SECTION V
SECURING FUTURE BEHAVIORGOAL
Participants will learn to use the network to develop and implement behavioral strategies to secure the patient's abstinence between therapy sessions.
OBJECTIVES
Upon completion of this section, participants will be able to:
1. Utilize the network to limit patient's exposure to cues.
2. Utilize the network to secure drug/alcohol free housing.
3. Orchestrate monitoring strategies for urinalysis or medication compliance.
4. Develop a behavioral plan to secure abstinence between sessions.
5. Develop a generic emergency plan.
6. Employ written strategies (e.g., reminder cards, letters to doctors, and contingency contracts) to secure abstinence.
TRAINER NOTE
Review goals and objectives for Section V.
CONTENT
A therapist treating addiction should always be thinking about strategies for shaping future behavior. Much of the art in this therapy rests on weaving together a fabric of interventions, none of them with a certain outcome, but all together directed at protecting the patient from the risk of relapse. In this chapter we will consider ways in which the strands of treatment are woven together to assure stability (Galanter, 1993b).
Patients vary in terms of the number of constraints they need to secure behavioral change as well as the intensity with which these constraints need to be applied. For example, certain patients with sufficient determination need only some minimal advice from their doctor in order to become and remain sober. In practice, though, we certainly find that most patients do not fare well with advice alone. As of now we do not know how to tell those few patients who might respond to a focussed, brief intervention from those who do not. It is therefore necessary to consider many potential behavioral strategies for securing abstinence which may be rapidly or gradually lifted depending on the patients progress in treatment.
Given this reality, let us now examine some techniques designed to shape the behavior of addicted people keeping in mind the day-to-day uncertainties of addiction treatment. We shall discuss a number of commonly used behavioral strategies and written agreements indicating how the network can assist in their implementation and execution. Then we will present a case which illustrates how a variety of controls can be woven together in a patient's treatment plan and then modified over the course of time.
* OBJECTIVE 1: BEHAVIORAL STRATEGIES: LIMITING EXPOSURE TO CUES
Once a network of drug-free members has been established, there are a number of ways in which this support system may assist the patient in maintaining abstinence.
As will be recalled from section III on maintaining abstinence, at the outset of treatment it is important to identify the various high-risk situations and conditioned cues in the patient's world. The next step is to develop strategies for limiting exposure to these situations and cues (Marlatt and Gordon, 1985; Galanter, 1993b). The network may be useful in helping the patient carry out such strategies. For instance, if the patient owns any drug paraphernalia, a network member may help the patient get rid of it and deal with any cravings that might result. Likewise, certain known events that the patient cannot avoid may give rise to cravings and some sort of strategy may need to be devised to insure that it does not lead to using. For example, payday often gives rise to intense cravings in cocaine addicts and the patient may need assistance from the network such as traveling with the patient to the bank to make certain the money is deposited.
Much of the work of network therapy is devoted to planning strategies to combat cue exposure effectively. The network therapist should remain vigilant for actual and potential cue exposures and should engage the network whenever possible in devising behavioral plans to avoid such exposures. Sometimes avoidance is not possible. For example, the patient may have to attend some function where alcohol will be served. Here the therapist must engage the network to devise a plan to protect the patient from using such as creating a plan to leave should the patient begin to crave. Finally, the patient should have some generic plan to meet high risk situations that are frequently encountered as will be discussed below in the section on written strategies.
* OBJECTIVE 2: SECURING DRUG-FREE HOUSING
This is a vital part of substance abuse treatment. The patient cannot expect to maintain abstinence in an environment which contains drugs and/or alcohol. Unless one can be reasonably assured that the patient's home is alcohol and drug-free, it may become necessary to secure, at least temporarily, different living arrangements. This may involve living with parents or some other relative until abstinence is in place. Or it might entail helping the patient create a substance free living environment. For instance, a non-alcoholic spouse may help the patient get rid of all substances in the home. The spouse may also promise to give up his or her own casual use during this critical period. Again, forming strategies on how best to achieve a substance free environment is critical to succeeding in treatment.
* OBJECTIVE 3: ORCHESTRATE MONITORING STRATEGIES FOR URINALYSIS AND MEDICATION COMPLIANCE.
Another strategy useful in securing behavior involves having the patient's urines monitored for drug use. With certain very stable and motivated patients, the act of submitting their urine for screening is alone enough to secure compliance. Less stable patients may need to be observed in the process of submitting urines (Azrin et al., 1982).
