideas of many clinicians and theorists in this area, including Alan Marlatt (Marlatt and Gordon 1985), Terrence Gorski (Gorski and Miller 1982), Dennis Daley (1986, 1988, 1993), and Arnold Washton (1990a, 1990b, 1990c).
This individual counseling model can be viewed as a component within a comprehensive outpatient treatment program for cocaine addiction. Alternatively, the model can be offered independently of other treatments, and referrals can be made for any additional services as needed.
The Collaborative Cocaine Treatment Study (Crits-Christoph et al. 1997) was a large study carried out at four sites in the northeastern United States that investigated the relative efficacy of four psychosocial treatments for cocaine addiction. The individual drug counseling model presented in this manual was developed for use in the study protocol.
Four hundred and eighty-seven cocaine-addicted adults were randomly assigned to individual drug counseling (IDC) plus group drug counseling (GDC), cognitive therapy (CT) plus GDC, supportive-expressive psychodynamic therapy (SE) plus GDC, or GDC alone (Crits-Christoph et al. 1997). Individual treatment sessions were offered twice weekly for 3 months, then once weekly for 3 months. Group sessions were once a week for 6 months. Results showed that patients in all treatment conditions reduced their cocaine use significantly; however, patients in IDC reduced their cocaine use more and did so more rapidly than those in the other conditions (Crits-Christoph et al. in press).
According to the philosophy underlying the IDC approach, addiction is a complex disease that damages the addict physically, mentally, and spiritually. Because of the holistic nature of the illness, the optimal treatment addresses the needs of the addict in many areas. Physical, emotional, spiritual, and interpersonal needs must all be addressed to support recovery.
The philosophy of this approach incorporates two important elements: endorsement of the disease model and the spiritual dimension of recovery. These elements differentiate the approach from some other forms of treatment currently in use and reflect the influence of the 12-step philosophy.
The disease model essentially states that addiction is more closely akin to an illness over which one has little, if any, control, compared to a behavior that one chooses to enact. Recent biologically oriented research suggests a genetic component to alcohol and other addictions and points to physiological changes in the brain that result from drug use. These findings are very consistent with the disease model (Bloom 1992; Heinz et al. 1998).
The element of spirituality is very general and not specific to any religion. Three of the main spiritual principles, as taken from Narcotics Anonymous (NA) philosophy, are honesty, openmindedness, and willingness. This spiritual component implies that there is a healing of one's life that needs to take place, and abstinence from the drug is merely the first step rather than the terminal goal. A holistic perspective on the individual is encouraged, which suggests that recovery involves a return to self-respect through honesty with oneself and others. Spirituality also involves a belief in or sense of connection to something greater than oneself, which is quite consistent with some of the newer models of psychotherapy. However, within addiction counseling, the role of spirituality in healing tends to be more focused and overtly stated than in most other therapeutic orientations.
Contributions of the 12-Step Approach
Numerous authors (e.g., Galanter and Pattison 1984; Washton 1989) have suggested that 12-step groups play an important role in addiction treatment. Historically, 12-step treatment programs are linked largely to recovery from alcohol abuse and addiction, which is a logical association. Since its inception in 1935, more than 1 million persons are estimated to have achieved recovery through involvement in Alcoholics Anonymous (AA) programs. Additionally, it is estimated that, at any one time, more than 100,000 men and women worldwide are involved in AA 12-step programs (AA World Services, Inc. 1986).
However, neither the 12-step philosophy nor its procedures are related intrinsically to alcohol. AA has spawned many related programs for recovery from other addictions or other emotional problems. Narcotics Anonymous is a 12-step program adapted from AA. The primary difference between the two is that NA is more inclusive with respect to addiction to any mood-altering substance. Cocaine Anonymous (CA) is a smaller group geared specifically to cocaine addiction, as the name implies. NA and CA, like the many other 12-step programs AA has spawned, adhere to the same philosophy and beliefs as AA. The underlying belief is that most aspects of chemical addiction are transcendent rather than specific to any particular drug.
