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C O G N I T I V E T H E R A P Y O F S U B S T A N C E A B U S E -•̂ .̂ '̂ ySi:'yf̂ '̂ ''->->*' 'r... ^'i-'Mt .#''a^K"'-M>' • M ^ i € • ̂ ^. M'^::. A A R O N T . B E C K • ^ • r f - F R E D D . W R I G H T C O R Y F . N E W H A N B R U C E S . L I E S E C O G N I T I V E T H E R A P Y O F S U B S T A N C E A B U S E C o g n i t i v e T h e r a p y o f S u b s t a n c e A b u s e Aaron T. Beck, M.D. Fred D. Wright, Ed.D. Cory F. N e w m a n , Ph.D. Bruce S. Liese, Ph.D. T H E G U I L F O R D PRESS N e w York London ©1993 The Guilford Press A Division of Guilford PubHcations, Inc. 72 Spring Street, New York, N Y 10012 www.guilford.com All rights reserved No part of this book may be reproduced, stored in a retrieval s or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America. This book is printed on acid-free paper. Last digit is print number: 9 Library of Congress Cataloging-in-Publication Data Cognitive therapy of substance abuse / Aaron T. Beck . . [et al p. cm. Includes bibliographical references and index. ISBN 0-89862-115-1 (he.) ISBN 1-57230-659-9 (pbk.) 1. Substance Abuse—Treatment. 2. Cognitive therapy. I. Beck, Aaron T. [DNLM: 1. Cognitive therapy—methods. 2. Substance Abuse— therapy. W M 270 C6765 1993] RC564.C623 1993 616.86'0651—dc20 DNLM/DLC for Library of Congress 93-5208 CIP To Phyllis, G w e n , Jane, and Ziana P r e f a c e s L-#ubstance abuse is widely recognized as a serious social and legal problem. In fact, the use of illegal drugs may be responsible for more than 2 5 % of property crimes and 1 5 % of violent crimes. Financial losses related to these crimes have been estimated at $1.7 billion per year. Homicides are also strongly linked to drug dealing. Approximately 1 4 % of homicides per year are causally related to drugs. The costs for criminal justice activities directed against drug trafficking on the federal level were approximately $2.5 billion in 1988, compared to $1.76 billion spent in 1986. There are also many health problems caused by these drugs. Alcohol can damage almost every body organ, including the heart, brain, liver, and stomach. Illegal drugs such as cocaine can have a serious effect on the neurological, cardiovascular, and respiratory systems. Cigarettes can cause cancer, heart disease, and more. The most widely used and abused drug in the world is alcohol. In the United States, two-thirds of the population drink alcohol. About ten out of a hundred people have problems with alcohol so serious that they can be considered "alcoholic" or "alcohol-dependent." (Interestingly, this 1 0 % of Americans buys and drinks more than half of the alcoholic beverages!) At least 14 million Americans take illegal drugs every month. Dur ing "peak months" this number climbs to more than 25 million users. Some experts have estimated that approximately 2.3% of Americans over 12 years of age have a problem with illegal drugs serious enough to warrant drug treatment. To a large degree, we have tried to put a halt to drug abuse by making drugs illegal. For example, heroin and cocaine are presently illegal in the United States. Cigarette smoking is becoming increas ingly proscribed. At one time we tried to stop alcoholism by legal Vll via Preface mechanisms (i.e., prohibition). Obviously, these methods will never make substances completely unavailable. Not all people who use drugs become addicted to them, although many people have asked themselves, "Am I [or is someone else] an alcoholic [or a substance abuser]?" The American Psychiatric Associ ation has defined the addictions very specifically. In fact, the official term for an addiction is "substance dependence." There are some specific signs of substance dependence, including (1) heavy use of the substance, (2) continued use even though it may cause problems to the person, (3) tolerance, and (4) withdrawal symptoms. Cultural and historical factors are implicated in substance use and abuse. The patterns and consequences of drug use have been influ enced by historical developments, which have had positive and neg ative effects. Two centuries ago, the extraction of pure chemicals from plant materials created more powerful medicinal agents. The inven tion of the hypodermic needle in the middle of the nineteenth cen tury was also a medical boon, which, on the other hand, allowed drug users to circumvent the body's natural biological controls consisting of bitter taste and slow absorption through the digestive tract. Many synthetic drugs developed in the twentieth century had medical appli cation but created further opportunities for abuse and addiction. In short, any activity that affects the reward mechanisms of the brain may lead to compulsive, self-defeating behavior. Social, environmental, and personality factors have affected sub stance use and abuse in ways that go far beyond the simple pharma cological properties of these agents. Alcoholism, for example, is preva lent among certain ethnic groups and practically absent among others, such as the Mormons, who require abstinence for group acceptance. O n the other hand, other social subgroups may condition group accep tance on using or drinking. The social milieu may influence using. Soldiers used illegal drugs extensively in Vietnam but, for the most part, relinquished heavy drug use after returning home. Impoverished environments have been shown in both animal experiments and human studies to lead to addiction. As pointed out by Peele, the com m o n denominator is the lack of other opportunities for satisfaction. Finally, our clinical experiences have indicated that addicted indi viduals have certain clusters of addictive attitudes that make them abusers rather than users. Successful treatment depends on clinicians' effectiveness in deal ing with these addictive potentials. And what form will this care take? As pointed out by Marc Galanter, president of the American Academy of Psychiatrists in Alcoholism and Addiction, the long-term efficacy of new pharmacological treatments is open to question. "Tricyclics, Preface ix dopaminergic agents, and carbamazapine for cocaine abusers have yet to be substantiated as a vehicle for continuing care. For opiates, naltrexone and buprenorphine offer only a modest niche in the do main that was traditionally occupied by methadone maintenance. Intervention in GABAergic transmission may hold promise for alco- hoHsm, but that promise is far from clinical application" (Galanter, 1993, pp. 1-2). W e have written this book in response to the ever-growing need to formulate and test cost-effective treatments for substance abuse dis orders, problems that seem to be multiplying in the population in spite of society's best efforts at international interdiction and domes tic control and education. W e believe that cognitive therapy, a well- documented and demonstrably efficacious treatment model, can be a major boon to meeting this pressing need. At one time, "drug abuse rehabilitation counseling" was regarded as a specialty area in the field of psychotherapy—now it is apparent that almost all who engage in clinical practice will encounter patients who use and abuse drugs. Therefore, it would be desirable for all mental health professionals to receive some sort of routine training and education in the social and psychological phenomena that com prise the addiction disorders. Our volume is intended to provide a thorough, detailed set of methods that can be of immediate use to therapists and counselors—regardless of the amount of experience they might have had with cognitive therapy, or in the field of addictions. Toward this end, we have strived to make our model and our proce dures as specific and complete as possible. W e certainly recommend that those who read this book also read the many valuable sources we have cited in the text. Nevertheless, our intention in writing Cog nitive Therapy of Substance Abuse has been to provide a convenient, centralized source that is comprehensive, teachable, and testable. Although advances in the field have been made in the form of pharmacological interventions (e.g., antabuse, methadone, and nal trexone), 12-step support groups (e.g.. Alcoholics Anonymous, Nar cotics Anonymous, and Cocaine Anonymous), and social-learning models and programs (relapse prevention, rational recovery, etc.), each of these approaches has posed problems that limit its respective poten tial efficacy. For example, pharmacological interventions have pro duced promising short-term data but are fraught with compliance and long-term maintenance difficultieŝ atients may not take their chem ical agonists and antagonists, and they are prone to relapse when the medications are discontinued. Twelve-step programs provide valuable social support and consistent guidance principles for individuals who voluntarily join and faithfully attend the program meetings, but can- X Preface not address the needs of those who will not enter the programs or who drop out. Social-learning approaches provide sophisticated models of substance abuse and relapse, and hold promise to produce and accumulate empirical data, but thus far the resultant treatments (with very few exceptions) have been less well described than the theories that gave rise to them. Although the cognitive approach that we have explicated is most closely related to the social-learning theories of substance abuse, we want to emphasize that we find value in all of the aforementioned treatment modalities. Cognitive therapy is not in "opposition" to 12- step or psychobiological models of substance abuse. W e have found that these alternative treatment systems may be complementary to our procedures. Many of the substance abuse patients that we treat at the Center for Cognitive Therapy concurrently attend Narcotics Anony mous and similar 12-step groups. Other patients take the full spec trum of pharmacologic agents, from antidepressants to antabuse, under strict medical guidance. The individualized conceptualization of patients' belief systems and the long-term coping skills (to deal with everyday life concerns, as well as to manage cravings and urges spe cific to drug use) that cognitive therapy provides for patients can mesh well with medication and 12-step meetings. The main variable that seems to influence whether or not patients avail themselves of all of these treatment opportunities (once they have been presented to the patients in a feasible manner) is not the practical compatibility of the treatments, but rather the attitudes of the treatment providers] At present, an earlier draft of this book is serving as a treatment manual in a National Institute on Drug Abuse collaborative, multisite study on the respective efficacy of cognitive therapy, supportive- expressive therapy, and general drug counseling. Data obtained from this project will help us to answer two important questions: (1) Does Cognitive Therapy of Substance Abuse succeed as a manual for the train ing of competent cognitive therapists for patients with addictions? and (2) Do patients who receive the treatment outlined in the text make demonstrable and lasting gains? In order to answer these questions, therapists are provided with intensive supervision (note: the authors of this text serve in that role), complete with competency and adher ence ratings on a regular basis; treatment is not confounded with adjunct medications, urinalyses are routinely conducted, and a host of measures other than drug monitoring per se are being administered and evaluated (to examine changes in mood and global adaptational functioning). Drug abuse is a sociological problem as well as a psychological issue. Factors such as poverty and lack of adequate educational and Preface xi vocational opportunities play a role in the epidemic. However, we believe that it is harmful to assume that low socioeconomic status patients cannot be treated as effectively as those of higher socioeco nomic status. While social change is desirable, individual change is not necessarily dependent on it. W e are optimistic that cognitive ther apy can serve as an important individual-focused treatment in today's society, and that the data will support this. A c k n o |
w l e d g m e n t s w w e would like to offer our thanks to our highly esteemed colleagues in the field of substance abuse treatment and research, Drs. Dan Baker, Lino Covi, Tom Horvath, Jerome Piatt, Hal Urschel, David Wilson, and Emmett Velten, for their extremely help ful insights and suggestions on earlier versions of this manuscript. Special thanks are due Dr. Kevin Kuehlwein, an important member of our own cognitive therapy team in Philadelphia, for his thorough evaluations and editorial work on many of the chapters in this book. The input of all of the above has been invaluable during the course of this project. W e would also like to offer our thanks and apprecia tion to Tina Inforzato, who did yeoman work in typing this volume, and its many revisions. Without her tireless efforts, this volume would still be "on the drawing board." Xll C o n t e n t s CHAPTER 1 Overview of Substance Abuse 1 CHAPTER 2 Cognitive Model of Addiction 22 CHAPTER 3 Theory and Therapy of Addiction 42 CHAPTER 4 The Therapeutic Relationship and Its Problems 54 CHAPTER 5 Formulation of the Case 80 CHAPTER 6 Structure of the Therapy Session 97 CHAPTER 7 Educating Patients in the Cognitive Model 112 CHAPTER 8 Setting Goals 121 CHAPTER 9 Techniques of Cognitive Therapy 135 CHAPTER 10 Dealing with Craving/Urges 157 CHAPTER 11 Focus on Beliefs 169 CHAPTER 12 Managing General Life Problems 187 CHAPTER 13 Crisis Intervention 211 CHAPTER 14 Therapy of Depression in Addicted Individuals 226 CHAPTER 15 Anger and Anxiety 242 CHAPTER 16 Concomitant Personality Disorders 268 CHAPTER 17 Relapse Prevention in the Cognitive Therapy 292 of Substance Abuse Append ixes 311 References 331 Index 347 xm C H A P T E R 1 O v e r v i e w o f S u b s t a n c e A b u s e T .he fabric of America is profoundly affected by problems of subsAtahnc(e abuse. They are problems that directly affect those millions of Americans who suffer from substance abuse and indirectly touch the lives of millions more in the larger social and vocational networks around them. One in every ten adults in this country has a serious alcohol problem (Institute of Medicine [lOM], 1987) and at least one in four is addicted to nicotine (Centers for Disease Control [CDC], 1991a). Approximately 1 in 35 Americans over the age of 12 abuses illicit drugs (lOM, 1990a). This level of substance abuse has profound social, medical, and psychological ramifications on both the individual and the larger societal levels. The C D C (1991b), for example, estimate that approximately 434,000 people in this coun try die each year as a result of cigarette smoking, and many thou sands also die as a result of alcoholism (lOM, 1987) and/or illicit drug abuse (lOM, 1990a). It must be emphasized, however, that substance abuse spans many more areas and the toll taken is far greater than these simple mortality figures convey. In this introductory chapter we set the stage for the cognitive therapy of substance abuse. W e begin with an overview of psycho-v active substances and substance abuse, we briefly review the history of psychoactive substance use, we describe the most commonly used and abused psychoactive substances, we discuss cognitive models for understanding substance abuse and relapse, and we scan traditional methods for treating substance abuse. 2 COGNITIVE THERAPY OF SUBSTANCE ABUSE BACKGROUND: PSYCHOACTIVE SUBSTANCES AND SUBSTANCE ABUSE Psychoactive substances are chemicals that affect the central nervous system, altering the user's thoughts, moods, and/or behaviors. The revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-lIl-R; American Psychiatric Associa tion [APA], 1987) categorizes psychoactive substances into 10 classes: alcohol; amphetamines or similarly acting sympathomimetics; can nabis; cocaine; hallucinogens; inhalants; nicotine; opioids; phencycli- dine (PCP) or similarly acting arylcyclohexylamines; and sedatives, hypnotics, or anxiolytics. Each of these substances has unique prop erties and effects. Some substances that are abused have low addic tive potential (e.g., hallucinogens), while others have high addictive potential (e.g., crack cocaine). Some are typically smoked (e.g., nico tine, cannabis, and crack cocaine); others are ingested orally (e.g., hallucinogens and sedatives); while still others are taken intranasally (e.g., powdered cocaine and inhalants). Some drugs lead the user to feel "up" or energized (e.g., amphetamines and cocaine); some cause the user to feel "down" or relaxed (e.g., sedatives, hypnotics, and anxiolytics); while others (e.g, alcohol and nicotine) simultaneously have both effects on the user. DSM-III-R distinguishes between substance abuse and dependence. Abuse is defined as a maladaptive pattern of psychoactive substance use while dependence (considered more serious than abuse) is defined as "impaired control of use" (i.e., physiological addiction). In this volume, we do not go to great lengths to emphasize this distinction. Instead, we view any pattern of psychoactive substance use as prob lematic and requiring intervention if it results in adverse social, voca tional, legal, medical, or interpersonal consequences, regardless of whether the abuser experiences physiological tolerance or withdrawal. Further, although we caution against an all-or-none view of addic tion and recovery, and although we acknowledge that some patients seem to be more successful at engaging in controlled, moderate sub stance use than are others, we advocate a program of treatment that strives for abstinence. In this manner we maximize the patients' chances of maintaining an able and responsible lifestyle, reduce the risk of relapse, and avoid giving patients the false impression that we view a mere reduction in drug use as the optimal outcome. History of Psychoactive Substance Use Psychoactive substances have been used by most cul tures since prehistoric times (Westermeyer, 1991). In fact, for centuries Overview 3 psychoactive substances have served many individual and social func tions. O n an individual level, they have provided stimulation, relief from adverse emotional states and uncomfortable physical symptoms, and altered states of consciousness. O n a social level, psychoactive substances have facilitated religious rituals, ceremonies, and medical functions. Egyptian and Chinese opiate use was evident from the earliest writings of these people (Westermeyer, 1991). Marijuana was referenced in India "as far back as the second millennium B.C." (Brecher, 1972, p. 397). Evidence of Mayan, Aztec, and Incan medici nal and ritual drug use was evident from their statues and from draw ings on their buildings and pottery (Karan, Haller, & SchnoU, 1991; Westermeyer, 1991). Alcohol use goes back to paleolithic times (Good win, 1981) and Mesopotamian civilization gave one of the earliest clinical descriptions of intoxication and hangover cures. In modern times the World Health Organization (WHO) has been concerned about drug and alcohol abuse problems on a worldwide scale (Grant, 1986). As early as 1968 the W H O conducted an interna tional study of drug use in youth (Cameron, 1968), and in a more recent study (Smart, Murray, & Arif, 1988) drug abuse and preven tion programs in 29 countries were reviewed. However, Smart and his colleagues concluded from their review that "the seriousness of the drug problem is well recognized in some countries but not in oth ers" (p. 16). Presently the W H O is addressing the issue of alcohol- related problems by developing an international secondary preven tion protocol (Babor, Korner, Wilber, & Good, 1987). Drug policies in the United States have been profoundly affected by historical and sociocultural attitudes regarding psychoactive drugs on a spectrum from less restrictive (e.g., libertarian) to more restrictive (i.e., criminal). Between the late 1700s and the late 1800s, for example, psychoactive dnigs (especially narcotics) were widely used in the United States. In fact, Musto (1991) reported that opium and cocaine were legally available during this time from "the local dmggist." A Consumers Union report (Brecher, 1972) described the nineteenth century as "a dope fiend's paradise" due to such minimal restrictions. In the late 1800s and the early 1900s, medical conceptualizations of addiction began to develop, however, influenced to some extent by Dr. Benjamin Rush's (1790) ear lier interest in the course of addictions. Magnus Huss, a Swedish physi cian, first used the term "alcoholism" in 1849 (lOM, 1990b). At the same time (late 1800s and early 1900s), criminalization of drug use was m- creasingly becoming U.S. policy. In the 1960s and 1970s, however, atti tudes about drugs became less restrictive as U.S. sociopolitical attitudes generally became more liberal. Simultaneously, the disease model of addictions was gaining widespread acceptance, partly due to the work ofjellinek(1960). 4 COGNITIVE THERAPY OF SUBSTANCE ABUSE Since the 1980s, the United States has again become less toler ant and more restrictive about drugs. At least two explanations can account for this phenomenon: (1) The negative effects of drugs on individuals, families, and society have become more apparent with increased use, and (2) sociopolitical attitudes in the United States generally have become more conservative. At the same time, however, there is increasing controversy about the disease model of addiction ("Current Disease model," 1992; Fingarette, 1988; Peele & Brodsky, with Arnold, 1991) and the criminalization of psychoactive substances (R. L. Miller, 1991). The Most Commonly Used Drugs Alcohol Alcohol is simultaneously a chemical, a beverage, and a drug that "powerfully modifies the functioning of the nervous sys tem" (Levin, 1990, p. 1). Approximately 1 0 % of Americans in the United States have a serious drinking problem; 6 0 % are light to mod erate drinkers; and the remaining 3 0 % of adults in the United States do not consume any alcohol. Alcohol abuse, however, accounts for approximately 8 1 % of hospitalizations for substance abuse disorders (lOM, 1987). Remarkably, half the alcohol consumed in this country is consumed by the 1 0 % who are heavy drinkers. A larger percentage of men than women drink and a greater percentage of men than women are heavy drinkers. Alcohol initially acts as a general anesthetic, interfering with subtle functions of thought, reason, and judgment (Miller & Munoz, 1976). As blood alcohol concentration (BAC) increases, however, the effects become more intense until gross motor functioning is also affected. At still higher BAC levels, sleep is induced, and ultimately death may occur as a result of respiratory depression. "Alcohol affects almost every organ system in the body either directly or indirectly" (National Institute of Alcohol Abuse and Alco holism [NIAAA], 1990, p. 107). Thus with chronic use, alcohol can cause serious multiple medical problems, including damage to the liver, pancreas, gastrointestinal tract, cardiovascular system, immune system, endocrine system, and nervous system. Alcohol has also been strongly linked to the leading causes of accidental death in the United States: motor vehicle accident, falls, and fire-related injuries. Further more, approximately 3 0 % of suicides and half of all homicides are alcohol related (lOM, 1987), and estimates of annual deaths related to alcohol use range between 69,000 and 200,000 per year (lOM, Overview 5 1987). In addition, a significant percentage of both violent and non violent crimes are committed under the influence of alcohol (cf. McCord, 1992). Chronic alcohol use can also have other profound negative social consequences, including loss of career, friends, and family. A great deal of physical and sexual abuse, for example, is related to the intoxicated state of the offender (Clayton, 1992; Frances & Miller, 1991; Harstone & Hansen, 1984), and general family dys function often is associated with the alcoholism of one or more adult members (Heath & Stanton, 1991). Medical complications can even reach insidiously into the next generation, in that maternal drinking during pregnancy can cause fetal alcohol syndrome and other seri ous birth defects. In fact, "prenatal alcohol exposure is one of the leading known causes of mental retardation in the western world" (NIAAA, 1990, p. 139). Illicit Drugs According to the lOM (1990a), at least 14 million persons consume illicit drugs monthly. During peak months this fig ures climbs to more than 25 million users. It is estimated that approxi mately 2.3% of the U.S. population over 12 years old has an illicit drug problem sufficiently serious to warrant treatment. This statistic is substantially higher, however, for individuals who are incarcerated (33%) or on parole or probation (25%). W h e n these people are included in the epidemiologic data, the estimate of illicit drug use problems in the overall population increases to 2.7%. Regarding |