Disulfiram (antabuse) and naltrexone (trexan) have been used in the treatment of alcoholics and opiate abusers respectively. They tend, however, to be of limited utility for most alcoholics and addicts, who typically "forget" to take the medicine while on their own recognizance, and go back to drinking or using. In actuality, both disulfiram and naltrexone can be used to considerable advantage in a broader range of patients when administered in the network therapy approach (Azrin et al., 1982; Higgins et al., 1993; Volpicelli et al., 1992; O'Malley et al., 1992; Galanter, 1993c). Each dose the patient takes is observed by a network member. The respective roles are clear in this approach. The patient's job is to assume responsibility for taking the disulfiram or naltrexone in a way that can be easily seen by the observer. The observer's job is only to report to the therapist if he does not actually see the patient take a given dose, but never to convince the patient to take his medication. He thereby provides an effective reminder to the patient to take the medication, but is not a lone enforcer.
This approach to medication monitoring serves as a safeguard should the patient "forget" his dose. The patient has responsibility for his treatment, yet the network is also engaged. If a dose is missed, the patient knows it will be reported to the therapist and discussed at the next network meeting, thereby assuring that denial does not undermine the drug's continuous long-term use.
If the therapist is a non-physician, arrangements are easily made for prescriptions with a consulting physician.
* OBJECTIVE 4: DEVELOP A BEHAVIORAL PLAN FOR ABSTINENCE EACH SESSION.
It is important to make certain that before a network session is completed that the therapist, patient, and network be clear on the nature and logistics of plans for continued abstinence. This may involve a newly devised plan or the reiteration of a current plan which has functioned well.
* OBJECTIVE 5: PLAN FOR EMERGENCIES
No matter how well a patient succeeds in identifying and avoiding high risk situations and conditioned cues, there will be inevitable unanticipated events and surprises along the way. These may include running into old drug acquaintances, severe craving episodes, any number of minor difficulties such as an argument with a family member or getting reprimanded by the boss, major life changes such as a loss of a loved one or unanticipated health problems, positive major life changes such as a promotion and so forth. It will be important to develop a generic emergency plan for coping with stressful problems that arise unexpectedly. The plan should be specific and can draw upon skills already learned. It should be written out and carried by the patient at all times. For example, the plan might 1) list all the names and telephone numbers of network members and require that the patient call and talk to at least one member and 2) dictate that the patient go immediately to a 12-step meeting. The plan may also include instituting certain cognitive coping skills.
A variant of an emergency plan within the context of a network involves a special event for the patient that might put him in a relatively riskier situation than normal thus necessitating extra support in securing behavior. The task for the therapist is to figure out how the network can provide such support. For example, the 43 year old male opiate abuser with lower back pain whom we have discussed before relied on his wife to manage the doling out of his pain medication. However, his wife was to be out of town for about a week. He would therefore have to be responsible for adhering to his medication regimen by himself without abusing. How can the network be recruited to help the patient? A plan was devised for the patient to contact various network members daily at preset times to report on how things were progressing. This sufficed to assist the patient to refrain from abusing his medication during his wife's absence.
* OBJECTIVE 6:
Because rationalization undermines so many of the addict's best plans, it is often useful to put the understandings that underlie treatment into writing. This leaves less room later on for confusion about what the patient expects of himself and affords him a check against reality if a question arises about what had been agreed on in treatment. Consequences of violating a plan can range from a reminder that the patient gives himself, to a more stringent contingency imposed from without. As with other aspects of treatment, the participation of network members in establishing a written understanding enhances its importance to the patient, and broadens the options for enforcement.
1. Calling Cards. The mildest of written interventions involves no more than the patient having some well-defined guidelines available when he encounters a stimulus for drug-seeking. In order to prepare for this, it is important to review in advance problem situations he is likely to deal with some frequency, and develop ways for him to respond. These can then be abbreviated and written on a small card that the patient carries with him to provide explicit reference points. The very existence of such written pointers makes rationalization, or "forgetting", a little harder.
This technique was used with a cocaine addict who owned a rock music rehearsal hall and had recently slipped at a party where his date had been offered some cocaine.
