SECTION III
MAINTAINING ABSTINENCE:
COGNITIVE-BEHAVIORAL ISSUES AND COPING STRATEGIESGOAL
Participants will learn to incorporate cognitive-behavioral techniques and coping strategies in Network Therapy.
OBJECTIVES
Upon completion of this section, participants will be able to:
1. Explain the process of addiction through an understanding of basic cognitive-behavioral concepts.
2. Teach stimulus control to the network.
3. Teach self-monitoring to the network.
4. Teach coping with craving to the network.
5. Teach thought management to the network.
6. Teach problem solving to the network.
TRAINER NOTE
Review goals and objectives for Section III.
CONTENT
Cognitive-behavioral techniques are utilized with growing frequency in many present-day addictions treatments (e.g., Marlatt and Gordon, 1985; McCrady et al., 1986; Carroll, Rounsaville and Keller 1991; Kadden et al., 1992). Often subsumed under the rubric of "relapse prevention" these techniques involve teaching the patient about the nature of addictive processes (such as craving) and helping to develop various coping strategies with which to hopefully avoid future drug use. In this section of the manual, we will focus on ways in which these may be incorporated in Network Therapy.
* OBJECTIVE 1: UNDERSTANDING THE PROCESS OF ADDICTION.
Conditioned Cues. From the cognitive-behavioral perspective, alcohol and drug cravings are the products of classical conditioning (Marlatt and Gordon, 1985). Just as Pavlov's dog was conditioned to salivate in the presence of a once neutral stimulus that had been paired consistently with food, so the addicted patient has learned to crave in response to stimuli that have been paired with previous drug or alcohol use. As Carroll et al., (1991) have indicated, these conditioned cues or "triggers," as they are sometimes called, may be quite obvious such as a paycheck or cocaine paraphernalia for a cocaine addict or a bar for an alcoholic. On the other hand, many conditioned cues are not obvious at all. For instance, one former free-base cocaine abuser who had been clean for six months reported being overwhelmed by cocaine cravings which appeared to have come out of the blue and for no apparent reason. It turned out, however, that the onset of the cravings occurred in that section of the supermarket where cotton balls were sold--cotton balls being used in the preparation of free-base cocaine. Another substance abuser, an alcoholic and cocaine abuser, required the careful probing of the therapist to help identify a number of triggers for recent urges to drink including the condensation on the outside of a cold can of beer.
It is important for the therapist to assist the patient in identifying such cues and other high-risk situations so that avoidance strategies and other coping mechanisms may be planned in advance of cravings. Cocaine triggers can be quite specific and somewhat different than alcohol triggers.
The Relapse Process. It is not at all uncommon for patient's to slip or relapse when exposed to such conditioned cues, particularly in the early phases of recovery (Carroll et al., 1991; Marlatt and Gordon, 1995). When this occurs in the context of individual cognitive-behavior therapy, the patient and therapist attempt to learn just how the slip or relapse occurred by 1) identifying the antecedent exposures to conditioned cues which the patient may or may not have noticed; and 2) building more effective coping strategies to deal with such cues and/or risky situations in the future. However well this is accomplished, it is not rare for significant others to become perplexed and frustrated with the patient's slips. This is where Network Therapy may have a potential advantage over individually administered cognitive-behavior therapy. By involving the network in learning about the addictive process along with the patient, greater understanding and support can be generated; moreover, network members can feel they are contributing to the process of helping the patient secure abstinence.
Consider the following example: the patient is a 43 year old opiate abuser who suffers from lower back pain and is, therefore, receiving Percacet despite his addiction. The patient's wife, as a network member, is charged with doling out the appropriate medication to him daily. Generally she keeps the medication hidden from view in a locked safe for which she alone has the key. In a network therapy session, the patient admits that he has slipped by gaining access to the pills which his wife had not yet put in the safe after refilling a prescription. Seeing the unattended bottle of pill on the kitchen counter, he grabbed a handful. He adds that he has been able to get into the safe as well. The patient, in recounting the slip, states that he thought of using only when seeing the bottle of pills prior to his wife having had a chance to put them away.
