Therapy Manuals for Drug Addiction Series

Individual Drug Counseling

Delinda E. Mercer, Ph.D.

George E. Woody, M.D.

University of Pennsylvania and

Veterans Affairs Medical Center

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Institute on Drug Abuse

Division of Clinical and Services Research

6001 Executive Boulevard

Rockville, Maryland 20892
ACKNOWLEDGMENTS

The development of this manual was supported, in part, by research grants for the

Collaborative Cocaine Treatment Study (CCTS) and for the Drug Dependence Behavioral Treatment Research Center from the National Institute on Drug Abuse

(NIDA). This manual was written by Drs. Delinda E. Mercer and George E. Woody

under contracts with NIDA. Debra Grossman, the NIDA project officer, offered valuable guidance and comments throughout the preparation of this manual.

The material presented in this manual is the result of extensive research and clinical

experience under the direction of Dr. Woody and colleagues at the University of

Pennsylvania (Penn) and Veterans Affairs (VA) Medical Center. The University of

Pennsylvania Center for Psychotherapy Research and the Penn-VA Center for

Studies of Addiction were both instrumental in the development of this manual and

in the Collaborative Cocaine Treatment Study for which this manual was originally

prepared. This drug counseling model is based on the clinical work of Nina

Chychula, Ph.D., John McGinnis, M.S.W., and Debra Wiles, M.S.W., in the Addiction

Recovery Unit of the Veterans Affairs Medical Center under the direction of Iradj

Maany, M.D. The work of many others was also quite valuable and is acknowledged

in the relevant portions of this manual.

The assistance of many dedicated therapists, counselors, and research assistants

who participated in the clinical trial of this therapy protocol is gratefully acknowledged and appreciated.

DISCLAIMER

The opinions expressed herein are the views of the authors and do not necessarily

reflect the official policy or position of the National Institute on Drug Abuse or any

other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product.

PUBLIC DOMAIN NOTICE

All material appearing in this report, except the appendix, is in the public domain

and may be reproduced without permission from the Institute or the authors. Citation of the source is appreciated.

NIH Pub. No. 99–4380

Printed September 1999
Foreword

More than 20 years of research has shown that addiction is clearly treatable. Addiction treatment has been effective in reducing drug use and HIV

infection, diminishing the health and social costs that result from addiction, and decreasing criminal behavior. The National Institute on Drug

Abuse (NIDA), which supports more than 85 percent of the world’s research on drug abuse and addiction, has found that behavioral approaches can be very effective in treating cocaine addiction.

To ensure that treatment providers apply the most current scientifically

supported approaches to their patients, NIDA has supported the development of the “Therapy Manuals for Drug Addiction” series. This series reflects NIDA’s commitment to rapidly applying basic findings in real-life

settings. The manuals are derived from those used efficaciously in

NIDA-supported drug abuse treatment studies. They are intended for use

by drug abuse treatment practitioners, mental health professionals, and

all others concerned with the treatment of drug addiction.

The manuals present clear, helpful information to aid drug treatment

practitioners in providing the best possible care that science has to offer. They describe scientifically supported therapies for addiction and

give guidance on session content and how to implement specific techniques. Of course, there is no substitute for training and supervision, and

these manuals may not be applicable to all types of patients nor compatible with all clinical programs or treatment approaches. These manuals

should be viewed as a supplement to, but not a replacement for, careful

assessment of each patient, appropriate case formulation, ongoing monitoring of clinical status, and clinical judgment.

The therapies presented in this series exemplify the best of what we currently know about treating drug addiction. As our knowledge evolves,

new and improved therapies are certain to emerge. We look forward to

continuously bringing you the latest scientific findings through manuals

and other science-based publications. We welcome your feedback about

the usefulness of this manual series and any ideas you have on how it

might be improved.

Alan I. Leshner, Ph.D.