In the network session that followed the group discussed how he could manage his activities so that he would stay free from drugs, and then looked at the variety of cues that had brought on this slip. The group was engaged in trying to develop a self-protective approach for him to apply when he was most vulnerable. This was particularly important when he was out on dates, or at parties, since any new acquaintance in his social set could turn out to be a drug user. Over the course of the session some guidelines were developed and summarized as follows:
1. No dates with anyone you suspect of using cocaine.
2. Don't go into a room where people are using the drug.
3. If cocaine is brought out, leave the room right away.These rules of thumb were written out on the therapist's calling card which the patient was asked to read back to the group and then carry the card in his wallet. The card would provide a reminder that he could summon up to discourage him from acting on these conditioned cues when he encountered them.
It is often surprising to see patients continue carrying these cards with them long after alcohol or drug use has ceased to be an active issue. The card forms an implicit contract, and can be an important adjunct to the treatment because it introduces some of the strength of the therapeutic relationship into a period of vulnerability. In this way, it acquires the quality of a talisman, symbolically embodying the network's function.
2. Letters to Doctors. Physicians are the principal source of mood-altering medications in our society, and they will inevitably allow some patients to become drug-dependent. Most commonly this takes place by inadvertence, when a patient is treated for a problem for which the drug is legitimately prescribed. Analgesics may have been used for an acute and painful illness, or minor tranquilizers for anxiety associated with family crisis. Much less commonly, unscrupulous physicians will prescribe drugs to produce dependence, and effectively become "pushers" of these pills, sustaining a lucrative, often illicit business.
Even if addicted patients want to avoid their prescribing doctors, the ready availability of a sanctioned source of drugs is generally more than they can avoid, so that formal means of enforcing an end to the relationship, generally in writing, may be needed. In a many of these prescribing circumstances a letter sent by the patient to the doctor has served to terminate such a cycle of unfortunate prescribing. Physicians are increasingly under the watchful eyes of both state licensing boards and malpractice lawyers, and any written document that might later compromise them with these parties will quickly produce a chilling effect in the prescribing relationship.
This approach was necessary with the 43 year old opiate abuser with lower back pain whom we have discussed elsewhere in the manual. After a few sessions early on in treatment it became clear in a network session that he was receiving ample prescriptions for opiates from a physician who was treating him for his pain but who was unaware of his substance dependence. This fact came to light accidentally when the patient's wife divulged this during the session.
Often when legitimate prescribers are involved, one generally has to cast a larger net of communication. Patients who draw on ethical physicians are rarely able to obtain the large quantities of drug that they need from a single source. One patient's experience illustrates this point. Her husband called when he became aware that she was hiding pills around the house and taking them secretly. As the therapist spoke with him, and later interviewed them together, the scope of the problem became apparent. The patient was taking some thirty Tylenol 3 tablets a day, each of which contain 30 mg of codeine, a dependency-producing opiate drug. In order to keep up with the many prescriptions she needed, she had to turn at intervals to her orthopedist, internist, and dentist, and then fill prescriptions in three different locations, manipulating pharmacists, as well.
Her descent into addiction was typical of many such pill-dependent people who were provided medication which they gradually began to abuse. Her drug use began with surgery a few years before to correct the chronic back pain produced by a slipped disc, later followed by extensive oral surgery. Despite her addiction, though, she appeared to be doing relatively well. She maintained a responsible job, and the relationship with her husband was good enough, except for the considerable strife that had recently emerged around her pill-taking.
As treatment options were discussed, Leslie made it clear that she did not now want to undergo the disruption of hospitalization. The therapist told the couple that it might be possible to get her free of drugs without hospitalization, but there was little chance of her doing well until we made sure that all of her sources of medication were eliminated. Each one would have to be notified and closed off with finality before the detoxification could commence. Leslie realized she had no reasonable alternative, and along with her husband and two sisters, discussed the various physicians with whom she was in contact. This exchange, carried out over a few family sessions, served to bring out some prescribing relationships that she might otherwise not have mentioned. She was less likely to keep back information in the network, as she would not want to be seen at a later time as having betrayed her family members. Ultimately, a list was drawn up of four physicians, two dentists, and three pharmacies who had serviced her prescribing, and she sent each one a simple note on the therapist's stationery:
Dear ---:
Please be advised that I am now in treatment to terminate opioid dependence (codeine) with Dr.____. Please do not prescribe or dispense any further medications of this type for me.