the social costs of illicit drug abuse, it is estimated that more than 2 5 % of property crimes and 1 5 % of violent crimes are related to illicit drug use by the criminal. Financial losses related to these crimes have been estimated at $1.7 billion per year. Homicides are also strongly linked to activities surrounding drug dealing. Approx imately 1 4 % of homicides per year are causally related to drugs. The costs for criminal justice activities directed against drug trafficking on the federal level were approximately $2.5 billion in 1988, com pared to $1.76 billion spent in 1986. In the following sections we present brief descriptions of the three most commonly used illicit drugs: marijuana, cocaine, and the opioids. In 1972, a Consumers Union report identified marijuana as the fourth most popular psychoactive drug in the world, after caffeine, nicotine, and alcohol (Brecher, 1972, p. 402). Although marijuanas use has declined since its peak in 1979, it still remains the most widely used illicit drug in Western society (APA, 1987; Weiss & Millman, 1991). 6 COGNITIVE THERAPY OF SUBSTANCE ABUSE Marijuana is typically smoked, although it can also be ingested. According to Weiss and Millman (1991), in spite of its generally sedat ing effects, marijuana's psychoactive effects in the user are quite varied, "profoundly dependent upon the personality of the user, his or her expectation, and the setting" (p. 160). The health effects of marijuana have been widely debated and remain quite controversial, probably due to the inconsistent effects of the drug on the individual user and across different users. For some time marijuana was considered relatively safe and nonaddictive (Brecher, 1972). Presently, however, it is associated with multiple adverse physical and psychological effects, including labile affect and depression, amotivational syndrome, impaired short-term memory, and pulmonary disease (Weiss & Millman, 1991). According to DSM- III-R, marijuana dependence is characterized by heavy use of the drug (e.g., daily) with substantial impairment. Marijuana dependence also puts one at risk for other psychological problems, as those who are dependent on cannabis are also likely polysubstance abusers or afflicted with other psychiatric disorders (APA, 1987; Weiss & Millman, 1991). Cocaine is a major central nervous system stimulant that produces euphoria, alertness, and a sense of well-being. It may also lower anxi ety and social inhibitions while increasing energy, self-esteem, and sexuality. Presently cocaine is among the most widely used illicit drugs. In fact, cocaine use increased in 1991, "despite the Bush adminis tration's three-year war against drugs" (Mental Health Report, 1992, p. 5). Clearly, for many people the positive short-term physiological and psychological effects of cocaine maladaptively supersede the dan gers associated with acquiring and using the drug. According to Gawin and EUinwood (1988), "The pursuit of this direct, pharmacologically based euphoria becomes so dominant that the user is apt to ignore signs of mounting personal disaster" (p. 1174). Cocaine is an alkaloid (as are caffeine and nicotine) which is extracted from the coca leaf. In its pure form, raw coca leaves can be chewed, although this practice is generally limited to native popula tions in the cocaine-producing countries (APA, 1987). In the United States, cocaine is most commonly taken intrana sally (i.e., snorted or "tooted") in the powder form of cocaine hydro chloride. In this form, the user pours the powder on a hard surface and then arranges it into "lines," one of which is snorted into each nostril (Karan et al., 1991). In powdered form, cocaine hydrochloride can also be mixed with water and administered by intravenous injec tion. This process is known as "shooting" or "mainlining" (Karan et al., 1991). Intravenous injection of cocaine results in intense sub jective and physiologic effects within 30 seconds Oones, 1987). Overview 7 Cocaine can also be smoked as a paste or in alkaloid form (i.e., "freebased"). In this form it also produces its effects within seconds. Crack cocaine (named for the sound made by the cocaine as it is freebased) is the currently popular form of freebase which is sold in relatively inexpensive, prepackaged, and ready-to-use small doses (Karan et al., 1991). According to Karan et al. (1991), low-cost crack, approximately $2-$ 10 per vial, "has been widely available on the streets in many American cities since 1985" (p. 125), making it easily within the financial grasp of most teenagers and even the impover ished. Adding to this high availability is the especially troublesome fact that crack cocaine produces an enormously intense and almost instant high. Crack cocaine is, therefore, extremely addictive, lead ing to significant impairment in life functioning after only a few weeks' use on average (Gawin & EUinwood, 1988; Smart, 1991), much faster than, for example, intranasal usage of cocaine. These charac teristics of crack cocaine make it especially prone to rapid increase in the prevalence of its abuse. Indeed, many observers suggest that cocaine use has already reached epidemic levels (Weinstein, Gottheil, & Sterling, 1992). In the popular press, for example, a graphic biographical Reader's Digest article describes cocaine as "the devil within" (Ola & D'Aulaire, 1991). This contrasts starkly with the glorification of cocaine in movies and songs of the 1970s and early 1980s, when cocaine was seen as the drug of choice of the affluent and powerful. In the scientific litera ture, Gawin and EUinwood (1988) explain that "believing that the drug was safe, millions of people tried cocaine, and cocaine abuse exploded" (p. 1173). These authors report that 1 5 % of Americans have tried cocaine, and 3 million people had abused cocaine regularly by 1986, resulting in "more than five times the number addicted to heroin" (p. 1173). Smart and Adlaf (1990) report also that an increasing num ber of cocaine abusers have sought treatment since the 1980s. Cohen (1991) attributes the "cocaine outbreak" to supply factors (e.g., low cost, availability, and high profitability), external factors (e.g., peer pressure and media portrayals of drug usage), internal factors (e.g., hedonism, sociopathy, depression, and life stress), and intrinsic drug factors (e.g., "the pharmacologic imperative"). Strikingly, cocaine abuse occurs and persists in spite of dramatic medical problems that are associated with its use: central nervous system damage, cardiac arrest, stroke, respiratory collapse, severe hypertension, exacerbation of chronic diseases, infection, and psychiatric complications (Estroff, 1987). Because cocaine abuse research has produced fewer pharma cological treatment alternatives than has research on some other illicit drugs such as heroin (Alterman, O'Brien, & McLellan, 1991; Covi, Baker, & Hess, 1990; Stine, 1992), and because of the extent and 8 COGNITIVE THERAPY OF SUBSTANCE ABUSE severity of cocaine-related problems, we have placed proportionatel greater emphasis on cocaine and crack cocaine than on other drugs in this treatment manual. The opioids, including heroin, methadone, and codeine, are drugs that pharmacologically resemble morphine. Drugs in this class pro duce feelings of euphoria, relaxation, and mood elevation. They also have the potential for reducing pain, anxiety, aggression, and sexual drives (lOM, 1990a), and are considered highly addictive. According to Thomason and Dilts (1991): Opioids have the capacity to commandeer all of an individual's attention, resources, and energy, and to focus these exclusively on obtaining the next dose at any cost. This vicious cycle repeats itself every few hours, 24 hours a day, 365 days a year, for years on end. Comprehending the implications of opioid abuse shocks and stag gers the inquiring mind. (p. 103) Although the use of pharmacologic agonists such as methadone (and antagonists such as naltrexone) traditionally has represented an important component of treatment in the heroin abuser, methadone itself is unfortunately subject to various forms of abuse (e.g., black market dealings or use with other drugs). Further, many heroin abusers find methadone to be inferior to the "real stuff," leading to high noncompliance and dropout (Grabowski, Stitzer, & Henningfield, 1984) rates with these programs. Therefore, we posit that pharmaco logic approaches (even for heroin) represent an incomplete treatment strategy unless utilized in combination with psychosocial approaches such as support groups and cognitive therapy. Nicotine Cigarette smoking is by far the single most prevent able cause of death in the United States. In fact, it has been estimated that 434,000 people died in 1988 due to cigarette smoking (CDC, 1991b). This figure includes those who died of cancer, lung disease, heart disease, house fires caused by careless smoking, and renal and pancreatic disease. Approximately 49.4 million Americans (28.1%) are regular cigarette smokers (CDC, 1991a), despite the fact that cigarette smoking is known to be a leading cause of morbidity and mortality in this country. Since the mid-1970s, however, the number of smokers has admit tedly decreased steadily. Historically, more men than women have smoked; however, a higher proportion of men than women have also quit smoking. It has thus been projected that by the year 1995, more Overview 9 women than men will be smokers. Ironically, in spite of cigarettes' historical and advertising linkage with status, wealth, and desirabil ity, it is increasingly the case that the socially disadvantaged are over- represented as smokers. The number of minorities, poor, and less educated people who smoke, for example, has been disproportionately higher than those who do not smoke, and this trend is expected to continue (Pierce, Flore, & Novotny, 1989). Nicotine is the psychopharmacologically addictive ingredient in cigarettes. As mentioned earlier, nicotine dependence is included in DSM-III-R, along with the dependence on other psychoactive sub stances (alcohol, opiates, cocaine, etc.). Not surprisingly, we have found the addictive process in cigarette smoking to be analogous to the addictive process involved in the other psychoactive substances. Therefore, although nicotine addiction is not associated with the same degree of social, vocational, and legal consequences as is addiction to illicit drugs, its medical hazards and the fact that early-life regular smoking often leads to addiction to "harder" substances (Henning field, Clayton, & Pollin, 1990) make it an important area for mental health intervention. Although this volume focuses relatively little on methods specifically geared to smoking cessation, we believe that the same principles of assessment and treatment (e.g., coping with crav ings and modifying beliefs) that we outline in this book are highly applicable to the patient addicted to nicotine. Polysubstance Abuse Individuals abusing one psychoactive substance are likely to be simultaneously abusing another substance. In fact, between 2 0 % and 3 0 % of alcoholics in the general public and approxi mately 8 0 % in treatment programs are dependent on at least one other drug. A prevalent combination is alcohol, marijuana, and cocaine (N. S. Miller, 1991, p. 198). N S Miller (1991) explains that polysubstance abuse occurs tor multiple reasons. For example, some drugs enhance the effects of other drugs, while some drugs are used to avoid unwanted side effects of other drugs. Some drugs are used to treat drug withdrawal effects of other drugs and, similarly, some drugs are used as substihites for other '^'"^The medical and psychological correlates of polysubstance abus are numerous (N. S. Miller, 1991). They include problems associated with each individual drug (e.g., liver and heart disease associated with alcohol abuse), as well as those more commonly associated with multiple substances (e.g., interaction-induced overdose). 10 COGNITIVE THERAPY OF SUBSTANCE ABUSE Dual Diagnosis: Substance Abuse and Other Psychiatric Disorders The coexistence of substance abuse with other psy chiatric disorders is also very common (e.g., Ananth et al., 1989; Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989; Bunt, Galanter, Lifshutz, & Castaneda, 1990; Davis, 1984; Hesselbrock, Meyer, & Kenner, 1985; Kranzler & Liebowitz, 1988; Nace, Saxon, & Shore, 1986; Nathan, 1988; Penick et al., 1984; Regier et al., 1990; Ross, Glaser, & Germanson, 1988; Schneier & Siris, 1987). In a survey of more than 20,000 Americans conducted by Regier et al. (1990) it was found that individuals with psychiatric disorders were 2.7 times as likely to have alcohol or other drug problems, compared to those without psychi atric disorders. In fact, 3 7 % of individuals with substance use disor ders had coexisting Axis I mental disorders. From these data it appears that individuals with substance abuse problems should benefit most from therapeutic interventions that simultaneously address their other psychiatric disorders. Cognitive therapy is ideally suited for these individuals, since it has been devel oped and tested on patients with depression, anxiety, and personal ity disorders (see Hollon & Beck, in press, for a most recent compre hensive review). |
In fact, an important component of cognitive therapy involves the case conceptualization (Persons, 1989), defined as the evaluation and integration of historical information, psychiatric diag nosis, cognitive profile, and other aspects of functioning (see Chap ter 5, this volume, for a detailed description of the case conceptual ization). When a coexisting psychiatric syndrome is found to exist with a dmg or alcohol abuse patient, for example, the therapist focuses simultaneously on substance abuse and the symptoms of the psychi atric syndrome as well as on any factors of interaction (see Chapters 14, 15, and 16, this volume, for more on the treatment of patients with dual diagnoses). RELAPSE P R E V E N T I O N Substance abuse and dependence are characterized both by remission and by relapse. In a classic review by Hunt, Barnett, and Branch (1971) it was found that heroin, nicotine, and alcohol were all associated with similar high rates and patterns of relapse (p. 455; see Figure 1.1). These investigators found that two-thirds of individuals treated had relapsed within 3 months. Many investigators have speculated about the meaning of these findings, most inferring Overview 11 RELAPSE RATE OVER TIME •----•HEROIN ASMOKING OALCOHOL 2weeksJ 6 101112 MONTHS FIGURE 1.1. Relapse rate over time for heroin, smoking, and alcohol addic tion. From Hunt, Barnett, and Branch (1971), p. 456. Copyright 1971 by Clinical Psychology Publishing Co., Inc. Reprinted by permission. that they reflect common processes that underlie the addictions. In fact, since the publication of Hunt et al.'s (1971) data, addiction experts have focused on developing and testing comprehensive models of addiction that include all the psychoactive substances, as well as gambling and binge eating. Marlatt and his colleagues (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Marlatt, 1978; Marlatt, 1982; Marlatt & Gordon, 1985) have made an important contribution to the addiction literature with their cognitive-behavioral model of relapse prevention. According to Marlatt and Gordon's (1985) model (see Figure 1.2), individuals view themselves as having a sense of perceived control or self-efficacy. When they are faced with high-risk situations, this sense is threat ened. High-risk situations for the drug abuse patient might include negative or positive emotional or physical states, interpersonal con flicts, social pressure, or exposure to drug cues. Individuals faced with high-risk situations must respond with coping responses. Those who have effective coping responses develop increased self-efficacy, result ing in a decreased probabiHty of relapse. Those who have relatively fewer coping responses or none at all may experience decreased self- 12 COGNITIVE THERAPY OF SUBSTANCE ABUSE Coping Increased Decreased response self-efficacy probability of relapse Higii-risk situation Decreased Abstinence self-efficacy violation No Initial effect: Increased coping Positive use of probability response outcome substance Dissonance conflict of expectancies and relapse (for initial self-attribution effects of (guilt and perceived substance) loss of control) F I G U R E 1.2. Model of relapse process. From Mariatt and Gordon (1985), p. 38. Copyright 1985 by The Guilford Press. Reprinted by permission. efficacy and increased positive o u t c o m e expectancies about the effects of the drug, followed b y a "lapse" or initial use of a substance. This initial use mi g h t result in w h a t Marlatt calls a n Abstinence Violation Effect (AVE; i.e., perceived loss of control) and a n ultimately increased probability of relapse. T h e w o r k of Marlatt and his colleagues has h a d a profound effect o n knowledge about addictive behaviors. In fact, m o s t current text books o n addictions n o w deal with the issue of relapse prevention in some way. Although most of the work on relapse prevention has been generated within the cognitive-behavioral model (e.g., Chiauzzi, 1991), various 12-step programs (e.g.. Alcoholics Anonymous) and other advocates of the disease model have recently also increased their emphasis on relapse prevention (e.g., Gorski & Miller, 1986). MODELS OF ADDICTION Numerous theoretical models have been developed to explain addictive behaviors (see Baker, 1988; Blane & Leonard, 1987, for recent reviews). As previously mentioned, the dominant trend Overview 13 among addiction experts is toward developing comprehensive theo retical models that explain all addictions. Cognitive Models of Addiction A variety of related cognitive models of addiction have been developed and evaluated (e.g., Abrams & Niaura, 1987; Marlatt, 1978, 1985; McDermut, Haaga, & Shayne, 1991; Stacy, Newcomb, & Bentler, 1991; Tiffany, 1990; Wilson, 1987a, 1987b) since Bandura's (1969, 1977) classic presentations of cognitive social learning theory. Marlatt (1985) describes four cognitive processes related to addictions that reflect the cognitive models: self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. Self-efficacy refers to one's judgment about one's ability to deal com petently with challenging or high-risk situations. Examples of high self-efficacy beliefs include the following: "1 can effectively cope with temptations to use drugs" or "1 can say 'no' to drugs." Examples of low self-efficacy beliefs might include the following: "I'm a slave to drugs," "I can't get through the day without drugs," or "I can't get what I want, so I might as well use drugs." Marlatt (1985) explains that low levels of self-efficacy are associated with relapse and high levels of self-efficacy are associated with abstinence. Marlatt (1985) also explains that self-efficacy increases as a function of success; to the extent that individuals effectively choose not to use drugs, they will experience an increased sense of self-efficacy, for example, believ ing that their sense of pride is greater than their need for a "high." Outcome expectancies refer to an individual's anticipation about the effects of an addictive substance or activity. Positive outcome expectancies might include the following beliefs: "It will feel great to party tonight," or "I won't feel so tense if I use." To the extent that one expects a greater positive than negative outcome from using drugs, one is likely to continue using. Attributions of causality refer to an individual's belief that drug use is attributable to internal or external factors. For example, an individual might believe the following: "Anybody who lives in m y neighborhood would be a drug user" (external factor), or "I am physi cally addicted to alcohol and m y body can't survive without it" (inter nal factor). Marlatt (1985) explains that such beliefs most likely would result in continued substance use, since the individual perceives his/ her use to be predestined and out of control. For example, the AVE is an individual's tendency to believe that he/she is unable to control substance use after an initial lapse. That is, the AVE occurs when an individual has had a "lapse" or "slip" (i.e., has used a drug after being 14 COGNITIVE THERAPY OF SUBSTANCE ABUSE abstinent for some time) and attributes this lapse to a "lack of w power" (i.e., an internal causal factor). Under such circumstances, this individual is likely to continue using, resulting in a full-blown relapse. This is analogous to Beck's (1976) description of all-or-none think ing; for example, "I've blown it, so I might as well keep using." Marlatt (1985) also describes substance abuse and relapse as a cognitive decision-making process. He demonstrates (with an amus ing example) that substance use is a result of multiple decisions (like forks in the road) which, depending on the decisions, may or may not lead to further substance use. He further explains that some deci sions initially appear to be irrelevant to substance use ("apparently irrelevant decisions"); however, these decisions ultimately may result in a greater likelihood of relapse because of their incremental push toward higher-risk situations. In his example, Marlatt "innocently" chooses to sit in the smoking section of an airplane after being absti nent from smoking for several months. As a result of this decision he is more vulnerable to relapse (by his exposure to other smokers, their smoke, and their offers of cigarettes to him). W e see this same phenomenon in patients who claim to have had every intention of remaining abstinent from alcohol and illicit drugs, only to bhthely accept an invitation to meet a friend at a local tavern, or to cavalierly choose to drive out of the way in order to go past a street corner where drugs are sold. When such patients lapse into alcohol and drug use, it is striking to see how they fail to realize the ways in which they set themselves up for a fall with their decisions that lead up to the actual using incident. Unfortunately, the cognitive models of substance abuse have not been integrated adequately into many addiction treatment programs (lOM, 1990a; Miller & Hester, 1985). This volume provides a focused, step-by-step treatment based on Beck's (1976) cognitive model. It is our hope that the chapters that follow will stimulate increased appli cation of this cognitive model to substance abuse treatment across treatment settings and modalities. The Motivation to Change Efforts to examine the treatment of addictions are incomplete without considering the issue of motivation. Miller and Rollnick (1991) address this issue, explaining that most addicts are genuinely ambivalent about changing (rather than resistant, weak- willed, or characterologically flawed). The authors view motivation as a "state of readiness or eagerness to change, which may fluctuate from one time or situation to another" (p. 14). Overview 15 Prochaska, DiClemente, and Norcross (1992) provide a compre hensive model for conceptualizing patients' motivation for change. In their work, Prochaska et al. (1992) identify five stages of change: precontemplation, contemplation, preparation, action, and mainte nance. In the precontemplation stage, individuals are least concerned with overcoming their problems and they are least motivated to change problematic behaviors. In the contemplation stage individuals are willing to examine the problems associated with their substance use and consider the implications of change, although they may not take any constructive action. They are also likely to respond more positively to confrontation and education, although they may still be ambivalent. In the preparation stage, patients wish to make actual changes and therefore desire help with their problems, although they may feel at a loss as to how to do what is necessary to become drug free. In the action stage individuals have made a commitment to change and they have begun to actually modify behaviors. Prochaska et al. (1992) point out that this is a particularly stressful stage, which may require considerable therapist support and encouragement. In the maintenance stage individuals attempt to continue the process begun in the contemplation and action stages. In recent years, with so much emphasis placed on relapse prevention, the maintenance stage has received increased attention. Prochaska and DiClemente (1986) caution that the process of change is very complex. They explain that "most individuals do not progress linearly through the stages of change" (p. 5). Alternatively, they offer a "revolving door model" (p. 6), based on the assumption that individuals make multiple revolutions around the circle of stages prior to achieving their long-term goals. Furthermore, they observe that some individuals "get stuck" in the earlier stages of change. In the words of Prochaska and DiClemente (1986), "Therapy with addictive behaviors can progress most smoothly if both the client and the therapist are focusing on the same stage of change" (p. 6). To use nicotine dependence as an example, a smoker in the precontemplation stage will benefit little from advice about specific strategies for quit ting smoking. The same smoker, however, might respond well to general questions about health maintenance, which might lead to a discussion of the health effects of smoking, which might lead further to a discussion of the benefits of quitting, which eventually might lead to a discussion of specific strategies. It is clear that the field can benefit from an understanding of what makes a patient ready to seek help (Tucker & Sobell, 1992). The Prochaska et al. (1992) stage model is a useful heuristic. However, it is important to note that patients in a precontemplative 16 COGNITIVE THERAPY OF SUBSTANCE ABUSE Stage of change are not impossible to treat (especially if they ar court order to attend therapy). Conversely, patients in the action phase or maintenance phases are not guaranteed to succeed in treatment. The same degrees of vigilance and commitment are required of the cognitive therapist regardless of the substance abuse patient's stage of change. Treatment Outcome Goals Some models of addiction (e.g., Alcoholics Anony |
