98 COGNITIVE THERAPY IN CLINICAL PRACTICE

disadvantages of this way of thinking, look for evidence about how successful other people have been who have used this method, or weigh up the possible gains versus losses of putting themselves in high-risk situations.

A thorough cue analysis will allow therapist and client to predict which situations might be risky. At each session the week ahead can be previewed and any occasions when the person will be at risk identified and strategies for coping rehearsed. In the early stages of therapy, avoidance of high-risk situations is essential. As therapy progresses exposure to these situations may be programmed as part of an exercise in learning to cope with the cues for drug use.

It may be helpful to introduce the client to the concept of Apparently Irrelevant Decisions (Marlatt and Gordon 1985). People find themselves in high-risk situations through a series of decisions which at first seem perfectly innocent but on further inspection may not be so straightforward. A 28-year-old ex-nurse irregularly abused amphetamines. She described one lapse where she found herself at a loose end on a Sunday afternoon and decided to visit a friend. Since most of her friends were out of town she got on the train to visit a girlfriend who lived a few miles away. This sequence of events led her to the friend who supplied most of her amphetamines.

Coping with high-risk situations

If these situations cannot be avoided the person needs to find ways of preparing for and coping with them. The first step is to get some distance from any urges they may have. Clients can practise observing their craving, using what Emery (Beck, Emery and Greenberg 1985) refers to as the observing self. Another technique is to ride the swells and ebbs of craving like a surfer, a method which Marlatt calls ‘urge surfing’ (Marlatt and Gordon 1985). Whatever metaphor is used the principle is the same, i.e. being able to stand back sufficiently not to be engulfed by the feelings. The next step is to look for more active strategies to use in the face of craving. Distraction may be a useful short-term strategy, and similar methods can be applied to those used for anxiety. Since cognitions play an important part in maintaining craving, challenging craving-related cognitions will also be helpful. The usual methods of monitoring and answering back automatic thoughts apply equally to drug addicts, but addicts probably need to practise recording and challenging thoughts related to lesser degrees of craving as a homework assignment before exposing themselves to high-risk situations.

Because of the difficulties people have in thinking of rational responses when they are craving, it may be necessary to rehearse self-statements which they can use. A form of stress inoculation can be employed in which the patient induces a craving within the session and practises controlling it using self-statements. Coping imagery can be employed in a similar manner. Anti-craving thoughts can be encouraged and reminder cards can be written out to help the patient remember them when in a tight spot.

Interpersonal factors should not be overlooked. Social pressure, whether direct or indirect, accounts for 20 per cent of relapses (Cummings et al. 1980). Assertiveness training may be needed to help the patient say ‘no’. Social support can play a part, just as social pressure can. A simple but highly effective way of preparing for a high-risk situation is for the patient to arrange for a non-using friend to go with them. The cocaine user who made the daily assertion of the ills of drug abuse to his wife (see p. 168) worked in the music business. He found that he could not say no if he was offered cocaine at a concert, but if he took his wife with him he was easily able to resist.

Modifying emotional factors

The decision to take a drug in a high-risk situation is often made in a state of strong emotion. Depression, anxiety, and anger are negative emotions which can act as triggers, and cognitive therapy offers unique methods for dealing with them. The basic techniques of thought monitoring, identifying distortions, and challenging negative cognitions are described adequately elsewhere (Beck et al. 1979; Beck et al. 1985). We will illustrate how some of these can be applied with the negative emotions experienced by drug abusers.

During the initial weeks of her stay on the unit Jane experienced a great deal of anxiety. This was related to her withdrawal from valium as well as heroin. She was taught to monitor and challenge her negative automatic thoughts. She also had patterns of depressive thinking associated with a poor self-image. Both anxiety and depression seemed to occur when Jane felt herself to be under criticism or facing the possibility of rejection by other people. This was particularly evident in the drug unit where she was one of the few females and was also older than most of the patients. She found herself thinking They think I’m old and unattractive’. She also found her stance as one of the more mature people in the unit working for her recovery a difficult one, since it brought her up against the subculture of rebellion which existed in the unit at the time. Cognitive techniques focused on her fear of rejection and disapproval. She reassessed her own strengths and began to challenge her belief that she needed to be valued and approved by everyone. Role-play helped her to develop new assertive skills. She responded well to these interventions and the frequency of episodes where she became sensitive to supposed criticism reduced.