How should the therapist proceed with this case? The patient presents a fairly common slip though he restricts his account to the events immediately surrounding his taking of the pills. The therapist, however, knows that the slip was most likely triggered off at some earlier point and asks the patient when he first noticed the desire to use. By seeking out the cues, the therapist hopes to demonstrate that the slip can be understood according to cognitive-behavioral principles and that such understanding may lead to modifications in the way the patient and network will manage the patient's medications in the future. The patient has some difficulty in identifying earlier cues but another network member, a friend, suggests that it might have started in the pharmacy and the patient readily agrees. At this point the patients mother adds that the patient had seemed "really uptight" during and after the visit to the pharmacy. In short a series of cues begins to emerge. Even though the therapist makes only a few interventions, they are all focused on the goal of clarifying the relapse process. Additionally, each member of the network becomes engaged in providing valuable information. The friend points out the pharmacy as the initial cue. The mother helps to identify a painful affect the patient was feeling. All of this data helps the therapist establish a clear and meaningful set of relationships which comprise the slip. Moreover, this understanding is acquired not simply by the patient but by the network as a whole. It becomes a shared experience. It is supportive of their teamwork.
It is also worth noting what the network therapist refrains from doing (Galanter, 1993b). First, after the cues have been identified the therapist queries the wife as to where she keeps the key to the safe and she reveals a number of enabling or co-dependent behaviors but the therapist steers clear of making any interpretations in this respect. The focus is on the patient's problem, on his achieving abstinence. Network members are there to assist. The therapist merely reminds the wife of an earlier suggestion to wear the key around her neck. When the wife somewhat
ruefully agrees, the therapist rejoins in a matter-of-fact, slightly upbeat manner that "Well, we're getting a better sense of the logistics." However strong her co-dependent needs, her genuine caring and good will toward her husband along with having learned from this experience are enough to motivate her to alter her behavior. Moreover the therapist's comment reinforces the idea that the network has worked together and accomplished something positive. Second, there is an impulsive quality to the patient's slip which contrasts with his otherwise detached, objective style. This may be an important aspect of his personality. While this may be grist for the mill in individual therapy, it is not commented upon by the therapist in the network session. The focus in on the pursuit of abstinence through the appropriate alteration of behavior.
Apparently Irrelevant Decisions. In the previous example, we saw how a patient exposed himself to cues which led to a slip. In the example it was fairly easy to establish the connections between the patient's exposure to cues and the eventual slip. However, this is not always the case. Often patients make decisions which bring them ever closer to cues, availability and opportunity to use; yet they do not connect these behavioral decisions to their actual use (Marlatt and Gordon, 1985). For instance, a cocaine abuser in early recovery leaves work. On his way driving home he approaches an intersection where he normally turns right. This time, however, he decides to turn left. He has the thought that this is a more scenic, relaxing route. Soon he discovers that this "scenic, relaxing route" has led to a street with a bar which he used to frequent. It's kind of a hot day so he decides to stop off for a soda. But as he walks in the bartender automatically pours him a beer. The patient hesitates but reminds himself that his problem is, after all, with cocaine. After his third beer, though, he runs into a friend, who happens to have a gram of cocaine and the slip ensues.
