Drug Avoidance Skills

In order to stop abusing cocaine, patients need to learn which people, places, and things stimulate the desire for cocaine and how to either avoid or cope with them. CRA + Vouchers teaches patients three interrelated ways to accomplish this:

• Functional analysis
• Self-management planning
• Drug refusal skills

All patients are trained in functional analysis in the early stages of treatment. Its purpose is to help them understand their drug use so they can effectively problemsolve for ways to reduce the probability of cocaine use. The approach described here is based on the work of Miller and Munoz (1982) and McCrady (1985). Functional analysis is used throughout treatment as needed. For example, if cocaine use occurs, therapists should encourage patients to analyze these events to determine how to avoid using in similar situations in the future.

Therapists should instruct patients on the concepts and procedures concerning functional analysis.

"We are going to focus on what is called a functional analysis of your cocaine habit. It is the first step in developing control over out-of-control behavior. Your cocaine use is triggered by certain events, situations, and feelings, and maintained by short- and long-term consequences. Therefore, it is important that you begin by analyzing your pattern of cocaine use. Once you have learned to analyze your use, you will know how to rearrange your environment - the triggers and consequences - and how to engage in positive alternatives to cocaine or other drug use so that you can achieve total abstinence from cocaine. When you have completed this process, you will have taken a large step toward beating your cocaine problem."

"There are four important points to keep in mind as you learn how to do a functional analysis of your cocaine use."

• Other people with drug problems like yours have been able to learn ways to stop using cocaine.
• It is important to begin thinking of your cocaine use as something that you have learned to do. Understanding exactly how your cocaine problem got started is not always necessary for learning how to stop using. Blaming other persons or events for the problem also does not help. What is important is that you begin to view your cocaine abuse as a problem that you can do something about. In other words, you are responsible for your own behavior.
• The goal of this treatment program is to help you learn how to stop using cocaine and how to live a drug-free lifestyle. You will get the most benefit from our program if we can help you stop your cocaine use early so we can focus on helping you make other lifestyle changes that will promote long-term abstinence from cocaine.
• However, if you use cocaine during treatment, it is important that you do not view it as a failure. It is common for persons trying to stop their cocaine use to have slips. We will use these instances to help you understand more about your cocaine use so you can more effectively learn to stop using completely. In other words, you want to figure out what happened in that situation and how you can prevent it from happening again in similar situations.
• It will be important for you to work on these new skills between sessions. Learning and practicing new skills and behaviors is necessary; talking about making changes is not enough to deal effectively with such a difficult problem as cocaine dependence."

Components of Functional Analysis

After briefly describing and providing a rationale for using functional analysis, therapists should begin to teach patients about the specific components of functional analysis. Such discussions can proceed as follows.

"A functional analysis allows you to identify the immediate causes of your cocaine use. You have probably noticed that in certain situations you use cocaine, while in other situations you do not. The situation around us can powerfully control cocaine use, particularly if we are unaware of its influence. Some of the situations that can influence cocaine use are -

• The people you are with.
• The place you happen to be.
• The hour or the day.
• How much money you have.
• How much alcohol you have consumed.
• What you are doing besides using cocaine.
• How you are feeling.

"The first step in understanding your cocaine use is to identify the types of situations in which you are likely to use cocaine. Your first assignment will help you identify these risky situations and what about them makes you want to use cocaine. These are called triggers.

"You will also need to identify the consequences of your use. There are two kinds of consequences: the immediate and often positive consequences, such as getting high or having fun; and the delayed, often negative consequences, such as blowing all your money and being unable to pay a bill or having an unwanted sexual encounter.

"As you identify triggers and consequences, you will discover that there are certain patterns to your use. These patterns will become important targets for intervention."

Therapists should then go over the four components of the functional analysis: triggers, behavior, and positive and negative consequences.

Triggers

A trigger is an event that occurs before a person uses cocaine and increases the likelihood of using. Triggers can be -

• Particular individuals.
• Environmental settings.
• A certain feeling.
• A combination of these.

"Triggers can be quite obvious or they can be difficult to identify. They should not be thought of as things that make you use cocaine, but as things that increase the chance that you will use. Many times, a trigger will lead to other responses, like thoughts about using and the potential consequences of using, such as 'cocaine will make me feel better' or 'doing some cocaine will be lots of fun' or 'cocaine will help me forget that.'"