Director

National Institute on Drug Abuse

iii
iv
Contents

Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Chapter 1 Introduction .....................................1

Introduction ....................................................1

Research Support ................................................1

Treatment Philosophy.............................................2

Contributions of the 12-Step Approach ...............................2

Role of Self-Help Groups ..........................................3

Role of Significant Others in Treatment...............................4

Chapter 2 Overview ........................................7

Overview of This Counseling Approach ...............................7

Comparison of Addiction Counseling and Psychotherapy.................7

Similar and Dissimilar Approaches ...................................9

Compatibility With Other Treatments ................................9

Chapter 3 Logistics of the Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Frequency and Duration of Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Duration of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Target Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Addiction Severity Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Biological Assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 5 The Role of the Addiction Counselor . . . . . . . . . . . . . . . . . 17

Patient-Counselor Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

v
Page

Behaviors That Should Not Be Done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 6 The Individual Drug Counseling Model . . . . . . . . . . . . . . . 21

Goals and Objectives of Individual Drug Counseling . . . . . . . . . . . . . . . . . . . 21

Stages of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

In Each Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Preparing for the Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

During Each Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 7 Treatment Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Treatment Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Ambivalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Introductory Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Session 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Session 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Chapter 8 Early Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Treatment Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Addiction and the Associated Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . 30

People, Places, and Things . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Structuring One’s Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Sample Schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Craving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

High-Risk Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Social Pressures To Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Compulsive Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Postacute Withdrawal Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Use of Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

12-Step Participation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 9 Maintaining Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Treatment Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Tools for Preventing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Identification of the Relapse Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Relationships in Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Development of a Drug-Free Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Spirituality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Shame and Guilt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Personal Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Character Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Contents

vi
Page

Identification and Fulfillment of Needs . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Management of Anger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Relaxation and Leisure Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Employment and Management of Money. . . . . . . . . . . . . . . . . . . . . . . . . 58

Transfer of Addictive Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Chapter 10 Advanced Recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Treatment Booster Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Goals of Booster Sessions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Chapter 11 Dealing With Problems That Arise . . . . . . . . . . . . . . . . . . 63

Dealing With Lateness or Nonattendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Denial, Resistance, or Poor Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Strategies for Dealing With Crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Dealing With Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Levels of Severity of Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Slips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Several Days of Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Sustained Drug Use With Resumption of Addiction. . . . . . . . . . . . . . . . . 66

Chapter 12 Counselor Characteristics and Training. . . . . . . . . . . . . . 67

Ideal Personal Characteristics of the Counselor. . . . . . . . . . . . . . . . . . . . . . . . 67

Educational Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Credentials and Experience Required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Counselors in Recovery Themselves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Chapter 13 Supervision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Training and Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Use of the Adherence Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Appendix: Adherence/Competence Scale for Individual

Drug Counseling (IDC) for Cocaine Dependence . . . . . . . . . . . . . 77

Contents

vii
Chapter 1 Introduction

Introduction

This manual is intended as a guide for the individual treatment of cocaine addiction by addiction counselors. The counseling model described here was developed originally for use in the Collaborative Cocaine Treatment Study (Mercer and Woody 1992) sponsored by the National Institute on Drug Abuse. This model was based on the counseling

in the outpatient, drug-free program in the Addiction Recovery Unit and

in the methadone maintenance program (Woody et al. 1977), which are

both part of the Veterans Affairs Medical Center. Twelve-step philosophy

and participation is a central component of the model. Additionally, we

have drawn upon the ideas of many clinicians and theorists in this area,

including Alan Marlatt (Marlatt and Gordon 1985), Terrence Gorski

(Gorski and Miller 1982), Dennis Daley (1986, 1988, 1993), and Arnold

Washton (1990a, 1990b, 1990c).

This individual counseling model can be viewed as a component within

a comprehensive outpatient treatment program for cocaine addiction.

Alternatively, the model can be offered independently of other treatments, and referrals can be made for any additional services as needed.

Research Support

The Collaborative Cocaine Treatment Study (Crits-Christoph et al.

1997) was a large study carried out at four sites in the northeastern

United States that investigated the relative efficacy of four psychosocial

treatments for cocaine addiction. The individual drug counseling model

presented in this manual was developed for use in the study protocol.

Four hundred and eighty-seven cocaine-addicted adults were randomly assigned to individual drug counseling (IDC) plus group drug

counseling (GDC), cognitive therapy (CT) plus GDC, supportive-expressive psychodynamic therapy (SE) plus GDC, or GDC alone

(Crits-Christoph et al. 1997). Individual treatment sessions were offered twice weekly for 3 months, then once weekly for 3 months.