mous and other disease-model programs) view total abstinence as the only acceptable goal of treatment. Proponents of these models view addiction as an all-or-nothing phenomenon, with any use seen as pathological and abstinence considered a state of "recovering" (rather than "recovered"). Alternatively, proponents of cognitive-behavioral models are more likely to view light or moderate use (i.e., "controlled drinking") as an acceptable goal of treatment in some cases. At one time controlled drinking was extremely controversial (Marlatt, 1983). Presently, however, it is generally accepted that the goals of treatment should vary according to the patient's needs, prob lems, and previous response to treatment. Sobell, Sobell, Bogardis, Leo, and Skinner (1992), for example, surveyed problem drinkers to deter mine their preference for self-selected versus therapist-selected treat ment goals (e.g., abstinence vs. controlled drinking). They found that most respondents preferred setting their own goals and believed that they would be more likely to achieve them; respondents with more serious drinking problems were even more likely to favor self-set goals. In general, we favor a collaborative approach in setting goals with patients. Therefore, to the extent that allowing severely addicted patients to set the modest goal of substance use reduction succeeds in getting otherwise resistant patients engaged in a more complete course of therapy, we are in favor of a controlled substance use approach. In the long run, however, we strongly advocate assisting patients in becoming drug- and alcohol-free. THE TREATMENT OF SUBSTANCE ABUSE A N D DEPENDENCE In reality, most substance abuse treatment programs are eclectic in theory and practice, and they include varying degrees of inpatient and outpatient services, 12-step program attendance, education, psychotherapy, family therapy, support groups, pharmaco- Overview 17 therapy, and so forth. In our view, cognitive therapy can be compat ible with any of these approaches. In fact, many of our drug and alcohol abuse patients attend support groups, have had inpatient detoxification, and take medication. The special strengths that cog nitive therapy adds to this battery of approaches are its emphasis on (1) the identification and modification of beliefs that exacerbate crav ings, (2) the amelioration of negative affective states (e.g., anger, anxi ety, and hopelessness) that often trigger drug use, (3) teaching patients to apply a battery of cognitive and behavioral skills and techniques, and not just willpower, to become and remain drug-free, and (4) help ing patients to go beyond abstinence to make fundamental positive changes in the ways they view themselves, their life, and their future, thus leading to new lifestyles. In the following section we present a brief overview of more tra ditional treatments of substance abuse and dependence. Alcoholism Treatment Miller and Hester (1980, 1986) have conducted exhaustive reviews of the alcoholism treatment literature. These authors have examined nine major classes of interventions. The four most common were pharmacotherapy, psychotherapy or counseling. Alcoholics Anonymous, and alcoholism education. The five less com monly employed approaches included family therapy, aversion thera pies, operant methods, controlled drinking, and broad spectrum treat ment. Miller and Hester (1986) conclude from their reviews that alco holism treatment is best approached as a two-stage process, requir ing different interventions at each stage. The first set of interventions should be focused on changing drinking behaviors to abstinence or moderation (e.g., behavioral self-control training). The second set of interventions should be focused on maintenance of sobriety (e.g., social skills training in order to increase confidence in relating to drug- free people). Miller and Hester (1986) also draw some disturbing conclusions, however, about the poor relationship between empirical research and traditional inpatient treatment approaches. Treatment methods that are supported by controlled research include aversion therapies, behav ioral self-control training, community reinforcement, marital and family therapy, social skills training, and stress management, whereas approaches actually currently employed as standard practice in alco holism programs include Alcoholics Anonymous, alcoholism educa tion, confrontation, disulfiram, group therapy, and individual coun- 18 COGNITIVE THERAPY OF SUBSTANCE ABUSE seling. They point out that there is little apparent overlap betwe these lists: Alcoholism treatment programs in the United States do not tend to use treatment methods that have been validated by controlled outcome studies. Furthermore, Miller and Hester (1986) point out that traditional inpatient treatment programs are very expensive, "despite clear evidence that they offer no advantage in overall effectiveness" (p. 163). Concurring in this, McLellan et al. (1992) note that stan dard detoxification and "28-day programs" (in spite of their high costs) are insufficient to deal with long-term issues. Clearly, to help drug and alcohol patients deal with more enduring issues, these treat ments need to be supplemented with ongoing outpatient treatment that focuses on attitude change and skills acquisition. The Institute of Medicine recently commissioned a National Acad emy of Sciences committee to make an exhaustive critical review of the research literature on treatment for alcohol problems (1990b). The committee discovered that interventions included "a broad range of activities that vary in content, duration, intensity, goals, setting, pro vider, and target population" (p. 86). The committee's assessment was that "no single treatment approach or modality has been demonstrated to be superior to all others" (p. 86). Its conclusions, published in Broadening the Base of Treatment for Alcohol Problems (1990a), included the following: 1. There is no single treatment approach that is effective for all persons with alcohol problems. 2. The provision of appropriate, specific treatment modalities can substantially improve outcome. 3. Brief interventions can be quite effective compared with no treatment, and they can be quite cost-effective compared with more intensive treatment. 4. Treatment of other life problems related to drinking can improve outcome in persons with alcohol problems. 5. Therapist characteristics are partial determinants of outcome. 6. Outcomes are determined in part by treatment process factors, posttreatment adjustment factors, the characteristics of indi viduals seeking treatment, the characteristics of their problems, and the interactions among these factors. 7. People who are treated for alcohol problems achieve a con tinuum of outcomes with respect to drinking behavior and alcohol problems and follow different courses of outcome. 8. Those who significantly reduce their level of alcohol consump tion or who become totally abstinent usually enjoy improve ment in other life areas, particularly as the period of reduced consumpfion becomes more extended (pp. 147-148). Overview 19 The findings of the Institute of Medicine (1990a) coupled with those of Miller and Hester (1986) make it apparent that there is still a profound need for effective alcoholism treatment interventions. It is hoped that the principles introduced in this text will be integrated into, and evaluated in, traditional treatment programs in order to move toward more effective and appropriate alcoholism treatment programs. Illicit Drug Treatment In addition to its report on alcohol treatment pro grams, the Institute of Medicine appointed a separate committee (1990a) to review the treatment of drug problems in the United States. Specifically, the committee divided treatments into four classifications: methadone maintenance, therapeutic communities, outpatient non- methadone programs, and chemical dependency programs. These findings (1990a) were similar to those of Miller and Hester (1986). The most empirically validated programs have been metha done maintenance clinics for opioid dependency. Some evidence also supported the efficacy of therapeutic communities and outpatient nonmethadone treatment. Nonetheless, "Chemical dependency is the treatment with the highest revenues, probably the second largest number of clients, and the smallest scientific basis for assessing its effectiveness" (lOM, 1990a, p. 18). The Institute of Medicine acknowl edges that most of the studies on methadone maintenance were con ducted in the 1970s and early 1980s, however. As a result, research has insufficiently addressed the growing cocaine problems in this country. By contrast, this volume will focus heavily on the cognitive therapy of cocaine and crack cocaine addiction. Smoking Cessation Interventions In a report published by the National Cancer Insti tute, Schwartz (1987) critically reviewed the literature on smoking cessation interventions. He divided the various methods into 10 cate gories: (1) self-care, (2) educational approaches/groups, (3) medica- fion, (4) nicotine chewing gum, (5) hypnosis, (6) acupuncture, (7) physician counseling, (8) risk factor preventive trials, (9) mass media and community programs, and (10) behavioral methods. Schwartz (1987) found considerable variability in cessation rates among these methods. Approximately 1 million Americans per year quit smoking, and most do so on their own through "self-care." In fact, three-fifths of all smokers would prefer to quit on their own, rather than seek group 20 COGNITIVE THERAPY OF SUBSTANCE ABUSE quit-smoking programs (Schwartz, 1987). There are many self-help aids for those wishing to quit smoking, including books, pamphlets, audio cassettes, drug store preparations, correspondence courses, and so forth. Almost all self-care efforts and aids involve some cognitive techniques. In fact, those who successfully quit on their own have higher levels of success expectancy and self-efficacy (areas strongly affected by cognitive interventions) than those who are unsuccess ful. Approximately 16%-20% of smokers who quit on their own are abstinent at 1 year (Schwartz, 1987). For those who wish to receive assistance with smoking cessation, there are nonprofit and commercial clinics and groups available. Most of these utilize cognitive methods, including education, self-monitor ing, and modifying attitudes about smoking. In a review of 46 group smoking cessation programs, Schwartz (1987) found median cessation rates ranging from 2 1 % to 36%, depending on the length of follow- up and the time the study was conducted. A number of medications have also been tried as aids to smok ing cessation over the years. These have included lobeline, mepro- bamate, amphetamines, anticholinergics, sedatives, tranquilizers, sym pathomimetics, anticonvulsants, buspirone, propranolol, clonidine, nicotine polacrilex, and most recently transdermal nicotine. Of these, the most promising medications have been those that replace the nicotine from cigarettes with prescription nicotine (i.e., nicotine gum and transdermal nicotine). In fact, the median cessation rates for nico tine gum at 6-month and 1-year follow-ups were 2 3 % and 11%. These rates were substantially higher when the gum was used in conjunc tion with cognitive-behavioral smoking cessation programs: 3 5 % and 2 9 % (Schwartz, 1987). At the time this book was being written, transdermal nicotine delivery systems had just been approved by the Food and Drug Administration. Hence, substantial field trials of these "patches" have not been conducted. Both hypnosis and acupuncture have been of interest to the gen eral public as smoking cessation techniques. However, empirical vali dation of these methods has been weak and hirther controlled studies are necessary prior to assuming their efficacy (Schwartz, 1987). SUMMARY Huge numbers of people in the United States are affected by substance abuse. Thousands of books and articles have been written and millions of dollars have been spent on research on the addictions. Nonetheless, there is a noticeable paucity of reliably effec- Overview 21 five substance abuse treatment strategies. For years, however, it h been noted that there are underlying cognitive processes common to the addictions. (Even Alcoholics Anonymous warns alcoholics about "stinkin' thinkin.'") W e believe strongly that understanding and work ing with these cognitive aspects more explicitly will help to resolve some of the uncertainty plaguing the field of substance use treatment. In the chapters that follow we strive for a high degree of speci ficity in describing the procedures that comprise this approach. A preliminary version of this book currently serves as a therapist manual in an ongoing National Institute on Drug Abuse pilot study compar ing cognitive therapy, supportive-expressive therapy, and general drug counseling treatment outcomes for cocaine abusers. Our hope is that Cognitive Therapy of Substance Abuse will continue to serve as a train ing guide for further clinical and empirical tests. C H A P T E R 2 C o g n i t i v e M o d e l o f A d d i c t i o n W R Y DO PEOPLE USE DRUGS (AND/OR ALCOHOL)? Some individuals are "generalists" and may use a wide variety of addictive substances almost randomly or depending on their availability. Others are "specialists" and their drug of choice may depend on its specific pharmacological properties as well as its social meanings (e.g., alcohol is often viewed as manly and associated with sports, whereas cocaine is associated with group acceptance and sexual activity). Cocaine may be used because of its stimulant properties- producing a rapid "high," for example. Similarly, amphetamines may be chosen as psychic energizers. In contrast, |
barbiturates, benzodiaz epines, and alcohol may be preferred because of their relaxing effect and, perhaps, their presumed relief of inhibitions. Hallucinogens are attractive to some to relieve boredom and "expand consciousness." Most people addicted to cocaine have also abused other drugs and/or alcohol (N. S. Miller, 1991; Regier et al., 1990; Stimmel, 1991). There are numerous explanations for why people use—and become addicted to-psychotropic substances. In general, the process of addiction can be understood in terms of a few simple, perhaps obvious, formulas. A basic reason for starting on drugs or alcohol is to get pleasure, to experience the exhilaration of being high, and to share the excitement with one's companions who are also using (Stim mel, 1991). Further, there is the expectation that the drug cocaine, for example, will increase efficiency, improve fluency, and enhance creativity. 22 Cognitive Model of Addiction 23 How do people progress from recreational or casual use to regu lar use? In time, additional factors may contribute to becoming depen dent on the drug. Some people find that drug taking-for example, heroin, benzodiazepines (such as Valium), or barbiturates^rovides temporary relief from anxiety, tension, sadness, or boredom. These individuals soon develop the belief that they can weather the frustra tions and stresses of life better if they can turn to drugs and/or alco hol for a period of escape or oblivion. People with adverse life cir cumstances are more likely to become addicted than are those with more sources of satisfaction (Peele, 1985). For a while, real-life prob lems fade into insignificance and life itself seems more attractive. As one patient put it, "If I take coke, m y bad thoughts go away." Fur ther, people whose self-confidence is low may find that the drug or alcohol boosts their morale—in the short run. Finally, many individu als discover that using drugs provides new social groups in which the only requirement for admission and acceptance is that they are users. If drug using has so many advantages, why should we be con cerned with getting people off the "drug habit"? The profound impli cations of breaking the law by using illegal drugs (and selling them in order to support their habit) are so obvious that they do not need further elaboration. Regardless of whether the drugs are legal, such as alcohol, or illegal, substance abuse creates serious personal, social, and medical problems (Frances & Miller, 1991; Kosten & Kleber, 1992). A major problem is that the drug seems to take control of addicted individuals. Their goals, values, and attachments become subordinate to the drug using. They cannot manage their lives effectively. They become subject to a vicious cycle of craving, precipitous drops in mood, and greater distress that can be relieved immediately only by using drugs again. The web of external and internal problems leading to and, later, maintaining compulsive drug use is a defining characteristic of addic tion. Far from soothing life's pains, the drugs create a new set of prob lems-enormous financial outiays (for illegal drugs), threat of or achial loss of employment, and difficulties in important personal relation ships, such as marriage. The individual also becomes stigmatized by society-as a "lush" or a "junkie." Finally, of course, chronic use may cause serious medical problems and even death. As pointed out by Peele (1989), the compulsive use of psycho tropic agents depends on a wide variety of personal and social fac tors. If the environment is malevolent and there is group support for drug use-as in the case of U.S. soldiers in Vietnam-widespread drug use is more likely. W h e n the environment is comparatively less stress ful (as when veterans retiirn to civilian life), individuals do not con- 24 COGNITIVE THERAPY OF SUBSTANCE ABUSE tinue excessive use—except for those who had been heavy users prio to military service (Robins, Davis, & Goodwin, 1974). A number of characteristics distinguish addicted individuals from casual users. A major difference, as pointed out by Peele (1985), is that while addicted individuals subordinate important values to drug using, casual users prize other values more highly: family, friends, occupation, recreation, and economic security, to name a few. In addition, drug users may have certain characteristics, such as low frus tration tolerance, nonassertiveness, or poor impulse control, that make them more susceptible. Thus, psychological and social factors may be the determinative factors—rather than the pharmacological prop erties per se—in converting a drug user into a drug abuser. Support ing this hypothesis is the commonly encountered phenomenon in hospital settings where "patients who take opioids for acute pain or cancer pain rarely experience euphoria and even more rarely develop psychic dependence or addiction to the mood-altering effects of nar cotics" {Medical Letter on Drugs and Therapeutics, 1993, p. 5). If drug addiction were merely a biological process, we would not expect this to be the case. The sequence of using or drinking is illustrated in Figure 2.1. An addicted individual who is feeling anxious or low decides to have a smoke or a snort. The short-term relief is followed by delayed, longer- term negative consequences: problems about breaking the law, seri ous financial problems, family difficulties, and possibly medical prob lems. These problems lead to realistic fears of being apprehended, becoming bankrupt, losing a job, disrupting close relationships, and becoming ill. These fears generate more anxiety and lead to craving and further using or drinking to neutralize the anxiety. Thus, a vicious cycle is established. Many other kinds of vicious cycles, which are described in Chap ter 3 (this volume), may be created. These involve a number of psy chological factors such as low self-esteem, emotional distress, and hopelessness. W H Y NOT STOP IF DRUGS OR ALCOHOL CREATE PROBLEMS? By definition, addicts are people who have difficulty in stopping permanently. They may have started to use voluntarily, but they either do not believe that they can stop or they do not choose to stop voluntarily. At the first sign of medical, financial, or interper sonal problems, many users ignore, minimize, or deny the problems Cognitive Model of Addiction 25 Anxiety/Low Mood Using ^k- Flnanclal, Social, Medical Problems FIGURE 2.1. Simple model of vicious cycle. or attribute them to something other than drugs (e.g., they m a y blame their spouse for domestic problems). Others m a y be aware of the problems, but they evaluate the advantages of using as greater than the disadvantages. M u c h of this evaluation is based