Almost anything can be a trigger.

• Being out at bars
• Your job
• An argument with a friend or family member
• Withdrawal symptoms
• Being at a certain friend's house
• Peer pressure to use
• Being home alone
• Parties
• Saturday night

These can lead to a variety of thoughts or feelings that encourage cocaine use.

Thoughts

• I can't deal with this.
• I need to get away.
• I need to forget.
• Using would be a blast.

Feelings

• Anxiety
• Depression
• Anger
• Frustration
• Happiness
• Loneliness
• Elation

Behavior

Cocaine use is one of several behaviors that could occur after a trigger. The patients' job is to learn new behaviors so they can either avoid the trigger or refuse to turn to drugs.

Positive Consequences

The positive, reinforcing consequences of cocaine use are usually experienced soon after taking the drug. Some typical positive consequences reported by users are -

• Forgetting bad negative events or feelings.
• Becoming more energetic.
• Getting rid of depressed feelings.
• Feeling less pain.
• Feeling good.
• An enhanced sexual experience.

Because cocaine use results in many of these short-term, positive consequences, it is hard to stop.

Negative Consequences

The negative consequences of cocaine use are usually experienced some time after using. These are the effects that interfere with life goals and are usually detrimental to relationships, work, finances, health, mood, and self-esteem. They are probably part of the problem that brought the patient into treatment. However, these delayed, negative consequences often occur so much later that they have little influence on future cocaine use.

Conduct a Functional Analysis

Next, therapists should instruct patients in how to do a functional analysis.

"The first step in doing a functional analysis of your cocaine use is to identify situations that function as triggers. We have created a form to help you get started."

Give the patient the Discovering Triggers form (exhibit 13). Therapists should work with patients to complete this form.

Next, give the patients a Functional Analysis form (exhibit 14) and go over each component of the diagram. The following steps can be used to guide this training.

"An easy way to identify and see your cocaine-use pattern is to use these Functional Analysis diagrams. Think of the last time you used cocaine. Write down your cocaine use in the box marked Behavior on your Functional Analysis form."

"Next, try to remember what you were doing just before you started using cocaine. Can you remember who you were with, where you were, what you were doing, or what time of day it was? Write these in the Trigger box on your chart."

"Before using cocaine the last time, what were you thinking and feeling? Were you saying anything to yourself? Write whatever thoughts and feelings you remember in the box called Thoughts and Feelings."

"Now I would like you to list your responses to each of these questions:

• What happened after you used?
• What were the effects of using cocaine?
• Did your mood change?
• Did you feel high?
• Did you act differently?
• What were your thoughts and feelings?

"Now make a list of the effects of your cocaine use over time since you began using cocaine. How has it affected your relationships, friendships, work/school, health, self-esteem, and so forth?"

"You will find that the lists you just made include some things that make you feel good and some that make you feel bad. Write down the good things in the Positive Consequences box and the bad things in the Negative Consequences box."

"You will probably notice that most of the positive consequences are events or feelings that occur with cocaine use or soon after, while the negative consequences occur some time after cocaine use, probably a long time after. This is why cocaine use becomes such a powerful habit that it is difficult to break."

"Congratulations, you have just functionally analyzed your cocaine use in that situation."

Therapists should now help patients complete one or two more functional analyses during the session. Patients should also be encouraged to complete additional analyses for the next session, using the Triggers form to identify other cocaine-use situations. Both the Triggers and Functional Analysis forms can be completed as homework if the session time expires. However, if the forms are not completed for the next session, be sure they are completed during that session.

Therapists and patients next turn to developing self-management plans for the various triggers identified in the functional analysis. Such plans will be developed throughout treatment whenever initial plans fail or new triggers are found. Therapists start by praising the patients for doing a thorough job on the functional analysis task and then introduce the next step: learning specific ways to deal with cocaine craving.

Rationale

Therapists can paraphrase the following to explain self-management planning.

"Now that you have identified the triggers and consequences related to your cocaine use, we are going to work on developing strategies for dealing with the triggers. To do so, I will teach you a strategy called self-management planning. This training involves learning how to avoid the triggers or to replace them with other things that are less risky. In addition, you will learn how to rearrange your environment to reduce the likelihood of using cocaine."