Group sessions were once a week for 6 months. Results showed that

patients in all treatment conditions reduced their cocaine use signifi1
cantly; however, patients in IDC reduced their cocaine use more and

did so more rapidly than those in the other conditions (Crits-Christoph

et al. in press).

Treatment Philosophy

According to the philosophy underlying the IDC approach, addiction is

a complex disease that damages the addict physically, mentally, and spiritually. Because of the holistic nature of the illness, the optimal treatment addresses the needs of the addict in many areas. Physical, emotional, spiritual, and interpersonal needs must all be addressed to support recovery.

The philosophy of this approach incorporates two important elements:

endorsement of the disease model and the spiritual dimension of recovery. These elements differentiate the approach from some other forms

of treatment currently in use and reflect the influence of the 12-step

philosophy.

The disease model essentially states that addiction is more closely akin

to an illness over which one has little, if any, control, compared to a behavior that one chooses to enact. Recent biologically oriented research

suggests a genetic component to alcohol and other addictions and

points to physiological changes in the brain that result from drug use.

These findings are very consistent with the disease model (Bloom 1992;

Heinz et al. 1998).

The element of spirituality is very general and not specific to any religion. Three of the main spiritual principles, as taken from Narcotics

Anonymous (NA) philosophy, are honesty, openmindedness, and willingness. This spiritual component implies that there is a healing of one’s

life that needs to take place, and abstinence from the drug is merely the

first step rather than the terminal goal. A holistic perspective on the individual is encouraged, which suggests that recovery involves a return to

self-respect through honesty with oneself and others. Spirituality also

involves a belief in or sense of connection to something greater than

oneself, which is quite consistent with some of the newer models of psychotherapy. However, within addiction counseling, the role of spirituality in healing tends to be more focused and overtly stated than in most

other therapeutic orientations.

Contributions of the 12-Step Approach

Numerous authors (e.g., Galanter and Pattison 1984; Washton 1989)

have suggested that 12-step groups play an important role in addiction

treatment. Historically, 12-step treatment programs are linked largely to

recovery from alcohol abuse and addiction, which is a logical associaChapter 1 Introduction

2
tion. Since its inception in 1935, more than 1 million persons are estimated to have achieved recovery through involvement in Alcoholics

Anonymous (AA) programs. Additionally, it is estimated that, at any one

time, more than 100,000 men and women worldwide are involved in AA

12-step programs (AA World Services, Inc. 1986).

However, neither the 12-step philosophy nor its procedures are related

intrinsically to alcohol. AA has spawned many related programs for recovery from other addictions or other emotional problems. Narcotics

Anonymous is a 12-step program adapted from AA. The primary difference between the two is that NA is more inclusive with respect to addiction to any mood-altering substance. Cocaine Anonymous (CA) is a

smaller group geared specifically to cocaine addiction, as the name implies. NA and CA, like the many other 12-step programs AA has spawned,

adhere to the same philosophy and beliefs as AA. The underlying belief is

that most aspects of chemical addiction are transcendent rather than

specific to any particular drug.

Twelve-step ideology offers patients seeking recovery a new modus vivendi, or way of living, that will support them in breaking the cycle of addiction and in maintaining abstinence. The strengths and usefulness of

the 12-step approach seem to have several sources. Procedurally, virtually any presenting situation can be dealt with effectively by applying the

appropriate lesson or lessons derived from the more than 60 years of

honing and refining the 12-step philosophy.

Essentially, these steps provide a developmental approach for recovering from addiction. The steps are organized in an order, going from the

most basic changes onward to the more advanced changes that individuals motivated to recover may seek to integrate into their life. Narratives

of others who are struggling with addiction offer compelling perspectives to support the individual seeking recovery. These narratives help

addicts to confront the reality of their addiction and recognize the harm

it has done to them personally and to the people they care about. The approach also asks addicts to recognize the existence of a higher power

and to incorporate this belief in their own lives, if only for the reason

that it has been shown to be helpful in aiding recovery (Galanter and

Pattison 1984).

Role of Self-Help Groups

Participation in a self-help program is probably not for everyone but for

many is an extremely valuable aid to recovery. Such participation helps

recovering individuals to develop a social support network outside of

their treatment program, teaches the skills needed to recover, and helps

patients to take responsibility for their own recovery. Participation in a

group provides a sense of belonging and can lead to a new identity for

Chapter 1 Introduction

3
individuals whose primary identity has been as an alcoholic or drug addict.