on avoiding a true assessment of the disadvantages (Gawin & EUinwood, 1988; Gawin & Kleber, 1988). As the problems increase, m a n y users become more ambivalent and begin to vacillate in their decision to use. One factor in maintaining drug use is the c o m m o n belief that withdrawing from the drug will produce intolerable side effects (Horvath, 1988, in press). However, these effects vary enormously from person to person—and from substance to substance—and the impact is greatly enhanced by the psychological meaning attached to the withdrawal symptoms. These meanings are often more salient than the actual adverse physiological sensations in determining the inten sity of withdrawal symptoms. Most cocaine abusers participating in detoxification programs, for example, feel better in the early stages after they stop using (Ziedonis, 1992). A major obstacle to eliminating using or drinking is the network of dysfunctional beliefs that center around the drugs or alcohol. Exam ples of these beliefs are: "I can't be happy unless I can use," and "I a m more in control w h e n I've had a few drinks." A n individual w h o is contemplating eliminating the use of drugs or alcohol m a y feel sad or anxious. Termination of reliance on drugs or alcohol is seen as a deprivation of satisfaction and solace or a threat to well-being and functioning Qennings, 1991). Stopping m a y mean, for some, remov ing the "security blanket" used to cushion dysphoria. Addicted individuals often try on their o w n to stop using or drink ing. However, w h e n they experience the craving (often stimulated by low m o o d or exposure to the drugs or related stimuli), they feel dis appointed if they restrain themselves from using or drinking. They perceive their feelings of disappointment and distress as intolerable; the thought, "1 can't stand this feeling," upsets them even more. Hence, they feel driven to yield to the craving in order to dispel the 26 COGNITFVE THERAPY OF SUBSTANCE ABUSE sense of loss and relieve their distress. Patients often have a cl of beliefs that seem to become stronger when they decide to stop using. These center around the anticipated deprivation: "If I can't use, I won't be able to bear the pain (or boredom)," "There is nothing left in life for me," "I will be unhappy", or "1 will lose m y friends." These beliefs are elaborated more in the section on low frustration toler ance (Chapter 15, this volume). Another set of beliefs centers around the addicted individual's sense of helplessness in controlling the craving: "The craving is too strong," "1 don't have the power to stop," or "Even if I do stop—1 will only start up again." These beliefs become self-fulfilling prophecies. Since the patients believe they are incapable of controlling their urges, they are less likely to try to control them and, thus, confirm their belief in their helplessness in overcoming their addiction. W H Y D O PEOPLE W A N T HELP? There are roughly five stages people go through in seeking help (Prochaska et al., 1992). In the precontemplative stage, they do not even acknowledge to themselves that they have a problem (or else they consider using more important than the problems it causes). In the contemplative stage, they are willing to consider their problems, but are still unlikely to stop using on their own. Individuals in the preparation stage intend to take action to cease their drug and alcohol use, but are uncertain about being able to follow through. In the action stage, patients behaviorally demonstrate a decrease in their drug-taking behaviors and a therapeutic modification in their drug-taking beliefs. Those who are successful enough to reach the maintenance stage have already taken great strides toward a drug-free and alcohol-free life, and are actively working to maintain consistency in this endeavor over a period of months and years. People come to therapy for a variety of reasons. Some users have been arrested for "dealing" or possession and are referred by the courts. Others see their lives deteriorating as a result of the financial, psychological, and interpersonal consequences of using or drinking. Still others are pressured by friends or family. By the time these patients are labeled drug abusers, addicts, or alcoholics, they have often hit a low point in terms of any combination of the following: health, social adjustment, employment and economic status, and psychologi cal well-being. Many people with drug and alcohol problems have tried repeat edly to "break the habit," only to relapse eventually. Others suffer from Cognitive Model of Addiction 27 a personality disorder (e.g., Mirin & Weiss, 1991; Nace, Davis, & Gaspari, 1991; Regier et al., 1990) and/or a psychiatric syndrome such as chronic anxiety (e.g., Kranzler & Liebowitz, 1988; LaBounty, Hat- sukami, Morgan, & Nelson, 1992; Walfish, Massey, & Krone, 1990) or depression (e.g., Hatsukami & Pickens, 1982; Rounsaville & Kleber, 1986). For some, drug use is simply a manifestation of their mani fold difficulties. For others, drugs represent a form of self-medication (Castaneda, Galanter, & Franco, 1989; Khantzian, 1985) to relieve their feelings of distress, sadness, or anxiety. Given the consequences of sustained drug use, it is important to consider the problem in terms of its sociological, interpersonal, and psychological dimensions, in addition to the strictly pharmacologi cal properties of drugs. In fact, substance abuse or addiction could be defined as compulsive use leading to a web of entanglement involv ing social, economic, and legal problems over which the patient no longer has control. Given their acknowledgment that they are addicted, many of these individuals come to the conclusion that the only way they can manage or even salvage their lives is to receive assistance, professional or otherwise. H O W C A N COGNITIVE THERAPY HELP? Cognitive therapy is |
a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behavior by modifying the faulty or erroneous thinking and maladap tive beliefs that underlie these reactions (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). The approach to a particular patient is derived from a thorough concephialization of the particular case. The specific case formulation, in turn, is based on the cognitive model of that disorder. The thor ough case conceptualization, including the relationship of early life patterns to current problems, at the beginning stages of treatment differentiates cognitive therapy from some of the other forms of therapy. The approach is (1) collaborative (builds trust), (2) active, (3) based on open-ended questioning to a large degree, and (4) highly structured and focused. As applied to substance abuse, the cognitive approach helps indi viduals to come to grips with the problems leading to emotional dis tress and to gain a broader perspective on their reliance on drugs for pleasure and/or relief from discomfort. In addition, specific cognitive strategies help to reduce their urges and, at the same time, establish a stronger system of internal controls. Moreover, cognitive therapy 28 COGNITIVE THERAPY OF SUBSTANCE ABUSE can help patients to combat their depression, anxiety, or anger, w frequently fuels addictive behaviors. A major thrust of cognitive therapy of substance abuse is to help the patient in two ways: (1) to reduce the intensity and frequency of the urges by undermining the underlying beliefs, and (2) to teach the patient specific techniques for controlling or managing their urges. In a nutshell, the aim is to reduce the pressure and increase control. When the patient's addiction is related to a coexisting psychiatric disorder, that condition also needs to be addressed by the cognitive therapist. Cognitive therapy is carried out in several ways. The therapist helps the patient to examine the sequence of events leading to drug use and then to explore the patient's basic beliefs about the value of drugs, alcohol, and nicotine. At the same time, the therapist trains the patient to evaluate and consider the ways in which faulty think ing produces stress and distress. Therapists help patients to modify their thinking so that they can gain a better grasp of their realistic problems and can disregard pseudo-problems derived from their faulty thinking. In addition, through rehearsal and practice, patients are trained to build up a system of controls to apply when confronted with strong urges. The techniques the therapist uses include a painstaking evalua tion of the short-term and long-term benefits and disadvantages of using: the cost-benefits analysis (also called the advantages-disadvan tages analysis; see Chapters 9 and 10, this volume). The therapist also helps the patient to find more satisfactory ways of coping with real istic problems and unpleasant feelings without turning to drugs or alcohol for relief. They also work together to structure the patient's life so that other sources of pleasure are made available (cf. Havassy, Hall, & Wasserman, 1991). Since many patients have a low frustra tion tolerance (Ellis, Mclnerney, DiGiuseppe, & Yeager, 1988), they are shown how their self-defeating attitudes about themselves and their capabilities lead to overreacting when they encounter obstacles, delays, or thwarting (Chapter 15, this volume). The therapist also demonstrates how patients can approach these obstacles as problems to be solved rather than as barriers to their goals. Many patients who suffer from difficulties in asserting themselves in an appropriate way are likely to be dominated and even exploited by other people, and thus are prone to experience frequent impatience, anger, and disappointment. By learning new interpersonal skills, the patients are able to assert their rights more effectively. The same type of assertion can help them to refuse when others coax them to start Cognitive Model of Addiction 29 using. Refusal can take on a new meaning for them^standing up for themselves, putting long-term interests before short-term gains, and becoming desensitized to derogatory or profane epithets. One of the main features of cognitive therapy is the use of "Socratic questioning." By skillfully asking questions, the therapist leads the patient to examine areas that the patient has closed off from scrutiny, for example, the true frequency and quantity of drug use, the actual losses from the addiction, and the quality and effects on interpersonal relations. Also, questioning leads patients to generate options and solutions that they have not considered. Finally, this approach puts patients in the "questioning mode" (as opposed to the "automatic impulse" mode) so that they will start to evaluate more objectively their various attitudes and beliefs. In a sense, stopping drug use or drinking is a technical problem. The patients coming for help would like to stop using but they do not know how. Many of them have tried to stop many times but have been unsuccessful. Cognitive therapy provides them with tools that will enable them to stop and maintain the abstinence from drugs or to moderate their drinking and smoking. Moreover, they can apply these same useful techniques to their daily problems and thus have a more enjoyable, more fulfilling life. D O SUBSTANCE ABUSERS H A V E ADDITIONAL PSYCHIATRIC PROBLEMS? Many of the patients seeking—or referred for—treat ment of addictions have a "dual diagnosis" (Mirin & Weiss, 1991; Regier et al., 1990). By this we mean that in addition to their diagno sis of addiction, they also have a syndromal diagnosis (Axis I), such as depression, or a diagnosis of personality disorder (Axis II), or a com bination of both. A good conceptualization takes into account the vari ous ways in which the patients' psychological problems play them selves out. For example, a patient with a dependent personality disorder centered around a poor self-concept may become depressed following a rejection and seek to counteract the depressed feelings through using and/or drinking. Linking these behaviors may be a common thread, such as "I am too weak or fragile to make it on m y own." This belief may lead to clinical depression when interpersonal supports are removed. The same belief promotes using or drinking when the patient is confronted with a difficult problem or a stressful situation: "I can't handle this without a drink (or drug)." 30 COGNITIVE THERAPY OF SUBSTANCE ABUSE WHY DO PEOPLE RELAPSE AFTER NOT USING FOR A SUBSTANTIAL PERIOD? Many individuals handle the withdrawal symptoms, if present, and go for significant periods without using but then relapse—sometimes, for no apparently compelling reason (Carroll, Rounsaville, & Keller, 1991; Tiffany, 1990). The problem seems to lie in the fact that these individuals have not become "inoculated" to the external or internal conditions that can trigger the craving and undermine the control. These circumstances fall into the category of "people, places, and things," which is described in 12-step programs. This category includes situations such as associating with compan ions or sex partners who urge one to have a "hit" or drink, visiting a place where one has previously used or drunk, seeing drug parapher nalia, or receiving one's paycheck. These individuals also may expe rience a craving for the substance if they are feeling sad, bored, or anxious. Some individuals have a lapse when an unusual stressful situation occurs: death of a friend or relative, serious argument with a spouse, or loss of a job. One of the underlying reasons why recovering addicts are still prone to react with powerful urges to various stimulus (high-risk) situations is that their basic beliefs regarding the relative advantages and disadvantages of drug taking have not changed substantially. They may have acquired a number of strategies for controlling their drug- taking behavior, but they have not significantly modified the attitudes that help to fuel the craving. Consequently, when their controls are weakened, perhaps as a result of stress, and their urges are stimulated, for example by exposure to a high-risk situation (a situation that activates their drug-using beliefs), they are vulnerable to lapse by using or drinking a minimum or moderate amount. This lapse is accentu ated by a sense of helplessness or hopelessness: "It proves I can't control m y urges"; "I will never be able to beat this problem." As they are swept back into the drug-using cycle, the lapse becomes a relapse. Sometimes, patients may lapse for no discernible reason—that is, they have not been exposed to a high-risk situation (Tiffany, 1990). The probability of such a lapse is increased any time the ratio of the perception of control to the intensity of craving is decreased; that is, when control is weakened by fatigue and a gradual slippage of the constructive beliefs (anti-indulgence behefs) and/or an increase in the desire to use or drink, based, for example, on tran sient unpleasant feelings. The degree of commitment to abstinence may simply decrease with the passage of time-perhaps because of fading of memories of the bad effects of using or drinking (Gawin & Cognitive Model of Addiction 31 EUinwood, 1988; Velten, 1986). At this time, a "normal" degree of craving may lead to a lapse. If the patient's reaction is, "My control must be pretty poor if I give in to such mild craving," he/she may progress into a relapse. The basic beliefs that have been dormant but become stimulated by exposure to the stimulus (high-risk) situations include notions such as "If I use, I can handle m y problems better," "Having a smoke or hit will make life more enjoyable," or "I need a drink to overcome my anxiety." As soon as these beliefs are activated, the individual experiences an exacerbation of craving. The patient's attempts at self- confrol are undermined by permission-related thoughts (stemming from the beliefs) such as "I can do it this once and stop," or "There's no reason why I should continue to deprive myself." There is, thus, a continuing conflict between the attitudes concerned with control ling the urge and those attitudes favoring yielding to the temptation (or, more strictiy, initiating the behavior that would satisfy the urge). P H E N O M E N A OF ADDICTION Cravings and Urges In helping patients deal with their substance use prob lems, it is crucial to have a full understanding of the phenomena associated with drug use. Craving refers to a desire for the drug, whereas the term urge is applied to the internal pressure or mobiliza tion to act on the craving (Marlatt, 1985, and Horvath, 1988, use the terms in a similar way). In short, a craving is associated with wanting and an urge with doing. The two terms are often used interchange ably, but it is useful to separate them. Cravings represent a strong desire for a particular type of experi ence, for example, the pleasure from eating, relaxation from smok ing, or the gratification from sex. The fulfillment of the wish may be labeled the consummation and the means, the consummatory act. When one form of consummation is not available, an individual may turn to another form. For example, if there is no satisfaction in sight for yearning for affection, an individual may reach for a sweet or a beer instead. An urge is the instrumental sequel to a craving. A person desires to experience a "high" or relief from discomfort and feels a pressure to act to obtain this experience. Marlatt and Gordon (1985) define an urge as a behavioral intention to engage in a specific consumma tory behavior. Urges may be regarded as compulsions when the indi vidual feels incapable of resisting them. Thus, an urge may be insti- 32 COGNITIVE THERAPY OF SUBSTANCE ABUSE gated by an unpleasant feeling state (such as anger or anxiety) or anticipation of an unpleasant stressful event. The ultimate goal of consummating the urge is a reduction of the instigating state, whether it be a craving for excitement or a desire to relax. The delay between the experience of craving and implementa tion of the urge does provide an interval for a therapeutic interven tion—for the technical application of control or what is called, in common parlance, "will power," which we define as an active pro cess of applying self-help techniques, not simply a passive enduring of discomfort. Additionally, fostering a delay between the craving and the use of drugs allows for the natural diminishing of the acute crav ing episode (Horvath, 1988), thus lowering the chances that the |
patient will act on the craving (Carroll, Rounsaville, & Keller, 1991). Urges are governed by the anticipated consequences, for example, reward for doing something or pain for not doing it. The urge may be accompanied by a positive feeling when it is driven by a positive expectation or a negative feeling when it is driven by expectation of unpleasantness unless the urge is consummated. Some people con fuse urge with "need." They will say "I need a smoke" or "I need a drink" as though they cannot survive, or at least function, without it. Such a belief is, of course, spurious and becomes a focus for thera peutic interventions. Cravings and urges tend to be automatic and may become "auton omous"; that is, they can continue even though the individual tries to suppress or abolish them. They may become imperative and are not easily dissipated even if blocked from being carried out. At this point, the word "compulsion" seems most appropriate to describe cravings and urges. W e see compulsions most clearly in obsessive- compulsive disorder, in which the individual experiences strong pres sure to engage in a repetitive act in order to ward off some feared event. Addictive behaviors incorporate some of the same characteris tics. The Role of Beliefs Dysfunctional beliefs play a role in the generation of urges. The beliefs help to form the expectation, which then molds the urge. For example, a patient with a serious drinking problem had the following beliefs: "If I am 'amusing and friendly' I will receive lots of praise" and "If I have a drink I will be more entertaining." He translated these beliefs into a specific expectation for receiving praise when an opportunity arose for entertaining people. The expectation, then, led to the urge to "show off." However, he was uncertain of his Cognitive Model of Addiction 33 success unless he had crack cocaine first. His expectation of succe was enhanced by his belief in the stimulating or disinhibiting effect of cocaine. As it happened, he would usually "overshoot the mark" and become so excited that people considered him "pathetic." Following Bandura (1982), Mariatt and Gordon (1985) have refined the concept "beliefs about the positive effect of using" into "positive outcome expectancies." Research by Brown, Goldman, Inn, and Anderson (1980) has shown that the expectancies of alcoholics fall into six factors: that drinking will (1) transform experiences in a positive way, (2) enhance social and physical pleasure, (3) increase sexual performance and satisfaction, (4) increase power and aggres sion, (5) increase social assertiveness, and (6) decrease tension. A simi lar set of expectations is associated with drug use (see Drug Belief Questionnaire in Appendix, this volume). The "Drug Habit" The habit of taking substances for relief or pleasure differs from the way the term "a bad habit" is generally understood. A particular "habit," such as grimacing when frustrated or leaving clothes on the floor, is a repetitive pattern—but it is not experienced as a craving or a need. For the drug abuser the immediate response to a relevant situation is subjective, namely, a craving or an urge. There is a delay between the stimulus and the consummatory act, such as preparing the syringe or the powder. What are chained to the stimu lus, thus, are the cravings and urges. Through continual repetition, the chain becomes stronger. In contrast to the habits involved in skilled acts such as driving, the pattern of drug taking is compulsive and dysfunctional. In addition, the skilled acts are based on volun tary decisions, whereas drug-taking cravings are involuntary (even though the control of the urges is voluntary). Because of the differ ence between using and the habits of everyday life, the term "drug habit" is probably a misnomer. Through a process of "stimulus generalization," the addicted individual is likely to respond with craving to an increasingly broader range of stimulus situations. Whereas originally the individual might have felt the craving for a drink or smoke only in a group, he or she now may experience it when upset, bored, or lonely. With the bind ing of the craving to more and more stimuli, there is a concomitant expansion of the dysfrinctional beliefs about drug use. Whereas ini tially the belief might be "I should take a smoke to be part of the group," the beliefs may build up to "I need a smoke to be accepted" and later to "I have to take a snort to relieve m y loneliness and dis- 34 COGNITIVE THERAPY OF SUBSTANCE ABUSE tress." The urges, thus, become more generalized and more impera tive in keeping with the broadening content of the beliefs. Furthermore, the rebound dysphoria experienced particularly after a "cocaine crash" (Karan et al., 1991; Ziedonis, 1992), for example, leads to a renewal of the craving in order to counteract this low feel ing. The consequence of the repetition of emotional distress leading to craving to indulgence to temporary relief of dysphoria is the develop ment of beliefs such as "I need a hit in order to feel better." When a drug or alcohol is taken to relieve stress-related or naturally occur ring tension, anxiety, or sadness, it tends to reinforce the belief "1 need the drug," as well as "I can't tolerate unpleasant feelings." The Control/Urge Equation There is a common belief that addicted individuals have little or no control over their urges and behavior or that the craving is irresistible. O n the surface, this seems to be true because these people seem to be driven by such