Sincerely,
Sometimes with highly reluctant patients it may be necessary for the therapist to mail the letter (s) after getting the patient's signature. One patient, for example, insisted that he deliver the letter to his prescribing physician and needed to have the network and therapist coax him into acknowledging that he really did not want to sever his connection to this source. Finally, the patient acceded to the suggestion that the therapist send the letter.3. Contingency Contracts. The contingency contract is a most dramatic form of written device. It involves a signed agreement that a contingency, or a threatened intervention, will be applied if the patient uses drugs (Crowley, 1984). The conception is straightforward: Patients must have a resource of great value they can ill afford to lose, be it the right to practice law, a medical license, or sizeable financial asset. In order to be accepted into treatment, they would sign a contract that guaranteed the loss of that resource if they were ever found to be using drugs; the agreement is carefully monitored by observed urinalyses. The assumption underlying this treatment model is that if the contingency is threatening enough, the patient, however badly addicted, will refrain from using the drug.
A lengthy contract is signed by the therapist, the patient, and a witness, defining all the particulars, specifically what will happen if the patient ever has a positive urine. An appropriate letter is then prepared. For instance, in the case of a cocaine addicted physician, the letter would be addressed to a licensing board, that includes a signed "confession" of the patient's addiction, and an agreement to relinquish his license. The contract includes authorization for the treating party to mail the letter if any urine is found positive for cocaine. Such an agreement clearly could not be managed casually, and the terms were spelled out very carefully. For example, it might be stipulated that missing a urinalysis without proper excuse would be considered equivalent to having a urine positive for cocaine.
The technique itself has not been used too widely in this form, since most therapists are not inclined to impose harsh consequences on their patients, as they see themselves as helping agents rather than enforcers. Psychotherapists are inclined to see themselves more as enablers of personal growth than as agents of coercion. Nonetheless, the contingency contract can have a place in addiction treatment under certain circumstances. Other treatment options, less compromising to the patient, should have failed, suggesting that a new idea is in order, and there should be enough good will between therapist and patient, with additional support from the network, so that the potential for imposing a harsh contingency is not seen as a punitive.
Case Illustration: Integrated Use of Controls
Let us now look at how a number of constraints can be introduced to assure a patient's stability during the early days of treatment, and then gradually lifted. Although very different in nature, these techniques can complement each other quite effectively. This orchestration was illustrated in treating Daryl, whose severe addictive problem made him an uncertain candidate for recovery when he first came for treatment. He had been snorting heroin daily for most of the previous fifteen years, and had been using cocaine heavily for the last eight, most recently in the form of free base cocaine and crack. Despite this serious problem, he had some important strengths that were demonstrated in his work. A talented jazz musician, he performed regularly, and he was also a faculty member in a local music college. Daryl was quite concerned over his students' development, although his teaching was often compromised by his drug-taking.
There was a measure of irony in the events that moved Daryl to seek help, since his long course of treatment was very successful in the end. Initially, however, he asked only for help to shore up his immediate situation and bring his drug use down to a more manageable level. He was concerned because his recent descent into unfettered addiction had been precipitous. He was completing a sabbatical at the music school, and had been relatively idle, and engaged in little productive work in recent months. He realized that his ability to return to teaching was now limited, as he had become dependent on crack smoking, which would be much more disruptive to any stable work routine than the heroin addiction alone. Furthermore, his wealthy girlfriend was thinking about going off to a residential treatment center for help with her own addiction, and he was troubled by the thought of losing her as a companion in drug-seeking, on whom he depended for emotional support, at that.
The therapist first made it clear to Daryl that he had to stop his drug use entirely, and underlined the fact that treatment would be useless otherwise. He was actually willing to accede this point, undoubtedly with ambivalence, as is typical of most addicts under these circumstances. Nonetheless, he agreed to proceed in this manner.
The treatment involved the introduction of a number of techniques into the network setting that were interwoven over more than two years of his subsequent recovery, all designed to stabilize his abstinence and secure a more positive lifestyle. Let us consider now how each of these played an important role in securing his long-term sobriety:
1. establishing a network with drug-free members;
2. a brief hospitalization;
3. changing his residence;
4. administering an opiate blocking agent (naltrexone) under observation;
5. monitoring his urines for drugs of abuse;
6. attendance at Narcotics Anonymous;
7. network sessions held in my absence;
8. focussing on his passive adaptation in individual therapy.This array of approaches is listed not to bewilder, but to point out how a rationale can be developed for interweaving a variety of interventions, each directed at managing behavior, each with its own time for introduction and withdrawal.