In the Collaborative Cocaine study, we studied pretreatment self-help

group attendance to see if it would predict initiation of abstinence in

519 cocaine-addicted patients entering treatment (Weiss et al. 1996). Of

the 519 respondents, 34 percent indicated that they had attended at

least one 12-step meeting in the past week. Of those who attended, 85

percent actively participated in program activities in some way, such as

reading 12-step literature, meeting with one’s sponsor, or speaking at a

meeting. We found that 51 percent of self-help attendees initiated abstinence, compared to 40 percent of nonattendees, a significant difference. Furthermore, active participation appears to be more helpful than

merely attending meetings: 55 percent of active participants became abstinent, compared to 38 percent of attendees who did not actively participate and 40 percent of nonattendees. AA and NA were the most frequently attended self-help groups, which may be because they are more

widely available than CA and some of the other 12-step organizations.

In addition to encouraging patients to attend self-help groups at least

three times a week and to get a sponsor, the addiction counseling program educates patients about 12-step ideology and incorporates many

of the 12-step concepts into the content of the counseling. By introducing and promoting many of the 12-step concepts, the program exposes

the ideas to patients who are unwilling to participate in meetings at that

juncture. Addressed within the content of the counseling sessions are

such concepts as breaking through denial; avoiding people, places, and

things that can trigger drug craving; taking a personal inventory; working on character defects; and incorporating spirituality as an element of

recovery.

Regarding 12-step versus other types of programs, participation in any

legitimate self-help program should be encouraged. Patients may gravitate toward a variety of non-12-step-based self-help groups, such as Rational Recovery, Women for Sobriety, or individual religious groups, depending upon their individual preferences. The selection is limited primarily by what is available locally. However, the 12-step approach to recovery is generally more well known, and such groups are more widely

available than other approaches. For mainly this reason, it has been an

integral part of many addicts’ recovery. Thus, we focus more on 12-step

programs than on other groups and draw from this approach in the

counseling itself.

Role of Significant Others in Treatment

This model of addiction counseling does not focus much attention on

the role of family members in treatment. The reason is not because family involvement is seen as unimportant in treatment, but rather because

Chapter 1 Introduction

4
IDC is not intended to provide all-inclusive treatment. Family members

can play an important role in recovery.

In general, including partners, family members, and even close friends

in addiction treatment, e.g., in the form of holding family sessions, can

facilitate recovery. Encouraging family involvement can help the recovering person create a better, more knowledgeable support network

(Galanter 1986). It may decrease the family’s addiction-enabling and/or

codependent behaviors that tend to impede the patient’s recovery. And

it will make it easier for the counselor to intervene in any problematic

family situations that might potentiate a relapse.

Chapter 1 Introduction

5
6
Chapter 2 Overview

Overview of This Counseling Approach

Individual drug counseling focuses on the symptoms of drug addiction

and related areas of impaired functioning and the content and structure

of the patient’s ongoing recovery program. This model of counseling is

time limited and emphasizes behavioral change. It gives the patient coping strategies and tools for recovery and promotes 12-step ideology and

participation. The primary goal of addiction counseling is to assist the

addict in achieving and maintaining abstinence from addictive chemicals and behaviors. The secondary goal is to help the addict recover from

the damage the addiction has caused in his or her life.

Addiction counseling works by first helping the patient recognize the existence of a problem and the associated irrational thinking. Next, the patient is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills and spiritual development to

continue in recovery as a lifelong process.

Within this counseling model, the patient is the effective agent of

change. It is the patient who must take responsibility for working on and

succeeding with a program of recovery. Although recovery is ultimately

the patient’s responsibility, the patient is encouraged to get a great deal

of support from others, including counselors and other treatment staff,

one’s sponsor, and drug-free or recovering peers and family members.

Overall, drug use is thought to be a multidetermined, maladaptive way

of coping with life’s problems. It sometimes becomes compulsive and

leads to a progressive deterioration in one’s life circumstances. Compulsive drug abuse is addiction, which is defined as a disease. It damages the

addict physically, mentally, and spiritually.

