DRUG ABUSERS 91

A scheme for cognitive behaviour therapy with drug abusers

The unique problems with which drug abusers present the cognitive therapist require a flexible and eclectic approach. The therapist may wish to choose between a variety of cognitive-behavioural methods when dealing with the individual patient. The scheme of treatment described here is derived largely from the work of Beck and Marlatt. The emphasis on identifying and coping with triggers for drug use as a means of relapse prevention owes much to Marlatt. The techniques described for modifying these triggers and dealing with emotional and interpersonal problems are direct applications of Beck’s cognitive therapy. The attempts to address underlying assumptions and self-schemas in the cases described are also applications of Beck’s cognitive model. The cases described were all patients attending the Bethlem Royal Hospital Drug Dependency Unit. Most were undergoing in-patient treatment for drug addiction on a unit which adopted a broadly eclectic approach, but which also paid attention to relapse prevention as a new and important contribution to management. The outline of therapy presented here is not by any means a comprehensive or definitive method for treating addictions, but merely suggests a framework which the author personally has found useful. There are five components which roughly correspond to the chronological order of therapy:

1.Engagement.

2.Problem definition and cue analysis.

3.Problem solving and cue modification.

4.Identifying and challenging underlying assumptions.

5.Redefining maladaptive roles.

Successful psychotherapy with any type of patient demands that a relationship of trust is set up as early as possible. This is particularly important when dealing with addicts whose motivation to change fluctuates so easily and whose experience of the ‘straight’ world often makes them distrustful of professionals. Engaging the patient and maintaining motivation is therefore the first goal of therapy. The next step is to carry out a detailed analysis of the factors which act as triggers for drug taking, and at the same time identify other problem areas. Cognitive and behavioural interventions are then used to reduce the risk imposed by these factors, and to provide strategies for coping with them. This phase will also include other measures such as help with interpersonal difficulties, social skills training, and preparation for work. The final stages of therapy address the deeper cognitive structures which make the person vulnerable to the use of drugs as an ineffective problem-solving strategy.

Engaging the patient

One of the most commonly voiced criticisms of cognitive behaviour therapy with substance abusers concerns the difficulty of working with these clients in a collaborative way. Addicts are ‘chaotic’, ‘deceitful’, ‘unmotivated’, and ‘personality disordered’, or so the conventional wisdom would have us believe. How is it possible to apply a complex package which requires introspection, self-observation, and a commitment to practising self-management techniques on a regular and ordered basis? It is too simple to answer that the conventional wisdom is wrong. Labelling all addicts as deceitful or psychopathic is certainly an example of a cognitive distortion on the part of the therapist, but neither are such patients an easy group to work with. Many people with anxiety or depression have discrete episodic disorders; in between they are relatively effective problem-solvers. Cognitive therapy makes use of these premorbid skills, bringing the patient’s rational self to bear on their present emotional state. There is in fact some evidence to suggest that patients who report the use of self-control strategies even when depressed respond best to cognitive behaviour therapy (Murphy et al. 1984). A large number of people who abuse drugs have never developed these problem-solving and self-control skills. Because of these skills deficits they find it harder to understand and work with the cognitive model, while their longstanding patterns of maladaptive behaviour may cause further problems in therapy. These difficulties are by no means limited to this client group, of course: many patients with neurotic disorders have chronic personality problems and prove to be equally hard to engage in cognitive therapy. The challenge in working with this type of patient is to find ways round the personality blocks, and to help them move from a vague, disjointed cognitive style to a more focused, problem-oriented one. Engaging them in therapy is the first, but vital, step in an educative process which goes on throughout the course of treatment.

Establishing a therapeutic relationship

The cognitive therapist needs to have good basic psychotherapeutic skills. Warmth, genuineness, and empathy are just as important as in any other therapy. In fact, these ‘non-specific’ factors may be more important with addicts. Interpersonal factors may intrude more obviously than in conventional cognitive therapy, requiring constant monitoring. Drug abusers usually elicit a dichotomous reaction from those around them. They either persuade friends and relatives to collude with them as ‘sick’,

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or they encounter a totally unsympathetic, rejecting response. A good therapist needs to tread a fine line, showing accurate understanding of the addict’s view of their circumstances, while refusing to be dragged into agreeing that the addict is a helpless victim of the drug or the world around them. The therapist must look out both for negative distortions, e.g. ‘I’ve messed everything up for everyone. I’m hopeless’ and positive ones such as rationalisation and denial, e.g. ‘I can handle this all right myself. It’s not a big problem at all’. With more disturbed clients this dichotomy becomes something which is almost forced onto the therapist. The person tries to test out the therapist by manoeuvring them into a totally accepting or rejecting position. If the therapist complies they are then seen as either too weak or unreasonable. In cognitive terms, the patient seems to structure all relationships as totally rejecting or totally accepting, and finds it difficult to establish behaviour patterns in between these two extremes. A similar picture is described by psychodynamic and cognitive therapists who treat patients with borderline personality disorders. This is not to say that addicts necessarily fit all the diagnostic criteria of the borderline personality, but that they sometimes present similar types of within-session behaviour. The key issue here appears to be establishing a relationship that has both trust and limits.

There is not space here to discuss this in depth, but a few guidelines can be outlined. To establish a trusting relationship which is also therapeutic:

1.avoid moralising;

2.take the patient seriously at all times;

3.show that you are on the patient’s side, even if you disagree with the methods they use to get what they want;

4.be flexible about appointment times etc., but not too flexible;

5.be reliable even when the patient isn’t;

6.if it turns out that the patient has lied to you, use it as grist for the mill of therapy, don’t take it as a personal rejection;

7.but don’t let the patient get away with it either.