a powerful force that they engage in addictive behavior even though they recognize its destruc- tiveness; many make repetitive abortive attempts to control their behavior and will say that they know they want to confrol their behav ior but simply carmot. This common observation of their cravings and urges overwhelming any resistance has led to the principle expressed by Alcoholics Anonymous: "I recognize that I am powerless." Their perception of "being out of control" has the positive bene fit of inducing addicted people to seek professional help rather than continuing to waste energy in futile attempts to exercise confrol—often followed by self-castigation for not successfully counteracting the urge. Developing control is a technical problem to a large extent. Learning specialized techniques for reducing craving and establishing some measure of control is generally necessary for those who are truly addicted. On the one hand, the sources of craving need to be explored. On the other hand, the notion of total loss of control is simplistic and does an injustice to the potential internal resources available to the individual. In actuality, most people who abuse drugs do exer cise control most of the time. When the urge is not strong or the substance is not currently available, they are able to abstain. They do not necessarily go off in wild pursuit of the drug at the first sensa tion of craving. There is a qualitative difference between the wish to use (to experience "benefits" of the drug) and the wish to control the urge. The craving activates a drug-taking routine: The individuals' sources for consummating the urge are scanned, a plan emerges, the body becomes mobilized to act, and the physiology shifts to a recep- Cognitive Model of Addiction 35 five state (e.g., the parasympathetic nervous system goes into an a vated state). Since craving is an "appetitive state," it is accompanied by a variety of bodily sensations somewhat akin to hunger or an unpleasant yearning for someone or something. This kind of appe tite operates according to the pleasure principle, in contrast to the wish to control the urge, which operates according to the reality principle. The wish not to use, thus, to control, is not expressed in visceral terms (as is craving) but is experienced as a sort of mental state. It has a sttong cognitive component, specifically, decision-making. What powers the decision-making is a sense of resolution or commitment that is felt in the musculature (in contrast to craving, which is more visceral). Thus, the two opposing motivations—craving and self-control (or will power)—are qualitatively different. Parallel to the decision not to use (refusal state) is the decision to indulge (permission giving). Permission giving and permission refusal are akin to gatekeepers. Their relative'strength determines whether the gates will open or close. There is more conscious (vol untary) participation in the gatekeeping than in the craving; there fore, the individual can reflect and decide whether or not to indulge. If the craving is strong, the decision to refuse/abstain may be too weak to control it. If the balance favors refusal, the using does not occur. Even when the urge is strong, addicted individuals can abstain at times, particularly if the drug is not immediately available. It is important to recognize that addictive behavior is related to the bal ance of control versus urge. Put in more abstract terms, the ratio of the strength of the control to the strength of the urge influences whether the individual will abstain or use. The formula or ratio power ofcontiol/power of urge may be used as a guide for intervention. Treat ment is focused on increasing this ratio. It does not require a super human effort to change the relative strengths. It may simply involve reducing the denominator (urge) or increasing the numerator (con trol) or, preferably, doing both. Beck et al. (1979) have used the analogy of the votes in Congress for a declaration of war to illustrate how suicidal behavior may be modified. A somewhat similar analogy may be applied to a decision to use. To declare war requires a simple plurality, a margin of one vote of the yeas over the nays. However, just as in the case of sui cide, if the decision is postponed or the relationship of yea to nay votes is changed in favor of the nays, the progression to action is arrested. In the case of declaration of war, lobbying for a few votes for peace may forestall the fateful action; in the case of addiction, strengthening the votes for abstinence can reverse the tendency to use. In the long run, however, it is necessary to build a solid "major ity" to forestall relapse. 36 COGNITFVE THERAPY OF SUBSTANCE ABUSE The point to this analogy is that it is not necessary to eliminate cravings totally or to institute absolute control. It is sufficient to change the relative strengths of the two parts of the equation. A change involving reduction of craving or increase in control may interrupt the drug-using progression in the short run. Since the goal is usually permanent abstinence, a durable improvement requires enough last ing change in the ratio to provide a sufficient margin of safety. Treat ment, thus, is directed toward both halves of the equation: increas ing control and reducing craving. Increasing Control Many addicted individuals simply have not developed the skills to control temptation. If such a skill deficit exists, one part of the therapy is directed toward increasing self-control skills. A vari ety of methods can be used to increase control. These techniques can be practiced in the therapist's office. The basic procedure is to repro duce stimulus conditions that will elicit craving and then to rehearse control behaviors as the craving is stimulated. For example, the indi vidual is asked to imagine a situation in which she is offered crack cocaine. She then imagines ways in which to refuse the offer. Or she might imagine feeling blue or anxious and then desiring relief from the discomfort. She then pictures what she will do when craving occurs: divert herself by calling a friend, become engaged in some pleasant activity, or read a flashcard detailing rational responses to cognitions related to craving. Another approach involves dealing directly with permission- giving thoughts. This exercise is carried out in the form of a debate. The patient mentally verbalizes or rehearses reasons for giving per mission to indulge and, at the same time, presents a rebuttal to this argument. At some point, however, it is necessary to identify and evaluate the underlying beliefs regarding permission giving and per mission refusing. Ultimately, of course, the therapist needs to help the patient reduce the craving by dealing with its various psychological and social sources. These sources may cover very broad domains of |
the patient's life ranging from low frustration tolerance to marital problems. "Will Power" In the context of drug using, "will power" refers to a deliberate conscious decision (plus sufficient drive and technical self- help know-how to enforce it) to halt or delay the implementation of Cognitive Model of Addiction 37 an urge. When the urge to use is low or absent, the individual's dr to abstain from further use may appear to be quite strong. However, when the temptation is strong, the will power may become attenu ated. Marlatt and Gordon (1985) consider will power in terms of the strength of the commitment not to use or drink. Commitment means attaching a value to a particular goal so that it supersedes other con tradictory goals. Thus, the allocation of importance to abstinence can power the resolve to resist cravings. The successful application of will power when cravings and urges are aroused depends on a number of factors. An individual may make a serious commitment to stop smoking, drinking, or using but may not have the technical skills to fulfill the commitment. The applica tion of this technical knowledge can greatly increase the amount of leverage when the resolve to abstain is opposed to cravings and urges. Further, core beliefs about oneself (e.g., whether one is effective or helpless) may affect one's capacity to apply will power to controlling urges. W e must caution that patients tend to misconstrue the mean ing of will power, seeing it as an almost masochistic battle to main tain an unceasing state of discomfort in the face of drug urges (Tiffany, 1990). Clinicians must emphasize to patients that they will be taught to modify their beliefs and behaviors (cf. Washton, 1988) so that positive self-image and lifestyle changes will take place. This, along with the natural dissipation of cravings over time (Horvath, 1988), will help patients to feel good about resisting drug use in the long mn, as opposed to feeling deprived and in pain. According to the myth of the "rational man" (e.g., in jurispru dence or economics), an individual weighs the risks and benefits of a given action and makes a rational decision. In the case of the addicted individual, however, the objective cost-benefit analyses, or advantages-disadvantages calculations, are thrown off by the momen tary appeal of using, drinking, or smoking. The immediacy and reli ability of the effect of the drug and the subjective certainty that some desired effect will be achieved right away contrasts with an uncer tain, possibly undesirable consequence in the future. Some individu als become oblivious to the negative consequences when they expe rience the craving (Gawin & EUinwood, 1988). Others simply shrug off the long-range effects with the attifride "I'll take m y chances," or rationalize, "It won't hurt if I give in this one time." O n the other hand, a number of individuals are able to summon up, on their own, arguments and unpleasant memories that deter them from yielding to the temptation. In any event, there is always a con flict when individuals try to utilize will power to forestall yielding to their urges. O n the one hand, for example, an individual experiences 38 COGNITIVE THERAPY OF SUBSTANCE ABUSE the craving (and the anticipated relief or pleasure) and, on the o the voice of reason and restraint (and the anticipated deprivation and distress). After many unpleasant experiences, one may be able to issue oneself warnings of the dangers of indulgence when exposed to a high- risk situation or when aware of the lowering of one's resistance. Whether one will be able to heed these warnings to oneself depends to a large extent on one's access to techniques to implement them. Addictive Beliefs In our work, we have been impressed by the common ality of certain beliefs across various types of addictions (cocaine, opiates, alcohol, nicotine, and prescription drugs) and various addicted individuals. Even individuals susceptible to binge eating or general ized overeating show these types of dysfunctional beliefs (Heatherton & Baumeister, 1991; Lingswiler, Crowther, & Stephens, 1989; Zotter & Crowther, 1991). The addictive beliefs characterize those individu als after they have become addicted (i.e., they are characteristic of the disorder), however, and cannot in themselves be considered predis- positional to addiction. Nonetheless, the addictive beliefs do contrib ute to maintaining the addiction and provide the groundwork for relapse. Addictive beliefs may be considered in terms of a cluster of ideas centering around pleasure seeking, problem solving, relief, and escape. The specific items will vary depending on the type of preferred sub stance. Among the dysfunctional ideas are (1) the belief that one needs the substance if one is to maintain psychological and emotional bal ance; (2) the expectation that the substance will improve social and intellectual functioning; (3) the expectation that one will find plea sure and excitement from using; (4) the belief that the drug will energize the individual and provide increased power; (5) the expecta tion that the drug will have a soothing effect; (6) the assumption that the drug will relieve boredom, anxiety, tension, and depression; and (7) the conviction that unless something is done to satisfy the crav ing or to neutralize the distress, it will continue indefinitely and, possibly, get worse. In addition to these expectations/beliefs, the patients have a variety of beliefs relevant to justification, risk taking, and entitlement. These attitudes fall into one category of "permission-giving beliefs," such as "Since I'm feeling bad, it's O K to use," "I've been having a hard time; therefore, I'm entitied to relief," "If I take a hit, I can get away with it," "The satisfaction I get is worth the risk of relapsing," or "If I give in this time, I will resolve to resist the temptation next time." Cognitive Model of Addiction 39 Predispositional Characteristics A number of characteristics of the drug abuser, how ever, may have existed prior to drug use and thus may be considered predispositional. These characteristics center around (1) general sen sitivity to their unpleasant feelings or emotions—for example, they have a low tolerance for the normal cyclical changes in mood; (2) deficient motivation to control behavior^hus, instant satisfaction is more highly valued than control; (3) inadequate techniques for con trolling behavior and coping with problems—therefore, even when motivated to exert restraint, they do not have the technical knowl edge to follow through with it; (4) a partem of automatic, nonreflective yielding to impulses; (5) excitement seeking and low tolerance for boredom; (6) low tolerance for frustration (low frustration tolerance in itself rests on a complex set of beliefs and cognitive distortions); and (7) relatively diminished future time perspectives, such that the individual's attention is focused on here-and-now emotional states, cravings, and urges and on the actions for relieving or satisfying them. None of the attentional resources are devoted to the consequences of these actions. Low frustration tolerance (LET) seems to be an important precur sor to drug using (Chapter 15, this volume). Specifically, a number of dysfunctional attitudes magnifying the usual everyday sources of fmstration lead to excessive disappointment and anger. Among the components of this belief complex are attitudes such as (1) things should always go smoothly for m e or things should not go wrong; (2) when I am blocked in what I am doing, it is awful; (3) I cannot stand being frustrated; (4) other people are to blame for m y being thwarted, and they should be punished; and (5) people deliberately give m e a hard time. When individuals with LFT find that their activity is blocked or their expectations are thwarted, they are likely to (1) greafly exagger ate the degree of loss resulting from thwarting, (2) exaggerate the long- range consequences of this loss, (3) blame whomever they think might be responsible for thwarting, (4) experience excessive anger, (5) have a sfrong desire to punish the offender, and (6) importantly, overtook other ways of achieving their goal, such as problem solving. The result of this sequence of events is that an individual becomes overmobilized to attiack the offender. Since there is rarely a legitimate avenue for expressing the hostile impulses, the individual is left in a highly energized state, full of tension and anger. At some point, such individuals find that drug taking may reduce the highly volatile state and relieve the pent-up tension. Of course, the use of drugs for this 40 COGNITIVE THERAPY OF SUBSTANCE ABUSE purpose is at best only a temporary remedy and in the long run is self-defeating because the individual never learns ways of coping directly with frustration and solving the contributing problems. Con sequently, LFT is perpetuated, as are the beliefs regarding helpless ness. S U M M A R Y Many addicted individuals have characteristics that predispose them to drug abuse. These predispositional factors include (1) general exaggerated sensitivity to unpleasant feelings, (2) deficient motivation to control behavior, (3) impulsivity, (4) excitement seek ing and low tolerance for boredom, (5) low tolerance for frustration, and (6) in many cases, insufficient prosocial alternatives for gaining pleasurable feelings, and a sense of hopelessness in ever achieving this goal. LFT is characterized by exaggeration of the degree of loss result ing from thwarting, blaming other people for any frustration, a strong desire to punish the offender, and overlooking other ways of prob lem solving. Each of these predispositional factors is addressed in the course of cognitive therapy. The sequence of addiction often follows a vicious cycle proceed ing from anxiety or low mood to self-medication by using or drink ing. This behavior, in turn, produces and/or exacerbates financial, social, and/or medical problems, which lead to further anxiety and low mood. Patients often ascribe their drug and alcohol use to "uncon trollable cravings and urges." However, certain dysfunctional beliefs tend to fuel these cravings. Abusers tend to ignore, minimize, or deny the problems resulting from their drug use or attribute these prob lems to something other than the drugs or alcohol. An important factor in maintaining psychological dependency is the belief that withdrawal from the drug will produce intolerable side effects. In actuality, through careful clinical management these side effects gen erally turn out to be tolerable. Another important set of core beliefs centers around the addicted individual's sense of helplessness in con trolling the craving. Cravings are associated with wanting gratification or relief, whereas urges are concerned with doing something to provide a grati fication or relief. The delay between the experience of craving and the implementation of the urge provides an interval for therapeutic intervention. Cravings and urges tend to be automatic and may become autonomous; the thrust of therapy is to provide voluntary methods for managing them. Patients tend to equate the strong crav- Cognitive Model of Addiction 41 ing with an imperative "need" and an uncontrollable urge. Although the craving leading to drinking and using is involuntary, controlling the urge is voluntary and can be adopted even though the patient may feel helpless. Increasing the ratio of the subjective power of control to the subjective power of the urge may be used as a guide for inter vention. Cognitive therapy is a system of psychotherapy that attempts to reduce self-defeating behavior by modifying erroneous thinking and maladaptive beliefs and teaching techniques of control. In the cogni tive therapy of drug abuse, the specific case formulation forms the basis for the therapeutic regimen. This formulation, in turn, is based on the cognitive model of addictions. The therapeutic approach consists of undermining the urge by weakening the beliefs that feed into the urge and, at the same time, demonstrating to the patient various ways of controlling and modi fying their behavior. Cognitive therapy of substance abuse is charac terized by the following: (1) It is collaborative (builds trust), (2) it is active, (3) it is based, to a large degree on guided discovery and empir ical testing of beliefs, (4) it is highly structured and focused, and (5) it attempts to view the drug or drinking problem as a technical prob lem for which there is a technical solution. C H A P T E R 3 T h e o r y a n d T h e r a p y o f A d d i c t i o n A b-ccording to the |
cognitive perspective, the way people interpret specific situations influences their feelings, motiva tions, and actions. Their interpretations, in turn, are shaped in many instances by the relevant beliefs that become activated in these situ ations. A social situation, for example, m a y activate an idiosyncratic belief such as "Cocaine makes m e more sociable" or "1 can be more relaxed if I have a beer (or a cigarette)," and lead to a desire to use, drink, or smoke. Specific beliefs such as these constitute a vulnerability to substance abuse. Activated under particular predictable circum stances, the beliefs increase the likelihood of continued drug or alco hol use (i.e., they stimulate craving). Beliefs also shape the individual's reactions to the physiological sensations associated with anxiety and craving (Beck, Emery, with Greenberg, 1985). Beliefs such as "1 cannot tolerate anxiety" or "I must give in to this hunger" will influence the person's reactions to these sensations. Individuals with such beliefs are likely to be hyperattentive to these sensations. Even a low-level degree of anxiety or craving can elicit a substance-using belief such as "I must take a hit (or drink) to relieve m y anxiety (or satisfy m y craving)." The activation of substance-using beliefs is illustrated in the expe rience of Les, a chronic cocaine user, w h o experienced a sudden crav ing for cocaine while attending a party. In this scenario, his acute urge to use was related to his sense of social isolation within a group. His underlying belief, "I can't stand it without cocaine," was activated by his sad feelings at seeing other people having a good time using drugs. Les lived in a rundown neighborhood in which there was a great deal 42 Theory and Therapy 43 of drug fraffic. He had a longstanding belief, "I'll never get out this awful environment." This belief (not the environment per se) led to chronic feelings of sadness and hopelessness. The belief underly ing his chronic urge to use cocaine was "I need some coke to get through the day." This case illustrates the coexistence of acute cravings and urges related to a specific situation with more chronic urges related to the patient's general life situation. The combination of these beliefs made Les prone to addiction. LAYERS O F BELIEFS There were several levels of beliefs underlying Les's addictive behavior: (1) his more general basic belief that he was "trapped" in a noxious environment; (2) his belief that the only way he could escape from his environment and his unpleasant feelings was to take drugs; and (3) the belief that he "needed" drugs to relieve any unpleasant feelings. Added to these drug-related beliefs was a basic belief that he did not belong and was not accepted as a member of his peer group. This cluster of beliefs made Les vulnerable to addic tive behavior; that is, they fed into a compulsive urge to relieve his distress through drug taking. The essence of a large proportion of addictive behaviors, consist ing of the types of general and specific beliefs held by this patient, are illustrated in Figure 3.1. The addictive beliefs (Chapter 2, this volume) seem to derive from either one or a combination of core beliefs (sometimes referred to as "core schemas"). The first set of dysfunctional core beliefs has to do with personal survival, achievement, freedom, and autonomy. Depend ing on the precise nature of the patient's vulnerability, the core belief that is expressed m a y have a content such as any of the following: "I am helpless, trapped, defeated, inferior, weak, inept, useless, or a fail ure." The second set of dysfunctional core behefs is concerned with Core Beliefs Emotions Addictive Beliefs "I am trapped/ Sad or "Drugs are an escape." alone." angry "Drugs make me more sociable." Addictive Behavior Go to a crack house FIGURE 3.1. Sequence of core beliefs and addictive beliefs. 