Comparison of Addiction Counseling and Psychotherapy

In the research protocol for which IDC was developed originally, it was

extremely important to clarify the boundary between addiction counseling and psychotherapy. Addiction counseling and psychotherapy were

compared to determine if one was more effective than the other for the

7
treatment of cocaine addiction. In clinical practice, however, the boundary between addiction counseling and psychotherapy often is blurred.

To aid understanding of the contrast between addiction counseling and

psychotherapy, the elements of addiction counseling that may differ

from psychotherapy are discussed here.

Addiction counseling involves setting and encouraging the patient to

work toward predominantly short-term goals. Although the goal of continued abstinence supported by a change in lifestyle is not short-term,

the 12-step adage of “one day at a time” creates a short-term way of working toward lifestyle change.

The goals of IDC are always directly related to recovery from addiction.

For example, an appropriate goal in addiction counseling might be for

the patient to terminate an abusive relationship that enabled the patient’s drug use, but it would not be an appropriate treatment goal for

the patient to work through issues stemming from his or her early abusive relationship with a parent. Another appropriate goal of addiction

counseling would be to recognize the impact of one’s dysphoric feelings

on one’s drug use and to develop a strategy for responding in a new way

that does not involve drug use. However, it would not be appropriate to

do a cognitive analysis of the thoughts that underlie the dysphoria. The

addiction counselor tries to provide the patient with concrete, behavioral options to facilitate recovery. Such options include avoiding those

things that trigger drug use, attending self-help groups, and leaving or

changing situations or relationships that contribute to the addiction.

Finally, addiction counseling focuses primarily on the present rather

than the past. The counselor might become familiar with some of the significant historical data but would not direct interventions aimed at understanding the effects of past events, except perhaps those events that

are related to the addiction.

Below is a comparison of addiction counseling with a typical model of

psychotherapy, which would include psychodynamic approaches and

cognitive therapy, as well as other approaches. However, not all models

of psychotherapy are consistent with this simplified model.

Addiction Counseling Psychotherapy

Short-term goals Short- and long-term goals

Behavioral goals Cognitive, emotional, and

behavioral goals

Goals directly related to Goals related to all areas of

addiction recovery

Focus on the present Focus on the past and present

Chapter 2 Overview

8
Similar and Dissimilar Approaches

Several other approaches used in addiction treatment are quite similar

to the model of counseling presented here. Probably the most similar is

the Minnesota Model, or what often is referred to as the Hazelden approach. Another popular drug counseling approach that is quite similar

is the CENAPS model (Gorski 1989). The 12-step facilitation model

(Nowinski et al. 1994), developed for use in the MATCH study (Project

MATCH Research Group 1993) sponsored by the National Institute on

Alcohol Abuse and Alcoholism, also is similar in its emphasis on the

12-step philosophy and participation.

Other approaches are more dissimilar, such as the traditional

Synanon-style approach as provided in a therapeutic community. The

difference is not in the content, which might, in fact, be similar, but in

the format which, in the therapeutic community situation, would probably be more structured, punitive, and confrontational. Also, our approach is tailored for use in outpatient treatment, so there is no opportunity for immersion in a community, which usually is regarded as a

powerful intervention. Another approach that would be dissimilar in

both philosophy and content would be any psychotherapy model that

does not focus primarily and specifically on changing addictive behaviors, such as psychoanalytic or psychodynamic therapies, including supportive-expressive therapy (Luborsky 1984; Mark and Luborsky 1992)

and interpersonal therapy (Rounsaville et al. 1985).

Compatibility With Other Treatments

This counseling approach is highly compatible with most other treatments for addiction. It fits well with many other treatments because it

was designed to be a component in a more comprehensive treatment

package. Such a treatment program would probably include initial medical and psychosocial assessments, detoxification if necessary, participation in group therapy, psychiatric and medical services if needed, a family support group, possibly employment counseling, and ongoing participation in a self-help program along with the individual addiction

counseling. However, this approach to addiction counseling also lends

itself well to being used in a private practice format where other types of

treatment could be added as desired. For example, it might be combined with family or couples therapy or alternative therapies.