Initiate Training

Before initiating self-management training, therapists should review with patients their functional analysis forms. This review should include the following.

• An explanation that external environmental events can often set off drug use.
• Categorization of triggers into places, people, time of day, activities, feeling, and so forth. Give examples and relate them back to the functional analysis (after work, weekends, watching television, others using, anticipation of sexual experience).

Therapists should then explain that there are three basic ways of handling these triggers to reduce the risk of cocaine use.

"One way is to avoid the trigger; for example, take a route home that is different from where you obtained cocaine in the past; avoid going by your dealer's house; don't go into bars; and avoid certain people. To do this successfully, you will have to engage in new or different activities."

"The second way to deal with triggers is to rearrange your environment. For example, don't keep cocaine or paraphernalia in the house, and don't carry money with you if you know you will be walking or driving past places where you might be tempted to buy cocaine."

"The third way of dealing with triggers is to develop some new coping method or plan that will help you not use when you are in a particular situation. For example, you experience a trigger such as extra cash in your pocket. Instead of using the money for drugs, engage in some incompatible behavior. For example, you might call your spouse or do some activity that you enjoy, like working out at a gym or shopping for something special for you or your family."

Make the Plan

Using the patients' Functional Analysis forms, therapists can ask them to pick out a few triggers and then discuss how they might handle those triggers to reduce the chances of using cocaine.

Using the Self-Management Planning Sheet as a guide (exhibit 15), therapists can lead patients through the following steps.

• Choose a trigger. Start with one that often leads to cocaine use. If possible, choose a trigger that is likely to come up in the near future, before the next session, so the patient will be prepared to deal with it.
• Brainstorm and write down a list of potential strategies for either avoiding the trigger, rearranging the environment so the trigger does not occur, or identifying a new coping method for dealing with the trigger when it does occur. Any and all possibilities should be written down. Therapists should encourage patients to be open to any ideas no matter how difficult, easy, simple, complex, or crazy they sound. If needed, therapists should model brainstorming by suggesting many possibilities, some outrageous, some impossible to do, and some simple.
• Together, therapists and patients should consider the overall effects or consequences of each proposed strategy for dealing with the trigger and write these down.
• Therapists should then ask patients how hard they think it will be to carry out each strategy using a scale of 1 (not very difficult) to 10 (extremely difficult).
• After considering all the potential strategies, their consequences, and their perceived difficulties, one strategy should be selected.
• Therapists then ask patients to rehearse the chosen strategy. For example, if the plan is to avoid passing by an old friend's home, have the patient plot a different way home. If the goal is to arrange to be at a safe person's house during a high-risk time, have the patient role-play calling this person to arrange to be there. Better yet, have the patient actually call that person during the session to arrange this get-together.
• Plans for handling two or three triggers should be completed in the session until therapists feel that the patients understand how to do self-management planning.
• Set a goal for patients to complete additional Self-Management Planning Sheets during the week. If they are not completed by the next session,they should be completed during the session.
• Set a goal for patients to carry out at least one of the plans before the next session. Discuss what situations might be coming up this week and review the plan again before patients leave the session.

Drug refusal training is included in most patients' treatment plans. As many as one-third of substance abusers relapse as a direct result of social pressure from friends to use. Most cocaine abusers who are trying to quit continue to have some contact, either planned or inadvertent, with friends or acquaintances who are still using. Turning down cocaine or opportunities to go places where cocaine is available will be much more difficult than most patients anticipate. The ability to refuse cocaine or other drugs when offered is a special case of assertiveness.(The structure of this training is adapted from McCrady 1986 and Sisson and Azrin 1989.)

Rationale

When initiating drug-refusal training, therapists begin by explaining why this will be important to the patients.

"Drug refusal training can be very important in helping you achieve a substantial period of abstinence and for maintaining that abstinence. We are going to practice ways to refuse cocaine or to refuse to go to places where cocaine is available. The ability to effectively say no in these situations will help you feel in control when faced with situations that are tempting and to which you may previously have said yes automatically."

"Our experience is that patients usually underestimate the difficulties encountered when trying to refuse or avoid cocaine. You may feel that you will have no problem saying no, or that no one will ask you if they know you are trying to quit. However, previous patients have found that, if they do not prepare themselves to deal with these situations, good intentions do not always lead to effective refusal. What we and our patients have found to be helpful is to plan and repeatedly practice using specific refusal skills for handling high-risk situations that may arise."