At the outset, Daryl and his therapist had to put together a network, in particular one that did not include any drug abusers. This was a task of no small dimension, since most of his current social ties were to people who were at the very least heavy drug users. This had to be done quickly, given his imminent vulnerability to his multiple addictions. The effort therefore involved a variety of maneuvers, such as quickly discounting some proposed members who were apparently drug dependent, and then including some of Daryl's sober relatives whom he was less close to at present. Later one member had to be tactfully dropped from the group when she herself became re-addicted after some years of abstinence.
It was necessary to hospitalize Daryl briefly as soon as the network was assembled. The need for this was compelling, and he himself acknowledged it. The combination of two major addictions, one to heroin and the other to cocaine, each relatively independent of the other, was more than could be addressed at once. Daryl's insurance did not cover extended hospital treatment, but would allow for several days' stay, and he was admitted to a local psychiatric hospital to detoxify him from heroin with the intention of placing him on a blocking agent for heroin. The strategy here was to use the hospitalization to get his heroin habit under control, and to address the cocaine problem more definitively after he left. Naltrexone (Trexan) would be a vehicle for his long-term abstinence from heroin.
Daryl was a good candidate for naltrexone because he had a reasonably stable network, one that included his sister, with whom he had an amicable and trusting relationship. The therapist therefore discussed with him and the group a plan to admit him to the hospital for several days to detoxify him from heroin, and to initiate naltrexone administration under his sister's observation as soon as he was drug-free and ready for discharge. In addition, the plan for taking naltrexone was discussed at some length with the network while he was on a short pass from the hospital, thereby setting the groundwork for shifting directly into the outpatient format when Daryl left the hospital.
The therapist also discussed with Daryl and his network that observed urinalyses would be needed for a considerable period of time, as it would be many months before his stability was assured. The opiate blocker would likely leave Daryl relatively free from craving for heroin, but it could not assure that he would stay away from the drug, since some people do try to use heroin while they are on naltrexone. More importantly, his addiction to cocaine would necessitate long-term urine monitoring, since it gave no protection against non-opiates.
There was little doubt as well that Daryl could not live with his girlfriend, at the very least until both had experienced some months of stable abstinence. They had long fed off each other in their addictions, and it was none too sure that the girlfriend herself would make it to a rehab. At this point, her wealth and petulance were buffering her from the need to seek an alternative to her life in addiction. While Daryl was in the hospital, it was therefore arranged that he would move in with his sister, who fortunately had a large apartment, the legacy of a divorce, for at least a few months.
The period after hospitalization was fraught with problems. Daryl's girlfriend clearly meant a threat of renewed drug use, and after lengthy deliberations in the network, his ensuing encounters with her were few in number. Nonetheless, it was necessary to discuss arrangements for a few brief meetings, and the network members helped to delimit their encounters. Fortunately, the girlfriend was willing to let him go off on his own after a while when she saw that he was giving her less attention than she got from other members of her social set.
Daryl had not been enthusiastic about connecting with Narcotics Anonymous, but the therapist pressed him nonetheless to attend at least twice a week upon leaving the hospital. Like many patients, he went grudgingly, saying that "it wasn't his thing," and he didn't "go for the religious angle." The therapist felt however that some attendance would be worthwhile nonetheless. Being exposed to peer addicts who have renounced drug use can at least introduce the concept of abstinence from a new perspective, even if affiliation with the group is unappealing. Furthermore, a reluctant patient may in the end become engaged, and then join. In any case, NA represented at a minimum a scheduled drug-free activity to fill some of Daryl's free hours, and in that respect it added some structure to his days. In response to the therapist's pressure and the group's support, Daryl went to NA intermittently for some months, and finally persuaded the therapist by his lapses in attendance that he should not be pressed to go any more. He later acknowledged that the experience was "useful," but still not his "thing," although he did attend occasionally when he was under stress.
The urinalyses came up as an issue at one network meeting not long after Daryl left the hospital, when he said he would like to drop the procedure. It was expensive, as his urines were monitored by another doctor, and inconvenient, as well, he said. However true this might be, the therapist felt his request represented an expression of his desire to protect his addiction especially in view of Daryl's shaky condition. The therapist stated: "I know you want to stop taking the drug and you're trying hard." He was, indeed, and it was important to give him credit for this even though he was clearly struggling with his ambivalence. "But we're all aware you've had some slips with the coke already, and there certainly could be some more."