The model can be coordinated easily with pharmacotherapy approaches, whether for treatment of addiction or comorbid psychiatric

disorders. While addiction counseling is provided for treatment of cocaine addiction, it is not unusual for patients also to receive antidepressant medication for comorbid depression. Similar counseling also has

been used in combination with naltrexone prescribed for alcohol addicChapter 2 Overview

9
tion. A trickier situation occurs when a patient being treated for chemical addiction also is being treated for a psychiatric problem with a potentially addictive medication. For example, a patient with cocaine addiction and comorbid panic disorder might be treated legitimately for the

panic with a benzodiazepine. In such cases, it is especially important to

monitor the use of medication to ensure that it is used appropriately. It

is also important, when any medication is being prescribed, to clarify for

the patient that being free of any mood-altering chemicals is not intended to include legitimately prescribed medications.

Chapter 2 Overview

10
Chapter 3 Logistics of the Model

Frequency and Duration of Sessions

The optimal frequency for counseling sessions is twice a week, at least

initially. More than twice a week may be a burden for the patient who is

functioning well enough to be employed and have a family or other social supports. Less than twice a week can be too infrequent to create a

strong sense of connection and support and provide the monitoring

that is helpful for the person who is struggling with recovery. The necessary frequency depends largely on the amount of structure and support

that already exist in the patient’s life and how able the patient is to create

structure and engage in healthy activities.

When the IDC model was developed for research, the counseling sessions took place twice a week from the first week through the twelfth

week and then decreased to once a week from the thirteenth week

through the twenty-fourth week of treatment. Following completion of

the active treatment phase at 24 weeks, less frequent booster sessions

were provided. Booster sessions usually help patients to retain the gains

they have made longer. Even infrequent check-in sessions, perhaps once

a month, tend to remind patients of the goal and help them feel supported and monitored.

Weeks 1–12 13–24 25–36

Sessions per week 2 1 0.25

In the IDC model, each session should be approximately 45 minutes,

unless the patient arrives late, thus causing the session to be curtailed.

The counselor is responsible for scheduling sessions and for dealing

with any missed appointments by promptly contacting the patient and

rescheduling. If the patient cancels a session, the counselor should offer

another appointment as soon as possible. The counselor should always

be prompt and keep in mind that the counseling relationship is a professional one and that the patient deserves to be treated with respect.

11
Duration of Treatment

This model is intended to be time limited, with 36 sessions planned to

occur over 6 months. It is difficult to determine what is the optimal

amount of addiction counseling, or of any therapy for that matter, because so much depends upon the motivation and progress of the patient. Six months is a fairly generous time allotment, longer than some

programs, however shorter than is probably standard in a private practice model of treatment. There is a benefit to offering a time-limited

treatment as it can help the patient to structure his or her recovery

knowing that there are only so many sessions. In time-limited therapy,

the counselor should highlight the length of the treatment in the introductory sessions, and the patient and therapist should complete treatment plans and review goals with this time frame in mind. Also, when

the patient nears the time of termination, the counselor should remind

the patient of the limit. In the terminating process, the counselor and

patient should establish plans or goals, so that the patient is left with a

clear idea of where to go after treatment ends.

Target Population

IDC has been developed for adult male and female outpatient cocaine

addicts. Individuals can be abusing or addicted to other drugs in addition to cocaine, with the exception of opiates if methadone maintenance

is to be used. Similar counseling would be appropriate for methadone-maintained, cocaine-addicted patients, with modifications recognizing the issue of being in drug maintenance therapy. Also, while this

particular approach specifically addresses cocaine addiction in describing postacute withdrawal symptoms and so forth, all of the general

themes (everything excluding specific information about cocaine) are

appropriate for use in treating other drug addictions as well.

Some individuals need more than IDC or other addiction-focused treatment. For example, dually diagnosed individuals with significant

psychopathology often require more attention to their psychopathology

than this approach provides. However, the approach can be used in

combination with pharmacotherapy for other psychiatric problems or

sometimes is employed as part of a package in which a counselor focuses

on the addiction and another clinician, usually a psychologist or psychiatrist provides psychotherapy and/or pharmacotherapy to address other

psychiatric problems.

Setting

This model was developed for use as part of an outpatient addiction

treatment program and could be used easily in a private practice setting.