Twelve-step ideology offers patients seeking recovery a new modus vivendi, or way of living, that will support them in breaking the cycle of addiction and in maintaining abstinence. The strengths and usefulness of the 12-step approach seem to have several sources. Procedurally, virtually any presenting situation can be dealt with effectively by applying the appropriate lesson or lessons derived from the more than 60 years of honing and refining the 12-step philosophy.
Essentially, these steps provide a developmental approach for recovering from addiction. The steps are organized in an order, going from the most basic changes onward to the more advanced changes that individuals motivated to recover may seek to integrate into their life. Narratives of others who are struggling with addiction offer compelling perspectives to support the individual seeking recovery. These narratives help addicts to confront the reality of their addiction and recognize the harm it has done to them personally and to the people they care about. The approach also asks addicts to recognize the existence of a higher power and to incorporate this belief in their own lives, if only for the reason that it has been shown to be helpful in aiding recovery (Galanter and Pattison 1984).
Role of Self-Help Groups
Participation in a self-help program is probably not for everyone but for many is an extremely valuable aid to recovery. Such participation helps recovering individuals to develop a social support network outside of their treatment program, teaches the skills needed to recover, and helps patients to take responsibility for their own recovery. Participation in a group provides a sense of belonging and can lead to a new identity for individuals whose primary identity has been as an alcoholic or drug addict.
In the Collaborative Cocaine study, we studied pretreatment self-help group attendance to see if it would predict initiation of abstinence in 519 cocaine-addicted patients entering treatment (Weiss et al. 1996). Of the 519 respondents, 34 percent indicated that they had attended at least one 12-step meeting in the past week. Of those who attended, 85 percent actively participated in program activities in some way, such as reading 12-step literature, meeting with one's sponsor, or speaking at a meeting. We found that 51 percent of self-help attendees initiated abstinence, compared to 40 percent of nonattendees, a significant difference. Furthermore, active participation appears to be more helpful than merely attending meetings: 55 percent of active participants became abstinent, compared to 38 percent of attendees who did not actively participate and 40 percent of nonattendees. AA and NA were the most frequently attended self-help groups, which may be because they are more widely available than CA and some of the other 12-step organizations.
In addition to encouraging patients to attend self-help groups at least three times a week and to get a sponsor, the addiction counseling program educates patients about 12-step ideology and incorporates many of the 12-step concepts into the content of the counseling. By introducing and promoting many of the 12-step concepts, the program exposes the ideas to patients who are unwilling to participate in meetings at that juncture. Addressed within the content of the counseling sessions are such concepts as breaking through denial; avoiding people, places, and things that can trigger drug craving; taking a personal inventory; working on character defects; and incorporating spirituality as an element of recovery.
Regarding 12-step versus other types of programs, participation in any legitimate self-help program should be encouraged. Patients may gravitate toward a variety of non-12-step-based self-help groups, such as Rational Recovery, Women for Sobriety, or individual religious groups, depending upon their individual preferences. The selection is limited primarily by what is available locally. However, the 12-step approach to recovery is generally more well known, and such groups are more widely available than other approaches. For mainly this reason, it has been an integral part of many addicts' recovery. Thus, we focus more on 12-step programs than on other groups and draw from this approach in the counseling itself.
Role of Significant Others in Treatment
This model of addiction counseling does not focus much attention on the role of family members in treatment. The reason is not because family involvement is seen as unimportant in treatment, but rather because IDC is not intended to provide all-inclusive treatment. Family members can play an important role in recovery.
In general, including partners, family members, and even close friends in addiction treatment, e.g., in the form of holding family sessions, can facilitate recovery. Encouraging family involvement can help the recovering person create a better, more knowledgeable support network (Galanter 1986). It may decrease the family's addiction-enabling and/or codependent behaviors that tend to impede the patient's recovery. And it will make it easier for the counselor to intervene in any problematic family situations that might potentiate a relapse.