"So long as we continue to examine the cues that lead to slips, and assure that the drug use isn't buried, we'll be on the right track. That's why the urines are so important. They mean that we will always be keeping the drug use in the open, and that you can't forget a slip. This way you'll have to let us know before we get a positive urine result, not afterwards." With some pressure from his network as well, Daryl agreed to keep up the urine monitoring.
Daryl did continue to have very real problems with cocaine over the months following his hospitalization, even though he met regularly with me and his network. The problem was a compelling one. So long as he was having slips on cocaine, he was vulnerable to denial, and this denial might lead him to hide this cocaine use from me and the network, and even worse, to develop an excuse for dropping out of treatment. This was further complicated by the fact that the therapist was to leave on vacation only a few months after Daryl left the hospital. It was essential to have a plan to secure what we had accomplished for that upcoming three-week period. It was arranged that during the therapist's absence Daryl's sister would get reports on his urinalyses from the covering doctor, and that the whole network would meet with him in each week to review his situation.
The therapist further decided to convert this rather shaky situation into one associated with a goal, by stating that his intention was to have Daryl abstinent from cocaine within two weeks of his return from vacation. The therapist felt that by that time he would be ready for an all-out assault on the residual cocaine use. This plan provided some needed assurance for Daryl and the network, and a reason to promote his stability over the vacation period.
The long course of these interlocking controls in Daryl's treatment is instructive. He continued to take the naltrexone under observation three times a week for a year, either at his sister's house, or in the therapist's office. After that we switched to his taking it on his own for almost a year more. When he did this, he would write down the time each morning when he took it, and bring in his record for review at intervals. Like some patients, Daryl was not chomping at the bit to be relieved of this pharmacologic constraint on his drug use. In fact, on one occasion late in the treatment, he himself demurred from terminating the naltrexone, saying that he was not yet sure that he was ready to give up his insurance against relapse.
Daryl was called by a doctor colleague for observed urinalyses each week for the first four months of treatment, and then twice a month for ten months more. After that he was called each month until he had been off the naltrexone for several months. This regimen assured a period of monitoring after he was off the medication and physiologically able to experience a heroin high. Each change in the frequency of his urine monitoring was preceded by discussion within the network, and the emergence of a consensus among its members that the new regimen would be a safe one.
Daryl and his therapist met twice weekly for two and one-half years, with some of these sessions held with the network as well. These meetings took place each week for the first few months, and then less often. Aside from events related to the addiction per se, perhaps the most important issue Daryl confronted in his individual sessions was the passivity which had compromised his life. He had been dependent on his mother as a youth, and was again dependent on his addicted girlfriend over the several years before entering treatment.
Although specific devices such as the opiate antagonist and observed urinalyses could launch his abstinence, it was important for him to have a new and active orientation toward life in order to assure long-term sobriety. The therapist struggled with Daryl to help him become more assertive with women and in his work, and with the aid of both sobriety and introspection, he was able to develop more constructive social relationships, and assume a more active role in his social life.
These changes came in the form of small triumphs. Thus, early on, Daryl came to appreciate that while living alone, his choice to not have an answering machine had psychological meaning. It served to isolate him from an active social existence, and assure that he would not establish meaningful ties outside the drug subculture. His buying an answering machine meant that he was now ready to consider at least the risk of entry into a drug-free social existence. In time, Daryl also undertook an initiative at the music school that drew on his considerable creative talents. He developed the capacity to deal with the institution's politics, an effort that had eluded him for years before.
The devices we have discussed in this chapter demonstrate ways in which behavior can be managed over the long term to secure protection from the vagaries of the addictive drive. The establishment of a web of protective measures and the use of written agreements illustrate how strategic thinking can be applied to this end. By no means, however, do they exhaust the options that a creative therapist can generate to manage his patient's behavior in planning for a secure recovery.
TRAINER NOTE
Continue role playing with the last scenario of Appendix B.
EXERCISE
Enact role-play #5 - Securing Future Behavior (Appendix B)
SUMMARYIn this section, trainees have learned a variety of methods designed to facilitate patient compliance. These techniques include using the network to limit patients exposure to ques and securing adherence to aspects of the treatment plan including behavioral strategies, urinalysis, and medication compliance. In addition, various written strategies to secure abstinence have also been discussed. This section has also provided a lengthy case description to illustrate these principles and techniques. Finally, we have provided a role-play exercise so that trainees may practice implementing these procedures.