Chapter 3 Logistics of the Model

12
It also could be adapted for use in an inpatient program or intensive day

treatment program. To do so would involve retaining the structure and

content of the sessions but modifying their frequency and the overall

length of the treatment. IDC is planned to span 6 months and offer 36

sessions during the active treatment phase and then provide

once-a-month followup sessions for 3 months. Usually inpatient and intensive day treatments are briefer, but there is opportunity for counseling to be provided more frequently.

Chapter 3 Logistics of the Model

13
14
Chapter 4 Assessment

Assessment

Treatment entry necessarily involves a relatively comprehensive assessment of the patient’s condition and specific problems or needs, including medical, psychiatric, and psychosocial status. Often for research protocols, the assessment is completed formally by research staff prior to

the start of counseling. However, in many other settings, the counselor

will be responsible for completing the psychosocial assessment in conjunction with the gathering of history in the initial one or two sessions.

Addiction Severity Index

The main assessment instrument that is used routinely with addiction

counseling is the Addiction Severity Index (ASI) (McLellan et al. 1992).

This interview examines drug use and related problems over the past 30

days, so it is typically completed when the patient enters treatment to establish a baseline and identify areas of need and then at selected

followup points thereafter to measure change. The ASI measures seven

addiction-related domains: drug use, alcohol use, medical problems,

psychiatric problems, legal problems, family/social problems, and employment/ support problems. It requires approximately 45 minutes for

the initial administration and about 25 to 30 minutes for each followup

administration.

Biological Assays

The only ongoing assessment procedures that are necessarily a part of

addiction counseling are self-reports of drug use corroborated by some

form of biological assay. The most commonly used drug screening test is

urinalysis, which can test for drugs of abuse, as well as many medications. Typically, laboratories will screen for a panel of drugs that are

commonly abused, including opiates, cocaine, benzodiazepines, amphetamines, barbiturates, and cannabis. Specific opiates and

benzodiazepines can be identified when a patient is receiving an opiate

or a benzodiazepine for a medical purpose, such as methadone maintenance, but also abuses heroin. The different drugs of abuse or their

15
metabolites remain in the urine for differing lengths of time. Typically,

alcohol is tested via Breathalyzer® because of the convenience, minimal

expense, and immediacy of this method. There are other methods, such

as saliva, hair, and blood tests, which have some advantages and disadvantages but generally are less widely used in drug treatment.

In the treatment of an addicted person in an outpatient setting, the patient’s self-reports should be corroborated with urinalysis or some other

form of biological assay. The counselor has much greater ability to monitor the patient’s recovery and to be more certain of the patient’s honesty

in reporting drug use. Usually, patients feel that the counselor’s careful

monitoring supports their recovery because it discourages them from lying to themselves or others about any drug use. Also, patients struggling

with recovery often appreciate the concrete feedback that urine screens

provide. The counselor always should remember to give feedback on

drug tests as promptly as possible and definitely should take every opportunity provided by a clean drug screen to compliment the patient on

his or her progress.

Chapter 4 Assessment

16
Chapter 5 The Role of the Addiction

Counselor

Patient-Counselor Relationship

The role of the counselor in addiction treatment is to provide support,

education, and nonjudgmental confrontation. The counselor must establish good rapport with the patient. The patient recovering from

chemical addiction deserves to feel understood and that he or she has an

ally. The counselor wants to convey to the patient that he or she appreciates the difficulty of this struggle and the need for support through the

recovery process.

The metaphor of the hiker and the guide is useful for conceptualizing

the counselor-patient relationship. The counselor guides the patient

through at least the early stages of recovery, but the recovery process ultimately belongs to the patient. It is the patient alone who is responsible

and accountable for his or her recovery. The counselor must emphasize

this point to facilitate personal responsibility. Confronting the patient

may be useful to emphasize personal responsibility. However, when

confrontation is necessary, the counselor should convey a supportive

rather than a punitive attitude.

The counselor must find a balance between being directive and allowing

the patient to be self-directed. This process is facilitated if the counselor

imposes a structure on the session that includes giving the patient feedback about the most recent urine drug screens and about the patient’s

progress in recovery and evaluatively processing any episodes of use or

near use. The counselor identifies the relevant topic for discussion,

based on what the patient seems to need, and introduces that topic. At

times, the counselor may directly pressure the patient to change certain

behaviors, perhaps, as an example, to start attending 12-step meetings.