44 COGNITIVE THERAPY OF SUBSTANCE ABUSE bonding with other individuals or to a group. This set of beliefs is concerned with lovability or acceptability. The various permutations of the core belief m a y take the following form: "I a m unloved, unde sirable, unwanted, repulsive, rejected, different, socially defective." Such core beliefs constitute a specific sensitivity or vulnerability: W h e n circumstances (e.g., social rejection) that are relevant to the core belief arise, they trigger the belief (e.g., "I a m defective") and lead to distress. Les had a double set of core beliefs revolving around the notions "I a m helpless" and "I a m undesirable." W h e n he noted the difficult conditions in his neighborhood, the first belief was triggered and took the form "I a m trapped." O n c e this notion took hold, he believed himself incapable of improving his lot, saw the future as hopeless, and felt frustrated and sad. The specific addictive belief-was then trig gered: "The only w a y to get relief is to take a hit." In a group situation his automatic thought was "I don't belong." This thought stemmed from his other core belief, "I a m unaccept able." These beliefs converged o n the addictive belief: "The only way to get accepted is to use coke." T h e relation between his two core beliefs, his automatic thought, his addictive belief, and his craving is illustrated in Figure 3.2. The same sort of constellation of core belief, addictive belief, and craving m a y apply whatever the instigating factor and whether the form of relief is alcohol, illegal drugs, legal drugs, or tobacco. The sequence generally proceeds from (1) a core belief, such as a nega tive view of the self (helpless, undesirable) and/or a negative view of the environment (noxious, oppressive), and/or a negative view of the future (hopeless), to (2) unpleasant feelings, such as dysphoria or anxi ety. From there, the addiction-prone individual experiences (3) crav ing and psychological dependency o n drugs (e.g., "1 need cocaine to m a k e m e feel better). Core Belief Automatic Thought Emotions "I am "I am trapped in this Sad or helpless." bad environment." frustrated .r Core Belief Addictive Belief Conclusion "I am "I don't belong unless I "1 need the drug" undesirable." use." \f Craving FIGURE 3.2. Interaction of multiple beliefs. Theory and Therapy 45 It is important to note that the perception of a noxious environ ment is not limited to inner-city individuals. Privileged individuals who perceive their job, family, or marital situation as inimical, who experience the same sequence of discouragement over life circum stances and have negative views of themselves and their future, may turn to drugs as a form of escape. In depression (Chapter 14, this volume), the negative view of the self, the current circumstances, and the future often is exaggerated. After patients modify their depressive thinking, the therapist often finds that compulsive drug use is dimin ished (Woody et al., 1983). Individuals like Les become habitual users because they regard using as a way of gaining or maintaining social acceptance. They have addictive beliefs such as "I can't let m y friends down ... they will reject me if I don't use." (This fear, of course, may be realistic and one of the goals of therapy may be to help the patient to develop friendships with nonusers.) One patient greatly admired his cousin who was addicted to cocaine. The patient constantly used crack when he was with his cousin. The instigating factor each time was a desire to please his cousin. Eventually, using became embedded in his sys tem of coping with his fear of becoming socially ostracized. S E Q U E N C E O F BELIEFS Although the core beliefs represent the background of the addictive beliefs, they are not immediately apparent unless the patient is depressed (Chapter 14, this volume). The addictive beliefs may be more accessible. These addictive beliefs are activated in a specific sequence. First in the sequence are anticipatory beliefs. Initially these take a form such as "It will be fun to do this .. . It's okay to try it occasionally." As the patient gains satisfaction from using, he/she often develops romanticized beliefs predictive of gratification or escape: "1 will have an hour or so of sheer pleasure ... I wiU feel less sad/anxious ... It wiU be a sweet oblivion." Some beliefs are predic tive of increased efficacy or socialization: "I will perform better ... I will be more entertaining and will be accepted into the group." As the individuals start to rely on the drug to counteract feelings of disfress, they develop relief-oriented beliefs, such as "I need cocaine in order to function ... I can't continue without it... I will feel well again if I use ... I need the drug ... I can't control the craving ... I must have it or I'll fall apart." Note the imperative quality of these beliefs: "I must have a smoke to make it through the day." The acti vation of these beliefs then leads to cravings. 46 COGNITFVE THERAPY OF SUBSTANCE ABUSE Activating Anticipatory Craving situation beliefs Drug-seeking Permissive < plan of action beliefs FIGURE 3.3. Sequence of anticipatory and permissive beliefs. Since addiction-prone individuals may have some conflict about using (e.g., medical, financial, social, or legal consequences of using), they generally develop a facilitating or permissive belief, such as "1 deserve it" or "It's all right, I can handle it... Since I'm feeling bad, it's all right to use . .. Nothing else is going right; this is the only right thing in m y life." The relation of these beliefs is illustrated in Fig ure 3.3. The sequence of these beliefs formed by Les is illustrated in Fig ure 3.4. His uneasiness in a social situation triggers the anticipatory belief "I will feel better if I use," which is immediately followed by a craving and then the plan of action to call his cousin for a "hit." CONFLICTING BELIEFS In the various stages of cocaine use the patient can have conflicting sets of beliefs, such as "I should not use cocaine" versus "It's O K to use this one time." Each behef can be activated under different circumstances or even at the same time. The balance between the relative strength of each belief at a given time will influence whether the patient uses or abstains. (Of course, the availability of the drug will also be a determining factor.) Sometimes the individual experiences a conflict between the desire to use and the desire to be free of drugs. This ambivalence may be formulated as a conflict between two beliefs: "It's O K " (permis sive) versus "It's not O K " (abstinent). The conflict between these beliefs results in discomfort or m a y increase the individual's current discomfort. Paradoxically, the individual m a y experience an even greater pull toward using in order to relieve the uneasiness produced by the conflict. The belief "I need relief from this feeling" becomes more potent and may tip the scales in favor of using. In therapy, patients learn skills to cope with the discomfort and to test out and restructure their belief that using or drinking is the most usefial way of dealing with discomfort. Theory and Therapy 4 7 Social 1 will leei situation Craving better If..." Call cousin "It's OK." , _ FIGURE 3.4. Simple model of Les's substance use (maps onto Figure 3.3). A C T I V A T I O N O F BELIEFS IN S T I M U L U S SITUATIONS Drug-using beliefs and desires typically are activated in specific, often predictable, circumstances, which we term "stimu lus situations." These are also labeled "cues" (Moorey, 1989). How ever, depending on the patient's current mood and self-control, the degree of riskiness of a situation may vary considerably from time to time. That is, a situation that is manageable at one time may be stimu lating enough to promote drug use at another time. These circum stances, which can be external or internal, correspond to what Marlatt and Gordon (1985) term "high-risk situations." These situations stimu late the craving to "smoke, shoot, snort, or swallow drugs." Examples of external stimulus situations are a gathering of friends using cocaine, contact with a |
drug dealer, or receiving a weekly pay check. Internal circumstances (or cues) include various emotional states such as depression, anxiety, or boredom, which can trigger drug- using beliefs and, consequently, craving for the drug. As shown in Figure 3.5, drug use may be regarded as represent ing the final common pathway of the activation of the cluster of the aforementioned beliefs. Cognitive therapy is aimed at modifying each of the categories of beliefs: anticipatory a n d permissive, as well as the underlying core beliefs (e.g., "I a m frapped") that potentiate these drug- Activating Beliefs Automatic > Craving/ stimulus: activated thoughts urges • Internal cues • External cues t \f Continued Focus on Instrumental Facilitating use or strateoies beliefs relapse (action) (Pe rmi 3sion) F I G U R E 3.5. Complete model of substance use. 48 COGNITIVE THERAPY OF SUBSTANCE ABUSE related beliefs. The therapist attempts to introduce or reinforce more adaptive beliefs relevant to each of the classes of beliefs. Other tech niques are concerned with dealing with major life problems (see Chapters 12 and 13, this volume) or personality difficulties or disor ders (see Chapters 14, 15, and 16, this volume) leading to drug use. As shown earlier, craving is aroused in a specific situation and seems to arise as a reflex reaction to the stimulus. However, the situ ation does not directly "cause" the craving: Interposed between the stimulus and the craving is a drug-related belief that is activated by the situation and an automatic thought derived from this belief. For example, w h e n he was feeling sad, Les would get the thought "If I take a hit now, I will feel better." His underlying belief was: "I can't stand discomfort... I need a fix to make the discomfort go away." The sequence then proceeded to craving, to facilitating beliefs ("It's O K this time"), to an actual plan for obtaining the drug, and finally to using. These beliefs can be ascertained by direct questioning and the use of inventories (see Appendix, this volume). The sequence proceeds so rapidly that it is often viewed as a "conditioned reflex" (O'Brien, 1992). The automatic thought, in par ticular, seems to be almost instantaneous and can be captured only if the patient learns to focus on the chain of events. Figure 3.6 illustrates the sequence from the activating stimulus to the implementation of the plan to get the drug. It should be noted that each step offers an opportunity for a cognitive intervention. Using the method of guided discovery (Beck et al., 1979), for example, the cognitive therapist questions the meaning attached to the activating stimulus, the relief-oriented belief that taking a fix is the most desir able solution, the permission-giving belief ("I can do it without harm"), and the implementation plan (the decision to look around for money). Les had a very low tolerance for unpleasant feelings, whether sadness, anxiety, or sheer boredom. His belief regarding the neces sity for alleviating feelings of distress was activated w h e n he attended a party. His drug-taking beliefs centered on the anticipation of reUef Feeling sad "If I take a fix I will feel better.' "What the hell." Craving Purchase and Look around to "I can do It this use drugs get the money. time without any harm." F I G U R E 3.6. Example of Les's drug-using sequence (maps onto Figure 3.5). Theory and Therapy 49 from any negative feelings. Other examples of his anticipatory rel oriented beliefs were: "There is only one way for m e to have fun," "I can't stand the withdrawal symptoms," "I feel better knowing it's there," and "If I don't take a hit regularly, I will feel much worse." It should be noted that the patient's permissive thoughts about the harmlessness of drug taking stemmed from a simplistic (and deceptive) set of beliefs. He believed that since he only snorted cocaine, he could not be addicted: He saw himself as being safe from addic tion provided he did not smoke crack. In fact, one of his typical per missive thoughts was, "I'm O K since I don't smoke crack." "Spontaneous craving" (i.e., craving in the absence of an obvi ous external stimulus) is also often observed. For example, a patient with a 5-year history of cocaine use reported having a dream about using cocaine. Upon awakening, he "felt high." Next, he started day dreaming about the last time he had used cocaine. This imagined scenario in turn activated the belief, "Life is more fun when I use," and was followed by the automatic thought, "I love this stuff." A permission-giving belief was also activated, "There is no harm in this." His attention then focused on checking to see whether he had enough money to buy cocaine. Although the craving appeared to be sponta neous in this case, the patient's mental state during the dream and upon awakening set the stage for daydreaming about using. This imagery served as a catalyst for the permission-giving thoughts. His attention then focused on implementing his craving and shut out any consideration of the ill effects of using. INFORMATION PROCESSING: MEANING, SYMBOLISM, AND RULES In referring to the kinds of circumstances (external or internal) that excite the craving-using cycle, we generally use the term "stimulus situations" or "triggers" rather than "high-risk sifrra- tions" introduced by Mariatt and Gordon (1985). Although many situ ations have a high probability of setting the craving-using pattern into motion, their effect varies from person to person and even for the same person over time. By conceptualizing these situations in terms of their stimulus properties and meanings, we can align our concept of drug use and abuse with concepts regarding stress (Beck, 1993), syndromal disorders (e.g., depression; Beck et al., 1979), and person ality disorders (Beck, Freeman, & Associates, 1990). While the term "high-risk situation" fits nicely into a descriptive model, the formulation in more cognitive terms can fit our observa- 50 COGNITIVE THERAPY OF SUBSTANCE ABUSE tion into an explanatory model. This model, encompassing concepts of the activation of beliefs, symbols, information processing, and motivation, provides a broader framework for understanding and psychological intervention. Although we use the terms "stimulus situations" and "stimulus properties," it should be noted that the actual situation is neutral. It becomes a stimulus if a person attaches a special meaning to it. For example, an addicted individual looks at a cocaine pipe and other paraphernalia and becomes excited and experiences craving. Another person, indifferent to drugs or not knowledgeable about the parapher nalia, simply sees a pipe. For the first person, the pipe is a symbol, a coded message, packed with meaning. The meaning is not inherent in the pipe but in the individual's personal symbolic code (embed ded in his or her information or cognitive processing system). The individual automatically applies this code when he/she perceives the paraphernalia, for example, and consequently experiences pleasure and craving. The therapist's task is to help the patient to decode the symbol. If one "unpacks" its meaning, it would read something like this: "The pipe means taking a hit, which will give me pleasure." The pipe and the concept of pleasure have become fused so that the expectation of pleasure in the future gives pleasure now and leads to craving. The drug abuser may seem to be stimulus bound. Any depiction of or reference to drugs on television, radio, or magazines, for exam ple, may be sufficient to excite the individual. The addicted person is actually "schema driven"; that is, Les's reactions are produced by inter nal cognitive structures, labeled schemas, that contain the code, for mulas, or beliefs that attach meaning to the situation (see Beck, 1967, for a complete description of schemas). Thus, a schema containing the belief "Using is necessary for m y happiness" will be primed when the person is exposed to a relevant situation. Similarly, a schema containing the belief "I cannot be happy unless I am loved" will be activated if the person perceives that he or she has been rejected by a lover and, thus, will feel sad. The experi ence of the sad affect will, in turn, be processed cognitively by behefs such as "I can't stand sadness," "I need relief by using." The indi vidual then experiences craving. The therapeutic application of this explanatory model involves attaching more importance to modifying the individual's belief sys tem than to simply getting him to avoid or cope with high-risk situ ations. Since some "situations" (such as internal states) are unavoid able and other sihiations (e.g., exposure to drug-related situations) may be inevitable (Childress, Hole, & DePhilippis, 1990; Moorey, 1989; Theory and Therapy 51 O'Brien, McLellan, Alterman, & Childress, 1992; Shulman, 1989), the best outcome can be derived from changing the beliefs that make these situations risky. Les, for example, often compared himself with other people more successful than he. W h e n he saw such a person, his negative beliefs ("I'm inferior" and "I'm no good") were activated. Thus, the mean ing attached to the perception of the other person was a self-devalu ation, leading to sadness. He also attached a meaning to sadness: "My life is intolerable ... I can't stand the pain." Following the activation of the belief "I need dope to ease the pain," Les experienced craving. In therapy, each of these beliefs was explored. The proposed mechanism for therapeutic change consists of align ing the belief system more closely with reality. Since the beliefs are maladaptive (e.g., "I need the drug [or alcohol] in order to function"), it is necessary either to modify these beliefs or to substitute more functional beliefs (or both). The process of change, however, involves more than simple modification of the beliefs. The therapist and patient need to work together to improve the patient's system of controls (e.g., by practic ing delay of gratification) and to learn coping techniques such as anticipating and solving problems. Thus, the therapeutic goals are (1) conceptual change and (2) tech nical development of proficiency in coping. Cognitive Blockade W h e n they are not experiencing craving, patients are generally able to recognize the disruptive effects of the drug on their lives. However, once the drug-taking beliefs are activated, a "cogni tive blockade" inhibits awareness of or attention to the delayed long- term consequences of drug use (Gawin & EUinwood, 1988; Velten, 1986) and increases the focus on immediate instrumental strategies, such as searching for money to buy drugs. As these beliefs become hyperactive, recognition of the drawbacks of drug use become attenu ated. W h e n Les was not feeling sad, he was convinced that using cocaine was bad for him, but once his craving was stimulated, he had difficulty in remembering his reasons for not using. His attentional processes were predominantly allocated to using. The immediacy of the stimulus and the activated meanings shut out serious consider ation of long-range consequences. This kind of "tunnel vision," in which the individual's attentional resources are devoted almost totally to the immediate situation, has been demonsfrated in cognitive psychology experiments (Beck, 1991). 52 COGNITIVE THERAPY OF SUBSTANCE ABUSE For example, very hungry individuals will be hypersensitive to sti relevant to food or eating and will be relatively insensitive to other signals. The introduction of danger stimuli, however, will shift the attention to the danger stimuli and away from food stimuli. Clinical states show the same type of phenomenon. Information that is con gruent with the clinical condition will be processed very rapidly and memories congruent with the state can be rapidly recalled, but the patient has trouble gaining access to stored information that is not congruent with the clinical condition. Depressed patients, for example, quickly assimilate negative information about themselves but block out positive information. Also, they recall negative information much better than positive information (Beck, 1991). Similarly, patients hav ing a panic attack readily respond to suggestions that they are expe riencing a serious condition but have problems in recalling benign explanations for their attacks or even in applying reason to counter act the catastrophic interpretations they are making (Beck, 1986). A somewhat similar phenomenon may be observed among many individuals addicted to drugs, alcohol, or nicotine. Although when sober they may be quite adept at reeling off (with sincerity and |
con viction) the reasons for not using, drug users have difficulty in recall ing or attaching the same significance to these reasons once they are in the throes of a specific drug-using episode. Since all their atten tion is focused on the mechanics of obtaining the drug, the reasons for using at that time become very salient and the contradictory rea sons become inaccessible or insignificant. This phenomenon is termed the "cognitive blockade" because of blocking out the incongruent (i.e., the corrective, realistic) informa tion. The therapeutic task is to lift the blockade, as it were, through a variety of tasks. One approach is to deliberately activate the crav ing cycle in the office (e.g., through imagery) and, while the craving is strong, review the reasons for not using. Of course, sufficient time must be allotted for this maneuver to preclude the craving's being maintained following the session (Childress et al., 1990). A similar strategy involves the preparation of flashcards (listing reasons for not using) which patients will read when they experience craving in the natural environment. SUMMARY At the core of the problem of the addicted individual is a set of addictive beliefs which appear to be derived from core beliefs such as "1 am helpless," "I am unlovable," or "I am vulnerable." These Theory and Therapy 53 core beliefs interact with life stressors to produce excessive anxiety, dysphoria, or anger. These stressful or stimulus situations do not directly "cause" craving, but they activate the drug-related beliefs that lead to the craving. Although w e use the term "stimulus situation," it should be noted that the situation itself is neutral. The meanings, derived from the beliefs, that are attached to a situation are what cause the individual's craving. Individuals with beliefs that they cannot tolerate anxiety, dysphoria, or frustration, for example, will tend to be hyperattentive to these sensations and m a y build up expectations that they can relieve the sensations only through using or drinking. Thus, w h e n an unpleasant affect arises, the individual attempts to neutralize it by using or drinking. A specific sequence of drug-related beliefs leading to drinking or using m a y be delineated. First is the activation of anticipatory beliefs relevant to obtaining pleasure from using or drinking. These antici patory beliefs usually progress to relief-oriented imperative beliefs, which define using or drinking as a dire necessity and stipulate that the craving is uncontrollable and must be satisfied. The anticipation of pleasure or relief leads to the activation of craving and facilitating 01 permissive beliefs, such as "I deserve it" or "It's O K this time," which legitimize using or drinking. Finally, the instrumental plans, which have to do with plans or strategies for obtaining drugs or alcohol, are propelled by the imperative craving. M a n y individuals have conflicting beliefs regarding the pros and cons of using. At times they are locked in such an unpleasant struggle between these opposing beliefs that, paradoxically, they m a y seek dmgs simply to relieve the tension generated by the conflict. The therapeutic application of this model, consisting of modify ing the individual's belief system, goes beyond teaching the individual to avoid or cope with "high-risk situations." C H A P T E R 4 T h e T h e r a p e u t i c R e l a t i o n s h i p a n d I t s P r o b l e m s A , , collaborative relationship between the therapist and the patient is a vital component of any successful therapy. The most brilliantly conceived interventions will be reduced in effective ness if the patient is not engaged in the process of treatment. All the support and effort that the therapist m a y put forth in an effort to help the patient will make little impact if the therapist has not gained some measure of the patient's trust. While this seems to be relevant to almost every type of patient, it is most especially true of the substance-abusing population. Numer ous potential factors interact to create an almost adversarial relation ship between the therapist and the drug-abusing patient at the begin ning of therapy and during the course of treatment. These factors include: 1. Drug-abusing patients often do not enter treatment on a vol untary basis. 