DRUG ABUSERS 95

it up and read them out to his wife every morning before breakfast. This had the effect of orienting him to the negative consequences of cocaine abuse and making a ‘public’ commitment to his wife that he was determined to give up.

Cue analysis

A variety of stimuli act as triggers for drug taking. The cognitive-behavioural model sees these as factors which lead to relapse and maintain drug abuse. Eliciting these triggers is easiest with people who are not physically addicted, and who are in their natural setting, because their drug use will vary in response to them. Addicts in a hospital in-patient setting, particularly those who have completed a detoxification programme, find it much harder to identify cues. It may be that physical addiction swamps most other cues with the overriding impact of withdrawal symptoms as the major cue for further intake of a drug. Once addicts are detoxified and removed from their usual setting they find it hard to remember.

Simon’s difficulties in coping with craving were mentioned earlier. He found it immensely difficult to identify any cues, and initially believed that his craving while going through withdrawal was constant and all-pervasive. His life before admission was a blur of drugs. Monitoring craving on a daily basis just produced a blank sheet. It required several sessions of painstaking reconstruction of events before the therapist got an impression of what factors might be significant. Even then this was based heavily on interpretation of the patient’s report, with very little in the way of identified thoughts or images. The four major cues seemed to be:

1.boredom,

2.depressed mood,

3.meeting new people, and

4.seeing someone with drugs.

Situations in which he felt unable to cope, or burdened with responsibility, caused depression, and drug taking seemed to be an escape route. The same theme of escape appeared in social settings, where a craving occurred if he was with new people. The cues and the hypothesis of drug taking as a means of escaping unpleasant situations fitted well with other facts about him. He was a rather empty young man with little in the way of initiative or motivation. He objectively overestimated the amount of responsibility he was expected to take by people, but he accurately assessed his own lack of coping skills. It proved difficult to engage him and he left the unit shortly after completing his withdrawal. Fortunately, not all clients have such difficulty in monitoring the internal and external cues for craving.

Jane was a 38-year-old heroin addict. She was an identical twin who came from a stable middle-class family. Her drug abuse started at the age of 21 when she worked as a volunteer in a drug rehabilitation unit. She found the idea of heroin attractive and romantic. It seemed to fit her view of herself as a tragic and vulnerable figure. She quickly became addicted and was a long-term user. Her life varied from episodes of illicit drug use to periods on maintenance prescriptions, with occasional attempts to come off drugs. Despite her addiction she was able to contribute to the rearing of her two sons. Her husband Tom was an addict whom she met in the unit during a previous admission.

Jane presented many of the triggers for an urge to take drugs in the initial interview where she listed the advantages of drugs for her. She seemed to be very sensitive to situational cues. This was further borne out when she monitored her craving between sessions. Programmes on television about drugs or times when other patients talked about drugs all produced a craving.

She was also able to identify her relationship with her husband as a potential risk factor. When he acted towards her in a cold way she became clinging and dependent. She had thoughts such as ‘He’s going to leave me …He doesn’t love me’. She would respond by seeking reassurance which resulted in her husband acting in a more withdrawn fashion. When this cycle reached a certain pitch she started to get an urge to take more heroin to relieve the ‘pain’. The only other cue she was able to identify was money: it represented drug availability.

There are several methods of identifying cues, which depend to a large extent on the psychological sophistication of the patient. Some will be able

Table 7.3 Methods of identifying cues

1.Circumstances of last relapse

2.Recent experiences of craving

3.Monitoring craving of drug use

4.Producing craving in a session and eliciting cognitions

5.Interviewing significant others