When such occurrences are reported in therapy sessions, patients often see only one decision as related to their slip: namely the decision to use when the cocaine is offered. The therapist's task is to help the patient see that this decision is really the last of a chain of decisions linked together. Once having done so, they may begin to develop strategies for interrupting the chain earlier. For example, it is likely that when the patient made his decision to turn left instead of right, he was less exposed to cues, was probably craving less, and lacked availability in contrast to being in the bar, where cues and availability abounded. Helping patients to acknowledge these "apparently irrelevant decisions" may be quite useful in averting slips. In such instances, the therapist explicates the concept of apparently irrelevant decisions to the patient explaining
that a whole series of decisions were linked together to produce the slip or near slip. The therapist can then point out that by the time the final decision is made, i.e., the decision to use, the patient is usually in a high risk situation surrounded by cues making it extremely difficult to avoid using. The therapist and patient then work together to discover ways for the patient to alert him or herself to the possibility of making an apparently irrelevant decision. In the example above the patient's use of the word "relax" when he decides to go left instead of right might provide such a key. The patient has probably used this word countless times in the past in connection with getting high. Or it may be his way of sensing the need to respond to a vague yet unpleasant tension state. In any event, finding some connection between the apparently irrelevant decision and the eventual use may provide a "red flag" which, in turn, can lead to a more adaptive plan of action.
TRAINER NOTE
Continue role playing.
EXERCISE
Enact role-playing #3 - Securing and Maintaining Sobriety (Appendix B)
* OBJECTIVE 2: COPING STRATEGIES: STIMULUS CONTROL
As noted above in the section on conditioned cues, a whole variety of stimuli may have acquired the ability to elicit strong craving responses in the patient. It is therefore important at the outset of treatment to identify as many of these stimuli as possible and then create ways to preclude or at least limit exposure to them (Carroll et al., 1991). Such stimuli may include cocaine paraphernalia (e.g., mirrors, razors, pipes), former drug associates, certain times of day or days with unstructured time, money or the anticipation of money such as an approaching payday, alcohol or other drugs, sex, MTV, etc. Try to engage the network as much as possible to support the patient's efforts to get rid of or avoid these stimuli. For example, on paydays the patient may need his spouse to pick him up at work and accompany him to the bank to facilitate depositing the money.
* OBJECTIVE 3: SELF-MONITORING
Self-monitoring is an exercise used for identifying the more subtle and non-obvious cues and high risk situations within the patient's environment (Marlatt and Gordon, 1985; Carrol et al., 1991; Kadden et al., 1992). The patient is asked to keep a log of hourly changes in cocaine use and cravings in relation to various internal and external events such as activities, locations, presence of others, specific feelings and thoughts. The log sheets are then reviewed in therapy sessions and often reveal hitherto unseen relationships and/or patterns in cocaine use or craving. The exercise may also function as a coping strategy in that patients are instructed to self-monitor whenever significant thoughts of craving for cocaine are experienced. In this way, patients learn to become more vigilant with respect to the awareness of high-risk situations and are able to introduce a delay by self-monitoring at these times.
* OBJECTIVE 4: COPING WITH CRAVING
One of the most useful cognitive techniques for handling cocaine cravings is knowledge (Carroll et al., 1991). It is helpful for both the patient and network members to get a realistic picture of the nature of cocaine cravings. You should explain that cravings, like other feelings, have a time course; that is they rise, plateau, and fall generally over a 30-60 minute period. They do not last forever. In addition, cravings only retain their strength if they are reinforced, i.e., with further use. If the patient can refrain from using, the craving response will gradually extinguish just as Pavlov's dog no longer salivated at the sound of the bell. While cravings may be more frequent and intense in the early phase of treatment, there are a number of coping skills one can utilize in the meanwhile:
1) Find a distracting activity.
2) Go with the craving, don't fight it, in the same way a driver turns the steering wheel with the skid. Eventually the craving will subside.
3) Decision delay: commit to not acting on the craving for some arbitrary amount of time such as 30 minutes. Often by this time the craving will have subsided.
4) Challenge thoughts associated with craving such as "I'll die if I don't take a hit."