2. Patients often maintain highly dysfunctional presuppositions about therapy. 3. Patients often are not very open and honest, at least at the start of therapy. 4. Patients may be currently involved in felonious activities, thus presenting confidentiality dilemmas. 5. Patients view their therapist as part of the "system," and not as an ally. 54 The Therapeutic Relationship 55 6. Patients have a difficult time believing that their therapist r cares about their problems. 7. Patients look askance at therapists w h o m they perceive to differ from them markedly in terms of demographics and attitudes. 8. Therapists may maintain negative presuppositions about drug- abusing patients. Many of these patients do not come into therapy of their own volition. Some are given an ultimatum by their significant others (e.g., spouse, children, or parents) or employers, while others are remanded by the courts following criminal legal proceedings (Frances & Miller, 1991). Consequently, the drug-abusing patient may enter the ther apist's office with any number of counterproductive automatic thoughts, such as "I don't want to be here; I'm only here so m y wife will get off m y back," "I'll just tell this doctor what he wants to hear, and then I'll blow out of here," "This whole therapy thing is like doing real easy time compared to prison; I'll just go along with this and do what I want to do anyway," "I don't really have a problem; maybe I'll show up for therapy, and maybe I won't," and "I'm not going to tell this shrink anything that can be used against me; m y life is nobody's business but m y own." The list could go on and on. To complicate matters further, drug-abusing patients typically enter therapy playing their cards close to their vests, and therefore conceal the kinds of automatic thoughts listed above. The therapist must actively probe for them, as the patients often will not divulge them in an unsolicited fashion (Covi et al., 1990). Another factor that militates against the ready formation of a positive therapeutic relationship is that substance abuse often repre sents felonious behavior. As such, patients are highly motivated to be dishonest in self-reporting their substance abuse activities. Although the vast majority of therapeutic interactions represent privi leged communications between therapist and patient, drug-abusing patients are typically well schooled in covering their tracks. As the stakes are high, such patients may simply decide it is best to take no chances, and therefore will not readily admit to drug-abuse-related behaviors. Furthermore, some actions of the patients may be serious enough threats to themselves or to the general public that the thera pist may legally and ethically be required to contact the authorities (e.g., when the patient admits that a drug-related murder has been arranged, or when the patient calls the therapist and claims to have taken a drug overdose in order to attempt suicide). Since therapists should inform their patients about the limits of confidentiality at the outset, drug-abusing patients will come to know 56 COGNTTIVE THERAPY OF SUBSTANCE ABUSE what information they cannot safely reveal. If they do come forth such sensitive material, the therapist is placed in the uncomfortable position of having to serve as society's watchdog, and may in the process completely discourage the patient from continuing with much needed treatment. This point highlights another more general factor that adds to the difficulty in forming a working alliance with drug-abusing patients-̂ iamely, that such patients often view the therapist as an agent of the police, the courts, "the system," or a more privileged socio economic class. Such patients find it hard to believe that their thera pists will sincerely try to help them with their problems, or will treat them with honesty, respect, and positive regard. As a result, the patients tend to dread and avoid therapy sessions. They may take con frontational statements from the therapist as confirmation that the therapist is working against them, while positive statements from the therapist may be seen as naive, manipulative, insincere, or patroniz ing. This places the therapist in a "damned if I don't, damned if I do" position, which, left unaddressed, may sabotage therapy before it gets started. Yet another stumbling block to the formation of a healthy thera peutic relationship is the perceived demographic and/or attitudinal differences between therapist and patient. For instance, the patient might think, "This doctor is probably rich and has everything she wants in life. There's no way that she could possibly understand what it's like to struggle every day of your life like I do. H o w in the worid can she help me? The rules of her world just don't apply to mine. Whatever she says is just bullshit." Another thought might be, "I wonder if this therapist ever used drugs. If he did, then he's no bet ter than me, so why should I listen to him? If he didn't, then how can he know what it's like to be hooked? Only someone who's been there could know what he's talking about." Similarly, the therapist may have maladaptive beliefs about the patient, such as "This guy is a low-life. At best he's going to waste m y valuable time, and at worst he's going to be a liability or a threat to m y personal safety," or "These types of patients are beyond help. They have a chronic disease for which there is little hope for cure or rehabilitation. Therefore, there's not much point in investing too much of m y time or energy," or "I can't relate to this patient at all. 1 wouldn't associate with him (or her) in 'real life' so I don't think I'll be able to form a working bond with this patient here in the office either." Admittedly, working with drug-using patients can be highly stress ful; therefore we strongly encourage therapists to engage in regular The Therapeutic Relationship 57 peer supervision with colleagues in order to receive professional support and objective advice. Such consultations can help therapists to avert burnout, and to combat their own dysfunctional beliefs pertinent to working with the drug-abusing populations (cf. Weiner & Fox, 1982). W e acknowledge that the obstacles are formidable. However, based on extensive clinical experience, we believe it is possible to establish a positive, collaborative therapeutic relationship with the substance abuser. W e consider this to be the case even when such patients exhibit severe concomitant Axis II disorders, such as para noid, narcissistic, and/or antisocial personalities (see Chapter 16, this volume). To be sure, the task is difficult, and frequently trying. At the same time, freating the substance-abusing patient can be reframed as represeriting a growth-enhancing challenge for the therapist. The skills of developing therapeutic alliances with difficult populations (e.g., substance abusers and borderline patients), comprise the "art" of therapy, and as such are very much a measure of the competency of the mental health professional. This chapter presents guidelines for facilitating the formation and maintenance of an adaptive and functional therapeutic relationship with the drug-abusing patient. Case illustrations are provided in order to highlight various techniques and strategies, as well as to demon strate how things can go awry. The central messages of this chapter are that (1) a positive therapeutic relationship does not occur by chance—it can be actively constructed, (2) treating the drug-abusing patient requires careful and vigilant attention to the vicissitudes of the interactions between the therapist and the patient, and (3) the management of the therapeutic relationship with the drug-abusing patient is neither a straightforward nor an overwhelming task. ESTABLISHING R A P P O R T The initial interactions between the patient who is just entering therapy and the therapist are extremely important. Even when dmg-abusing patients are self-referred, they often have a great deal of ambivalence about seeking ongoing contact with a therapist (Carroll, Rounsaville, & Gawin, 1991; CarroU, Rounsaville, & Keller, 1991; Havassy et al., 1991; Institute |
the patient's thoughts, followed by sincere involvement by way of questioning and direct, honest, humble feedback, will be a boon to the establishing of rapport. As patients attempt to engage in the process of treatment, thera pists can help facilitate the establishment of rapport by giving posi tive verbal reinforcement for the patients' pro-therapy behaviors and attitudes. For example, therapists can provide encouragement and praise to patients for demonstrating good attendance, promptness, active participation in sessions, and cooperation with therapeutic homework assignments (e.g., writing down the disadvantages of using drugs each time the patient experiences a strong urge to go out to make a "score"). Such positive feedback from therapists helps patients to feel supported, to understand their role in therapy, and to decrease their anxieties and negative expectations about the process of work ing with mental health professionals. BUILDING T R U S T Trust does not develop immediately. It cannot be asked for, and it cannot be artificially rushed. Only through the therapist's consistent professionalism, honesty, and well-meaning actions over a period of time can trust enter fully into the therapeu- The Therapeutic Relationship 63 tic relationship. It does no good for the therapist to say merely, worry, you can trust me." It is far more realistic to admit that there is little reason for the patient to trust the therapist in the beginning, but that "I hope that in time you will decide for yourself whether or not I can be believed and trusted." Unfortunately, trust can be impaired or lost relatively quickly, and therefore it must be nurtured and managed in a delicate, painstaking fashion. In short, therapeutic trust with the substance-abusing popu lation is difficult to establish, and may be more difficult to maintain. Furthermore, even if the patient learns to trust the therapist, there may be little reason for the therapist to trust the patient. Inaccurate and/or incomplete reporting by patients is a frequent phenomenon with this population, a situation to which the therapist must remain sensitive. Nevertheless, since the professional is held to a higher stan dard of behavior than is the patient, the therapist must be willing to continue benevolently to assist the substance-abusing patient, even if that patient has been untruthful. Later, we discuss ways in which the therapist can confront such dishonesty on the part of the patient, yet continue to strengthen the therapeutic relationship and work toward greater progress in treatment. The following suggestions and illustrations are offered to assist the cognitive therapist in achieving and holding on to this most valu able therapeutic asset. The basic elements of trust building are very simple and undra- matic. They include behaviors that consistently demonstrate the ther apist's genuine involvement in the therapeutic process, and com mitment to being available to the patient. Such behaviors include (1) being available for therapy sessions on a regular basis, (2) being on time for sessions (even if the patient is not), (3) returning patient telephone calls in a prompt manner, (4) being available for emergency intervention (e.g., by giving the patient a telephone number where the therapist can be reached in case of the need for crisis interven tion), (5) showing concern and being willing to try to contact the patient if he or she fails to keep an appointment, and (6) remaining in touch with the patient (and available for the resumption of outpa tient cognitive therapy) if inpatient hospitalization, detoxification freatment, halfway house rehabilitation, or reincarceration takes place during the course of the therapeutic relationship. Therapists foster trust when they assiduously avoid making dis paraging comments about the patient, the patient's family members, other substance abusers with w h o m the therapist has had contact, or any socioeconomic, ethnic, or gender group. Even if the therapist makes the derogatory comment about someone else, the patient may 64 COGNITIVE THERAPY OF SUBSTANCE ABUSE think that this is how the therapist truly thinks of him or her wh not working in the role of "therapist," and such a remark may foster the patient's possible belief that the therapist is insincere in his or her show of respect. Trust is also built when therapists serve as role models who have "clean" lifestyles and attitudes. Offhanded comments by therapists about their own "partying" or "getting buzzed" clearly are contra- indicated. Such statements give drug-abusing patients a confusing mixed message. This message may lead the patient to perceive the therapist as a hypocrite who operates on a "Do as I say, not as I do" policy. Related to this issue is the situation that arises when patients ask therapists about their own experiences with drug use. Certainly, thera pists are under no obligation to answer this type of question. A typi cal appropriate response would be, "I know you're curious about it, but I'm going to have to decline to answer your question. W e really have to stick to talking about issues that are relevant to you." At the same time, therapists may use their discretion in choos ing whether to answer. A brief, honest reply may go a long way toward fostering the patient's sense of trust for the therapist. For example, the therapist might answer, "No, I've never used any drugs on more than a try-and-see basis, and even that was fifteen years ago. I was playing with fire, and I guess I'm lucky it never progressed. But I've seen enough misery in the lives of those who've gotten into more regular drug use to know that I'd be a damned fool to ever try any thing again." Another honest answer could be, "No, I've never used drugs. I was always too afraid that I might like them. But really, we need to focus back on you because this is your session." Those thera pists who have used drugs in the past may choose to be silent about this matter or may use the experience to make rare but relevant self- disclosures as a way of keeping a patient engaged in treatment or to drive home an important point. The goal here again is to nurture the therapeutic relationship, not to get sidetracked from the work of therapy. SETTING LIMITS While it is crucial that therapists strive to work in a collaborative fashion with their drug-abusing patients, they must take care not to become oversolicitous to the point that patients know they can take advantage of their therapist. Limits must be set (Moorey, 1989)-for example, that a therapy session will not be held if it is de termined that the patient is in an inebriated or drug-intoxicated state. The Therapeutic Relatioruhip 65 Another such limit might be that the therapist will not condone "a little bit" of drug use. Therapists can establish such ground rules without sabotaging the therapeutic relationship if they take care to maintain a respectful tone, and reiterate their commitment to act in ways that are in the best therapeutic interest of their patients (Newman, 1988, 1990). When one of our patients arrived drunk to a session, the following dialogue took place: TH: Walt, pardon me for asking this ... and if I'm mistaken please accept m y apology... but have you had something to drink before coming to this session? PT: I had a few. N o big deal {belches to be humorously obnoxious). TH: H o w many is "a few"? PT: You know, a few. TH: Walt, I think you're intoxicated. PT: I'm fine. I can hold m y beer pretty good. TH: Walt, we've discussed this before. If you're in an altered state of mind ... and believe me, drinking "a few" means that you're in an altered state of mind ... there's no point in going through with this session. I have no reason to believe that you'll be able to pay serious enough attention to what we do here to warrant continuing with this session. PT: Shit man, you're making a big deal out of nothing. TH: Walt... PT: I'm fine I tell you. TH: Walt... PT: I shouldn't have said anything. TH: Walt... I'm glad you were up front with me. I respect you for it. I'm depending on you to be a man and tell m e the real story to m y face. It's just that we can't go through with this session. That was our agreement, and I think we should stick to our agreements. PT: Shit, man. TH: Did you drive here? PT: No, I was beamed down {sneers). TH: I have something important to ask you. I need to ask you to hang out in the waiting room for a couple hours until you're sober enough to drive safely. 66 COGNITIVE THERAPY OF SUBSTANCE ABUSE PT: Doc, I don't got time for this shit. I got here fine, and I'll home fine. TH: Walt, you've worked too hard to get to this point to mess up now. If you get pulled over, or worse, you're risking going back to jail. I don't want to see that happen to you. What's a couple of hours to ensure your freedom? You can have m y newspaper to keep you occupied for awhile. The patient ultimately complied with this therapist's request. The limit was clearly set, but the tone of the communication was neither critical nor controlling. The therapist emphasized that he was look ing out for the patient's welfare, and this had a lot to do with the patient's compliance and willingness to continue actively with cog nitive therapy. When the therapist sets a limit, sticks to it, and does so in a respectful way, trust is fostered and the patient learns to have respect for the therapist as well. Parenthetical to the above, it is necessary that the therapist be amenable to continuing with therapy once the patient is in compli ance again after a slip (Mackay & Mariatt, 1991). Since many drug- abusing patients frequentiy test limits, no gains will be made if thera pists are disinclined to go forward with therapy when their patients engage in defiant and/or manipulative behaviors. Therapists serve their drug-abusing patients best when they follow through on predeter mined agreements on how to deal with counterproductive patient behavior but also show genuine support and encourage the patients to "get with the program" again. The above vignette brings up the issue of the role of alcohol in the illicit drug-abusing patient's life and therapy. While we believe that it is theoretically possible for illicit-drug-abusing patients to con tinue to drink alcoholic beverages on a casual basis during treatment, in practice our experience tells us that the use of alcohol undermines their abstinence from drugs such as cocaine and heroin. One reason is that the use of alcohol lowers patients' inhibitions. Patients have reported that when they are drinking they are less likely to think about the compelling reasons for staying free of drugs. Even when they can stay focused on the disadvantages of drug use, patients report that they are less apt to care about the long-term consequences of their behavior than when they are sober. Thus, they are more likely to resume the use of harder substances. Further, when patients use alco hol as a "substitute" for drugs such as cocaine or heroine, their con sumption quickly escalates to levels indicative of abuse and depen dence. Therefore, we discourage the use of alcohol durtng patients' treatment and recovery from illicit drugs. The Therapeutic Relationship 67 PROTECTING CONFIDENTIALITY As alluded to previously, there are limitations to con fidentiality. Therapists should spell this out to their patients from the very start. The following monologue may serve as a model: "Mr. A, I want you to know that almost everything we discuss here will be kept just between you and me, unless you want rne to talk to someone else about your situation or you otherwise give m e permission. So, for the most part, things that you tell m e here will be kept confidential. But I want to inform you that there are certain exceptions to this rule. If you tell m e something that indicates that you or someone else is in danger, and you're not willing to help me fix the situation so that everyone is safe, then I am legally obligated to contact the authorities and anybody else who |