"We have developed a training protocol that is designed to teach or remind you of some effective ways to say no when opportunities arise. An important component of this training is for you to be creative in anticipating many of the situations that may come up in the following months. We have developed some examples that we feel are typical of what many cocaine abusers face, but each person has a unique set of circumstances. This training will benefit you most if you include situations relevant to your life so that we can rehearse how to handle them."

Refusing Cocaine and Other Drugs

Therapists then initiate a discussion and provide information concerning how patients can learn to effectively refuse cocaine. Some important concepts and instructions are presented as follows.

"Remember that those persons who offer you cocaine or alcohol are not thinking of your best interests. They may be your friends, but once you have decided to quit, it is important for you to consider anyone who asks you to use cocaine or go party as a pusher. They must be discouraged - politely, if possible, but firmly."

"Saying no is the first and most important part of your refusal response. There are different ways of saying no that are appropriate in different situations. Different people say no in different ways. It is important to feel comfortable, which means that you have to develop your own style. When working to develop your style, it is important to keep a few goals in mind.

• Your primary goal is to refuse or turn down cocaine.
• Your secondary goals might be to -
  • Reinforce your commitment to not use.
  • Feel good about yourself for doing it."

Components of Effective Refusal

"When creating your own refusal style, a few basic components of your refusal responses will increase the likelihood that they will be effective.

• No should be the first thing you say.
• Tell the person offering you drugs or asking you to go out not to ask you now or in the future if you want to do cocaine. Saying things like 'maybe later,' 'I have to get home,' or 'I'm on medication' just make it likely that they will ask again.
• Body language is important.
  • Making good eye contact is important; look directly at the person when you answer.
  • Your expression and tone should clearly indicate that you are serious.
• Offer an alternative if you want to do something else with that person. Make sure that it is incompatible with cocaine use (taking your children for a walk or to the park, going to work out).
• Change the subject to a new topic of conversation.

Next, therapists help patients begin to develop personal refusal styles. Basic examples of saying no are provided.

• No, thank you.
• No, thank you, but I'll have some coffee or something to eat.
• No, I'm not using anymore; it is causing me too many problems.
• No, I've got a cocaine problem, so I'm not using anymore.

Therapists then help patients construct at least three typical scenes in which patients have had or may have difficulty refusing cocaine. Examples of such situations are friends stopping by with cocaine, friends calling on the telephone, running into friends while shopping, special occasions, parties, or leaving work. The situations that they choose should be very specific. That is, they should include specific people, specific times of day, and so forth.

Therapists and patients then role-play two or three of these situations. Before starting, therapists remind patients of the components of effective refusal and the goals for the situation. A list of these components is provided for the patient to refer to before and during refusal practice attempts (exhibit 16).

For each situation, therapists first have the patients function as themselves, with the therapist acting as the person offering cocaine. After each trial, constructive feedback is given. Therapists continuously refer to the components and goals of effective refusal when giving feedback. Examples or alternatives are given as needed. Problems with some of the patients' tactics are pointed out if they seem ineffective. Following the feedback, the role-play is repeated. When patients experience a lot of trouble, therapists reverse roles with them and model an effective response.

Second, therapists have patients act as the person offering drugs, and the therapists act as the patient. The same procedures are followed. Therapists initiate a discussion of how it feels to be in the different roles: What is hard? What is easy? What feels comfortable? What does not?

Patients may have difficulty with some components. Teaching the components one or two at a time may be a useful method for helping them develop effective refusal skills. Therapists should model the components that they have difficulty with by using role reversal.

Homework

Therapists should remind patients that the most important thing in developing effective refusal skills is practice. Weekly practice goals are set. For example, two high-risk situations can be identified, and patients can practice these scenes each day between sessions. If the patients have partners to practice with, this can be scheduled either during or outside of the session. If patients do not have anyone to practice with, they can either practice aloud in front of a mirror or write down a refusal scenario with responses and bring it to the next session for practice.

In addition, therapists should ask patients to identify situations during the next week in which they may be confronted by a pusher. These situations should be rehearsed in session, and therapists should contract with patients to practice this refusal scene daily and to refuse in that real-life situation.

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