The collaborative relationship goes a long way towards preventing interpersonal issues becoming too much of a problem in therapy. Once a trusting relationship is established the addiction can be defined as a problem which patient and therapist can work on together. Sometimes the therapeutic alliance is established with surprising ease. The following case example shows how the ideal collaborative relationship is, however, not always achieved.

Ted was a 38-year-old multiple-drug abuser. He came from a family with strict, traditional values, and frequently came into conflict with his father during his adolescence. He left school to work as an apprentice fitter, but became bored with this job after he finished his training. During the 1960s he drifted in and out of jobs, spending some time as a fairly successful rock musician. His occupation on admission to the drug unit was a street trader who worked on the fringes of legality. Ted abused alcohol, cannabis, and opium, on and off, over most of his adult life. His introduction to hard drugs was in an ‘opium den’ in the Bristol docks, while still in his teens. But he most frequently abused tranquillisers, amphetamines, alcohol, and cannabis. He had two reasons for wanting to give up drugs—threats from his wife that she would leave him, and an impending charge of supplying cannabis.

Ted’s behaviour throughout his admission suggested that he was testing out the unit’s rules and limits to the full. He would deliberately overstay his pass, coming back perhaps half an hour late. It was quite difficult to confront him on this because of his slightly menacing manner. In therapy this issue of who was in control seemed to be a central one. It interfered with the collaborative relationship since the patient brought very little homework to the session claiming that the problems identified at the beginning of therapy had now disappeared. It later became clear, however, that Ted was in fact operating his own treatment programme, which drew ideas from, but did not directly comply with, that of the unit. He would set himself graded exposure tasks such as going into pubs and visiting old haunts where he knew drugs were in evidence. His argument was, ‘I’ve got to go to these places to do business, so I’d better get used to going unstoned as soon as possible.’ Once it was evident that Ted would be ‘his own man’ to the last, and had to think of himself as ‘screwing the system’, it became easier for the therapist to redefine the format of therapy. Specific homework tasks were not set. Instead various strategies were discussed and Ted was left to get on with his own treatment programme. This is an example of how it is sometimes necessary to work with rather than against the patient’s personality style, even if it is to some extent maladaptive. An alternative approach to psychopathic behaviour is described by Beck and Emery (1977). They assume the patient’s goals are legitimate, but the psychopathic behaviour represents a socially inefficient means of achieving them. The therapist sets up a collaborative relationship where alternative methods of reaching the goals are explored and tested out.

Motivation

The person who experiences unpleasant mood states such as anxiety or depression is usually highly motivated to change. Substance abusers are in a very different situation. They are choosing to change an aspect of their behaviour not because it is intrinsically unpleasant, but because its consequences are undesirable. There is inevitably always a state of tension and

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Table 7.2 Tom’s list of advantages and disadvantages of drugs

what has been termed a decision matrix. With some clients this further subdivision may be useful since they often have difficulty in thinking of longer-term consequences of their actions.

Rationale

An integral part of any self-control therapy is the explanation of the rationale to the patient. Explaining the connection between thoughts, feelings, and behaviour is much the same as with cognitive therapy (see Beck et al. 1979). Booklets can be given to patients, e.g. ‘Coping with substance dependency problems’ (Beck and Emery 1977). It may take longer to socialise the addict into the model and the therapist may need to reiterate continually the basic concepts and make use of examples from the addict’s behaviour within and between sessions. Beck and Emery suggest that the first three sessions are devoted to engagement, orientation, and instruction, but with many addicts this may take much longer.

The role of negative cognitions in the process of engagement and commitment

Once the patient’s personal balance sheet becomes evident it is possible to look at how distorted thinking may be unfairly weighting it in favour of maintaining the use of drugs. Two common types of negative cognitions involve helpless/hopeless views of the situations and denial/rationalisation responses. Both of these can be addressed using cognitive therapy. Addicts who are depressed will talk of feelings of worthlessness, the hopelessness of their position, etc. Others who are not clinically depressed may still have maladaptive beliefs which interfere with their ability to work on the problem. For instance Simon, a 23-year-old heroin addict, felt himself to be in the grip of strong cravings which he had no power over. Exploration of his view of the situation showed that he believed that he could not stand strong craving, and that the only way to solve the problem was to remove craving completely. The dichotomous thinking of addicts has been described already. This seems to be one of the major distortions standing in the way of effective cognitive therapy.

John was a 28-year-old man who had been making a successful living as a carpet fitter. He began using alcohol and heroin as a way of winding down after a hard day’s work. His personal life suffered greatly and he nearly lost his wife. He experienced great remorse over this and determined to give up heroin. His determination relied so heavily on willpower that he could not allow himself to contemplate being unsuccessful in this. The dichotomy of addiction versus abstinence prevented him from looking at the middle ground of risk situations, trigger factors, and coping strategies, and meant that he went out of the unit without addressing these issues.

With patients like this, part of the problem lies in their use of the all or nothing thinking as a way of motivating themselves to give up. The therapist may want them to examine ways of preventing a lapse turning into a full relapse, but they say that if they let themselves even consider this they might use it as an excuse for trying the drug again.

Rationalisation and denial are commonly encountered defences in drug abusers. They are not character traits but genuinely seem to vary with the general motivation of the client. The therapist can deal with the excuses the patients make to themselves by enlisting the help of their rational self when they are in a state of high motivation. The patient is instructed to look out for habitual self-deceptions, e.g. ‘I’ll just try it to see what it’s like’; ‘One little drink won’t hurt me’. This can initially take the form of self-monitoring of excuses using a wrist counter, and move on to challenging the distorted cognitions. When a strong urge to take the drug is felt it may be difficult to counter the excuses. The patient can rehearse self-statements which can be used at times of stress. One patient found it difficult to remember the bad things about cocaine. He wrote down his reasons for giving