their home tele phone numbers for use in emergency situations, we realize that some therapists may prefer instead to make use of an intermediary such as an answering service. In either case, we believe that it is necessary for patients to be able to make contact with their therapist after hours in the event of critical situations.) APPEALING T O PATIENTS' POSITIVE SELF-ESTEEM As many substance abusers evidence defiant attitudes and/or pathological levels of self-importance, it is often necessary for the therapist to appeal to patients' narcissism in order to elicit col laboration from them. This does not have to entail gross hyperbole on the part of the therapist. If fact, such an approach is contraindicated as the intelligent patient will rightly see it as an insincere, manipula tive ploy. Rather, the therapist needs to focus on some of the patient's actual strengths and positive points, and express appreciation for these qualities. This approach serves to strengthen rapport and to elicit greater cooperation. The following clinical vignette demonstrates an appeal to the patient's sense of entitlement in order to defuse his anger toward the therapist. The problem arose when the patient did not show up for his session, and instead called 5 hours later to say that he had gotten a fiat tire on the way to the therapist's office. The dialogue (a con densed version of the actual interchange) proceeded in the following manner: TH: Walt, we've talked about how important it is for you to get to sessions on time, and to keep me informed of your whereabouts. The fact that you waited five hours to call me concerns me. PT: {Exasperated) I was on the road. I couldn't get to a phone. I didn't have a spare tire so I had to wait to get help. There was no way 1 could call any sooner. TH: Walt, ninety percent of m e wants very much to believe you, but I have to be honest with you—ten percent of m e has m y doubts. I can't help but wonder whether your lateness in getting in touch with me is drug related. [The patient responded very angrily, vilifying the therapist for being "such a hard-ass" and for insulting the patient by "calling me The Therapeutic Relationship 73 a liar." The therapist answered with a reply that was geared to use Walt's narcissism in the service of repairing the therapeutic relation ship.] TH: Walt, I'd like to believe everything you say to me. But you and I both know that you have a lot of skill and experience in cov ering your tracks. You could easily outsmart m e if I'm not care ful. If I just blindly believe everything you tell me, then I'm a fool, and frankly, I think you deserve better than to have a fool for a therapist. This latter statement achieved its intended effect of disarming th patient's hostility long enough to get him to agree to come in for a session early the next day. Later in treatment, the therapist and Walt were discussing Walt's unsafe sexual habits. Walt noted that he did use condoms when he had sex with prostitutes, but refused to wear one with his many "girl friends," stating facetiously that it was against his religion. Therapist and patient discussed these practices at length, trying to get a handle on the automatic thoughts and beliefs that led him to act so reck lessly in this era of the AIDS epidemic. Additionally, the therapist attempted to focus Walt's attention on the dangers involved in his sexual behavior by noting the pros and cons of wearing condoms. Finally, when it seemed that these tactics were falling on deaf ears, the therapist resorted to making an appeal to Walt's intelligence by saying: TH: The fact that you wear condoms with hookers is a smart move. I wouldn't expect anything less than a smart move where you're concerned. You're very good at taking care of number one. So it confuses m e how you would stop short of doing the smart thing with your girl friends as well. It just doesn't seem like you, Walt. It's out of character for you to leave any loose ends like that [no pun intended]. You normally have all your bases cov ered [again, no pun intended]. This approach effectively pitted Walt's desire to be seen as an intelligent person against the "macho" rules that governed his unsafe sex practices. It allowed the therapist to be confrontive without dam aging rapport or collaboration. In other cases, we have helped bring our patients back into a collaborative mode by appealing to their sense of justice, their posi tive feelings for involved significant others, their survival skills, their integrity, their potential abilities to be positive role models for others, and other personal attributes. 74 COGNITIVE THERAPY OF SUBSTANCE ABUSE MANAGING POWER STRUGGLES In spite of the therapist's best efforts to maintain an ongoing positive therapeutic relationship with the drug-abusing patient, there will almost certainly be times when therapist and patient are at odds, and when negative feelings will be rather intense on one or both sides. However, this does not have to spell doom for the working alliance. W e rely on the following guidelines for managing such power struggles: 1. Don't fight fire with fire. 2. Maintain honesty. 3. Remain focused on the goals of treatment. 4. Remain focused on the patient's redeeming qualities. 5. Disarm the patient with genuine humility and empathy. 6. Confront, but use diplomacy. 1. Don't fight fire with fire. When a patient becomes hostile, lou intransigent, and/or verbally abusive, it does little good for the thera pist to respond in kind. In fact, such a reaction on the part of the therapist could potentially lead to a dangerous escalation of the con flict. Instead, therapists must show confidence and conviction in their position in a matter-of-fact way. Concern and strong feelings can be expressed (e.g., "Ms. G, I urge you to reconsider your intentions in this matter. I am greatly concerned that you are headed for a big-time fall if you go ahead with your plans to attend that dealer's party!"); however, it is advisable that such sentiments be expressed in a way that communicates a genuine concern for the patient's well-being and best interests. A controlling or disrespectful response (e.g., "You're dead wrong! If you go to that party you're an idiot! I simply can't allow you to do it.") will undermine the therapeutic alliance and probably will not effectively control the patient's behavior anyway. Instead, the strategy advocated here is more akin to the philosophy espoused in Asian martial arts that states that a strong opponent must not be fought head on but rather through leaning back and allowing the adversary's misguided brute force to carry him past you, to stag ger, and to fall. 2. Maintain honesty. During times of conflict with a drug-abus ing patient, there is often a great temptation to try to appease the patient artificially through reassurances that are less than completely truthhil (e.g., getting a patient "oft your back" by telling him that it won't really matter too much if he continues to be late for therapy The Therapeutic Relationship 75 sessions). Not only is it unwise to reinforce patients' maladaptive interpersonal behavior by capitulating to them, it also sets up the therapist to look like a liar if the therapist later reverses his/her posi tion or otherwise reneges on the reassurances. Instead, the therapist must be willing to "take the heat," and not simply say things that the patient wants to hear in order avoid the unpleasantness of a power stmggle. 3. Remain focused on the goals of treatment. W h e n therapist and patient are at odds, it is extremely helpful if the therapist calls atten tion to mutually set goals. In effect, therapists can remind both them selves and their patients that a disagreement in one area does not alter the fact that there are fundamental areas of agreement and collabora tion in other areas. One therapist diffused a heated exchange by tell ing his ex-football player patient, "We may not agree on whether we should run the ball, or pass, but we have to remember that we're on the same team and we both want to get into the end zone." 4. Remain focused on the patient's redeeming qualities, as well as your own {as therapist). Power struggles are often fueled in part by the therapist's cognitive biases. This happens when the therapist reacts to an aversive power struggle by focusing only on the patient's irri tating qualities, and glossing over his/her strengths. Similarly, the therapist may lapse into dysfunctional self-blame (regarding the lack of the patient's therapeutic cooperation and progress), thus engen dering more ill feelings. In such instances, it is extremely helpful for therapists to use cognitive therapy procedures on themselves in order to notice and modify the following types of automatic thoughts that might be exacerbating negative interactions with patients: • "This patient is a loser. He'll never listen to me." • "This patient is so dense. I'm going to have to beat this guy over the head with m y point of view until he agrees with me." • "Why can't I reach this patient? What am I doing wrong? I'm ready to give up on working with this patient." • "Maybe I'm not cut out to work with such a patient. I don't like being reminded of m y shortcomings, so this patient is really on m y shit Ust." • "You just can't compromise and be reasonable with these people. If you give them an inch, they take a light-year. There fore, I will not budge from m y position one iota." • "Why did I ever take on the responsibility of treating this patient in the first place? I must have been an idiot. I almost wish this patient would get arrested so I can be rid of this case." 76 COGNITIVE THERAPY OF SUBSTANCE ABUSE Obviously, the aforementioned automatic thoughts are very del eterious to the therapist, the patient, and the prospects for the con tinuation of treatment. Therapists would do well to focus on their own idiosyncratic automatic thoughts, to produce the kinds of rational responses that would diminish the anger, frustration, and exaspera tion that escalate power struggles and undermine problem solving and therapeutic collaboration (Weiner & Fox, 1982). Examples of such rational responses might be: • "There have been a number of sessions in which the patient and I worked very well together. Those were very rewarding experiences that 1 must not forget. • "This patient is not dumb. He's convinced he has his reasons for defying the therapeutic plan the way he's doing. Let me try to understand his resistant automatic thoughts and beliefs, rather than simply label him a troublemaker." • "My worth as a therapist does not hinge on m y patient believ ing everything 1 say, doing everything I suggest that she do, and staying free of drugs for the rest of her life. I'd like for her to be compliant and to make progress, but the fact that she sometimes thwarts this doesn't prove that she can't succeed in therapy with me, and it certainly doesn't prove that 1 should throw in the towel with all drug-abusing patients." • "If 1 keep m y cool, present m y point of view resolutely, and also show that I'm willing to be flexible within reason, I'll probably get a lot more therapeutic mileage out of this con flict than I will if I become strident or stubborn." • "This power struggle is a great opportunity to get at some really hot interpersonal cognitions!" 5. Disarm the patient with genuine humility and empathy. Fre quently, drug-abusing patients will become angry if they perceive the therapist to be flaunting their authority over the patient or acting with a holier-than-thou air. This perception can lead the patient to fight against the therapist's position in order to reassert some measure of control. This implies that it is important for therapists to be aware of the possibility that the patient is viewing him or her in this negative way, and to respond with behavior that gives the patient evidence to |
process that is associated with their emotional life. The patient's behaviors are the end products of the vulnerable situations, and the activation of beliefs, automatic thoughts, and emotions. C o m m o n dysfunctional behaviors include actively seeking drugs, using drugs, engaging in irresponsible activities (e.g., unpro tected sex), abusive interpersonal confrontations, avoidance of self- help activities, and others. The integration of the above data is the most challenging and most important step in the ongoing process of conceptualizing the patient's life and problems. Here, therapists piece together all the information into a "story of the patient's life" that provides plausible explanations for the patient's difficulties and suggests treatment recommendations that may break into the patient's self-defeating patterns and vicious cycles. For example, the therapist may posit the following: "The patient was subject to a frequent barrage of harsh disap proval in childhood, and came to believe that he was inadequate and unlovable. These core beliefs have been carried into adulthood, where the patient experiences chronic discomfort in social situations where he believes that he will not measure up. The patient took to using cocaine in the belief that it would make him feel confident enough to make positive impressions on others. Unfortunately, this dysfunc tional compensatory strategy has led to compulsive use of cocaine, leading further to a depletion of his money and endangering his marriage. These life problems have fed back into the patient's cycle of anxiety, sadness, low self-worth, and renewed belief that the only way to be accepted is to become outgoing through the use of cocaine. As a result, his drug, financial, and marital problems have worsened, and his sense of helplessness and hopelessness have increased." CASE STUDY The following case illustrates in more detail the ten essential components of a case formulation. The patient (described in the integrative example above), David, is a 40-year-old white male. He has been married for eight years and has one child. His complaints at intake evaluation included high anxiety and a long history of alcohol and cocaine abuse. He reported recently feeling more anx- 84 COGNITFVE THERAPY OF SUBSTANCE ABUSE ious in social situations, and he feared that if his anxiety got w he might have a relapse and start using cocaine and alcohol. In other areas of his life, he was working and received a good salary; however, he was $40,000 in debt as a result of his cocaine "habit." His mar riage was "on the rocks," and he also suspected that his wife was an alcoholic. Upon completion of his intake evaluation, David met the DSM- III-R criteria for polysubstance use, with cocaine as his preferred drug, social phobia, and generalized anxiety disorder. The social phobia was the area on which David wanted to work first. David felt an urgency in this regard because it was the holiday season and he had several business obligations that required his attendance at social functions such as dinner-dances and parties. David felt that if he did not learn to cope with his anxiety in these situations, he would lose control and start using cocaine again. David grew up in a household where his father was seen as a workaholic and someone who "drank too much." David stated that his mother was nurturing but somewhat timid around her husband. In school, David did not do well. He received mostly C's and D's and only stayed in college for one year. David first began drinking at about age 9. Because of his father's business, the family was involved in many social activities and David would often go around drinking out of the glasses of some of the guests. By age 13, David already had experimented with alcohol, marijuana, speed, and diet pills. As a child David was often humiliated and degraded by his father, usually at social events, after his father had been drinking heavily. O n one occasion after his father called him "stupid," he ran outside and sat under a tree and felt humiliated, worthless, and helpless. On another occasion, he ran out onto a pier and sat there feeling ashamed and helpless. These were significant childhood events for David, and they served as the foundation for some of his core beliefs and com pensatory strategies. His typical style was to run away and avoid unpleasant situations. Later in life, David realized that alcohol and drugs helped him to cope with unpleasant emotions. Since drugs and alcohol worked so well, David did not develop many other strategies for coping with unpleasant emotions. Under relevant childhood data, we can see that there were several incidents when David was shamed by his father. These incidents helped to form his core belief, "I am unloved, unwanted." He later developed a conditional assumption for coping, "If I do everything perfectly, then people will like me." David had several compensatory strategies, such as always to strive to do things perfectly or to avoid doing things that were unpleasant. Other strategies included avoid- Formulation of the Case 85 ing showing others how he really felt, and using alcohol and drugs. After using cocaine, David felt especially confident that he could do "everything perfectly," which in turn led him to believe that he was loved and wanted by others. A vulnerable situation occurred when David was invited to a din ner party at a friend's house. Prior to going to the friend's house, David was acutely aware of the fact that he was becoming anxious and ner vous. He was also aware of the fact that his automatic thoughts cen tered on such ideas as "I'll screw up," and "They will see m e trem bling," and he imagined himself being "overcome with anxiety" and eventually running out of the house. This, in turn, led to taking a drink and snorting a line of coke before going to the party. From this example, the clinician can see the relationship between the development of David's core belief, his conditional assumptions, and his compensatory strategies, as well as their cumulative impact on a vulnerable situation—being invited to a dinner party at his friend's house (see Figure 5.1). Once again, we need to remember that these compensatory strategies tend to be rather compulsive, inflexible, inappropriate at times, energy depleting, and not balanced by other adaptive strategies. In addition, in spite of the compensatory strate gies, the patient still tends to have hidden doubts and secret fears about coping. GATHERING DATA FOR CASE FORMULATION The Case Summary and Cognitive Conceptualization Worksheet is an excellent form for compiling data that will be used in the case formulation. This worksheet is divided into eight main sections: I. Demographic Information II. Diagnosis III. Inventory Scores IV. Presenting Problem and Current Functioning V. Developmental Profile VI. Cognitive Profile VII. Integration and Conceptualization of Cognitive and Develop ment Profiles VIII. Implications for Therapy The demographic information section is where the therapist collect such information as the patient's age, sex, race, religion, employment 86 COGNITIVE THERAPY OF SUBSTANCE ABUSE Relevant Childhood Data Father was alcoholic. H/lother took verbal abuse from father. David often humiliated by father. Core Belief(s) I'm unloved, unwanted. Conditional Assumptions/Beliefs/Rules If I do everything perfectly, then people will like m e and I'll feel com fortable. If I show others how I really feel (anger), they will abandon me. Compensatory Strategy(ies) Use drugs If you are uncomfortable. Don't do anything unless you are 1 0 0 % sure you can accomplish it. Don't show others how you really feel. Situation # 1 Situation # 2 Situation # 3 Invited to a dinner party. Automatic Thought Automatic Automatic "I'll screw up." Thought Thought 'They will see m e trembling." Meaning of the Meaning of Meaning of Automatic Thought the Automatic the Automatic "People won't want Thought Thought to be around me." Emotion Emotion Emotion Fear; apprehension T Behavior Behavior Behavior Took a drink. Did a line of coke F I G U R E 5.1. Cognitive conceptualization diagram developed by Judith S. Beck. From J. S. Beck (in press). Copyright Guilford Press. Reprinted by per mission. Formulation of the Case 87 status, marital status, and other pertinent identifying characteris This is standard information that would be a part of any psychologi cal evaluation. In the diagnosis section, it is advantageous to formulate a diag nosis on all five axes of DSM-III-R. Clinical syndromes are designated on Axis I. O n Axis II, developmental disorders and personality disor ders are noted. Physical disorders and conditions pertinent to the patient's psychological difficulties are presented on Axis III. Severity of psychosocial stressors is identified on Axis IV. The level of sever ity of psychosocial stressors ranges from code 1 (none) to code 6 (cata- sttophic), such as the death of a child, the suicide of a spouse, or a devastating natural disaster. Axis V can be determined from the Global Assessment of Functioning Scale, which has a code number descend ing from 90 to 1, with 90 signifying abstinence and ideal coping, and progressively lower numbers indicating an increasing severity of drug use or deficits in coping and functioning. All the data on the five axes will have an impact on the clinician's understanding of the patient, and in the subsequent designing of the treatment plan. Inventory scores, such as the Beck Depression Inventory, Beck Anxiety Inventory, and Beck Hopelessness Scale (discussed later), are listed in this section. Intake scores plus scores from the first six ses sions are reported. There is also an extra column in order to note the scores of the most recent session. These inventory scores are extremely important because the therapist can quickly see general trends and patterns—changes for the better or for the worse. The presenting problem and current functioning section describes the patient's current difficulties and focuses on such areas as employment, concurrent psychiatric disorders, nature of drug use, criminal activ ity, interpersonal problems, and other data. This is a cross-sectional analysis of the patient's current functioning. The developmental profile examines the patient's social history, educational history, medical history, psychiatric history, and voca tional history. In addition, relationships with parents, siblings, peers, authority figures, and significant others over the life span are also noted. It is also important to ascertain any significant events or trau mas in the patient's formative years or recent past. This longitudinal analysis is akin to paging through a family photo album. The thera pist can see the patient in different stages of development. This retro spective analysis also includes an evaluation of the patient's introduc tion to psychoactive substances and how the problem became a full-blown addiction. The cognitive profile section addresses the manner in which the patients process information. The patients' typical problem situations 88 COGNITIVE THERAPY OF SUBSTANCE ABUSE are noted, and the corresponding automatic thoughts, feelings, and behaviors in these situations are outlined. In addition, possible core beliefs, conditional beliefs, and drug-related beliefs are described in this section. The integration of cognitive and developmental profiles takes into consideration the patient's self-concept and concept of others. It also focuses on the interaction of life events with cognitive vulnerabili ties, as well as compensatory and coping strategies. An important part of this section is a description of how self-concept and concept of others might have played roles in the onset and progression of sub stance abuse. This section is illustrated by the case of Mike, a 31-year- old cocaine addict. The patient lives with his parents in a rundown neighborhood where there is high unemployment and high crime rates. He grew up around drugs and alcohol, and his mother and all his siblings have had problems with drugs and alcohol. Mike is now serving five years probation for insurance fraud. The patient's work history is poor. After dropping out of high school, Mike found only unskilled labor jobs, and he is currently unemployed. There is lots of dealing in his neighborhood; Mike has sold drugs in the past and knows there is lots of fast money in deal ing. Mike sees himself as a loner and does not have any real friends. His problematic beliefs are "I'm no better than the rest of my fam ily," "I'll never get a job," "I can't get away from it (drugs)," "Deal ing is the only way out of here (urban ghetto)," and "Using |
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README
Healix-Shot: Largest Medical Corpora by Health 360
Healix-Shot, proudly presented by Health 360, stands as an emblematic milestone in the realm of medical datasets. Hosted on the HuggingFace repository, it heralds the infusion of cutting-edge AI in the healthcare domain. With an astounding 22 billion tokens, Healix-Shot provides a comprehensive, high-quality corpus of medical text, laying the foundation for unparalleled medical NLP applications.
Importance:
Healix-Shot isn't merely a dataset; it's a revolution in how we approach medical text:
- Comprehensive Knowledge: With data spanning academic papers, medical encyclopedias, and more, it covers a broad spectrum of medical topics.
- Quality Assured: Leveraging techniques like the one in "Textbooks is All You Need," along with internal processes, ensures that the data stands up to rigorous quality checks.
- Open-source Nature: By providing this vast repository to the public, Health 360 encourages communal contribution, fostering innovation and advancements in medical NLP.
Dataset Composition:
| Resource | Tokens (Billions) | Description |
|---|---|---|
| Filtered peS2o | 19.2 | High-quality medical papers |
| Various Sources | 2.8 | Medical Wikipedia, textbooks, medical news, etc. |
| Total | 22.0 |
Methods:
- Textbooks is All You Need: One of our primary extraction and cleaning methods. This approach emphasized the vast knowledge encapsulated within textbooks, making them invaluable.
- Internal Processing: Health 360 has employed proprietary processes to ensure data purity and relevance, further cleaning and refining the data.
Usage:
Healix-Shot is primed for various NLP tasks, such as:
- Medical information retrieval
- Automatic summarization of medical articles
- Medical question answering
- Drug interaction prediction
- And many more...
Acknowledgments:
We are grateful for the global medical community's incessant efforts, from whom much of this data originates. Their dedication to spreading knowledge empowers projects like Healix-Shot.
Licensing:
This dataset is open-source, adhering to the Creative Commons Attribution 4.0 International (CC BY 4.0). Kindly refer to the license document for detailed rights and restrictions.
Note: Embedding the dataset into your projects? Do cite Health 360's Healix-Shot from HuggingFace!
By merging quality and quantity, Healix-Shot stands at the precipice of a new era in medical NLP. With the support and collaboration of the global community, the potential applications are limitless. Dive in, explore, and let's shape the future of medical informatics together.
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