5) Remind oneself of the negative consequences of using. Substance abusers find it difficult to remember the negative consequences of using when in the throes of craving. The following is a useful exercise that results in a worthwhile coping strategy. During the session (an excellent network session exercise), give the patient a 3X5 card on which to list the pros of using cocaine on the left side and the cons on the right. Start with the pros. The patient may come up with one or two pros but usually runs out quite quickly. When this occurs, tell the patient to leave the pros aside for the moment, and come back to it later. Now start the cons. The patient, unaided or with a little help, will quickly generate a voluminous list. He will also begin to question whether some of his pros more rightly belong on the con side. Have the patient carry the card with him in his wallet next to his money. It provides a quick reminder of the disproportionate negative consequences associated with substance use.
6) Contact someone supportive such as a network member or someone in AA, NA, or CA.
* OBJECTIVE 5: THOUGHT MANAGEMENT
Related to cocaine cravings are various thoughts about using. In fact, it may be helpful to think of such thoughts as a subtype of the craving response. Often such thoughts exemplify how the defenses of rationalization and minimization serve to reinforce denial in the addict. AA refers to it as "stinking thinking." Classic examples include "I can handle it"; or "I'll just take one hit". Other thoughts may include nostalgic reveries of the good old days stripped of any negative content, thoughts about 'testing' oneself, or simply thinking "Screw it". The therapist needs to alert the patient to the likelihood of developing such thoughts. In addition, when such thoughts emerge patients often do not notice that they precede episodes of using. Quite often such thoughts are experienced as quick and fleeting. The therapist needs to help the patient learn how to slow down his thought processes so that he can focus in and articulate them (Carroll et al., 1991). In this way it is easier to establish the connection between one's thoughts and actual use. Once the patient can learn to recognize the presence of such thoughts, he can then interrupt them utilizing the strategies used for coping with cravings.
* OBJECTIVE 6: PROBLEM SOLVING TECHNIQUES
One of the interesting characteristics associated with the cognitive style of many addicted people is their propensity to think in either/or, all or none, black and white terms. Such thinking seriously limits the range of options when confronting problems. As a result, problems are often regarded as sources of frustration often leading to substance use. In addition, the patient must now address his or her many problems associated with being an addict in a more adaptive manner. For these reasons, teaching patients basic problem solving skills is most helpful (Kadden et al., 1992). This should include 1) recognizing and identifying the problem to be solved; 2) generating alternative solutions (especially brainstorming solutions without passing judgement as to how good or bad they are); 3) selecting the most promising approach; and 4) assessing effectiveness the approach so as to modify, alter or refine as needed.
As with other cognitive techniques, problem solving can be quite effective in engaging the network in a positive manner. In the following example, the patient, a 39 year old polysubstance abuser, has been clean for seven months. During this time he has lived with his parents. He is now considering moving back to his apartment. He reveals a number of his anxieties about the move stating that his recovery feels safer living with his parents. Nevertheless, he admits that sooner or later he needs to get back to his apartment and resume an independent life. Although the patient has recounted this with considerable thoughtfulness and reflection, it has the effect of making his mother anxious and she suggests that he forget about the move for now. At this point the patient and mother begin to get drawn into a defensive struggle at which point another network member, a cousin, suggests an alternative. Instead of thinking of the move in all or none terms why doesn't the patient try living in his apartment a few days per week and see how it goes. Eventually the network, including the mother, agrees that this compromise is viable and with the assistance of the therapist they then devise a strategy for the patient to establish contact with network members on days he spends in his apartment.
These cognitive behavioral skills and coping strategies can be taught in either network or individual sessions. We think that incorporating them as much as possible in network sessions furthers the involvement and cohesiveness of the network in the patient's recovery.
TRAINER NOTE
Continue role playing. Select new participants.
EXERCISE
Enact role-play #4 - Maintaining Abstinence (Appendix B)
SUMMARYSection III has focused on explicating in cognitive-behavioral terms the process of addiction and interventions directed toward interrupting and arresting this process. Such interventions have included self-monitoring, coping with craving, management of thoughts, and problem solving techniques. These have been adapted to the NT approach. As in earlier sections, we have provided role-play exercises for trainees to practice these techniques in vivo. In the next section, we will discuss supportive techniques as they pertain to Network Therapy.