However, the patient also is encouraged to be self-directed. For example, within the framework of a particular topic, perhaps coping with

“social pressure to use,” the patient may explore how to manage this

problem best, and the counselor will respond to the patient’s direction. If the patient seems unable to change some aspect of addictive behavior—for example, being around dangerous situations—the

17
counselor should accept where the patient is and assist the patient

to explore those perceptions or situations in a way that might allow

himself or herself to do it differently, i.e., in a better way, the next

time. However, the counselor should discourage regressive or other

movements that lead back toward addiction. A balance needs to be

struck so there is respect for the patient and acceptance of where he

or she is and continual, ongoing pressure in the direction of abstinence and recovery.

Therapeutic Alliance

The counselor should create a sense of participating in a collaboration and partnership. This goal is best accomplished through three

main avenues of approach. First, the counselor should possess a

thorough knowledge of addiction and the lifestyles of addicts. Second, no matter how expert the counselor is, he or she must acknowledge that the patient is the true expert in discussing his or

her own life. The counselor must listen accurately, empathize effectively, and avoid passing judgment. Third, the counselor should

convey to the patient that he or she has an ally in the difficult progress toward recovery. Each of these approaches should help

strengthen the therapeutic alliance and make the relationship a

collaborative one.

Generally, the interventions that are most helpful in fostering a

strong therapeutic alliance are those that involve the counselor’s active listening and those that emphasize collaboration (Luborsky et al.

1997). For example, after the patient reports a relapse, the counselor

might say, “Let us examine what happened and together develop a

plan to help you avoid using next time.” Such language highlights the

combined effort in the relationship.

If the therapeutic relationship initially seems weak, the counselor

might use the following simple strategy to address the problem: Ask

the patient what is not working in the relationship or what the patient

thinks is causing it not to work. Often the patient knows full well what

might improve the therapeutic relationship but, for whatever reason,

does not feel comfortable enough to mention it until the counselor

initiates the topic. For improvement to occur, the counselor should

be willing to accept feedback from the patient and possibly change

the approach. However, in responding to a patient’s request to

change, the counselor should not feel pressured to change, or in any

way compromise, his or her philosophy of addiction treatment.

Rather, the counselor may adjust his or her interpersonal style to improve the working alliance.

Chapter 5 The Role of the Addiction Counselor

18
Behaviors That Should Not Be Done

The counselor should not be harshly judgmental of the patient’s addictive behaviors. After all, if the patient did not suffer from addiction, he or

she would not need drug counseling, so blaming the patient for exhibiting these symptoms is useless. Also, patients often feel a great deal of

shame associated with their addictive behaviors. In order to help resolve

those feelings of shame and guilt, the counselor should encourage the

patient to speak honestly about drug use and other addictive behaviors

and be accepting of what is said.

The counselor should be respectful of the patient. The counselor should

always be professional, including not being late for appointments and

never treating or talking to the patient in a derogatory or disrespectful

manner. Moreover, the counselor should avoid too much

self-disclosure. While occasional appropriate self-disclosure can help

the patient to open up or motivate the patient by providing a role model,

too much self-disclosure removes the focus from the patient’s own recovery. A good rule for when to self-disclose, if the counselor is indeed

so inclined, is for the counselor first to have a clear purpose or goal for

the intervention and then to analyze why he or she is choosing to

self-disclose at this particular time. If any doubt results from this analysis, it probably should lead to a more conservative, nondisclosure position.

Lastly, counselors need to be aware of when their own issues are stimulated by a patient’s problems and refrain from responding from the context of their own personal issues. For example, consider the case where

a counselor in recovery feels that it was extremely important for him or

her to break ties with addicted peers. Now this counselor is working

with a particular patient who has an addicted spouse or partner and

does not want to break these relationship ties. It is imperative that the

counselor be flexible and respond creatively to the patient’s own perception of the problem. In this case, the counselor must not rigidly adhere to the notion of insisting that breaking ties with all addicts is the

only acceptable path to recovery. In general, the reflexive, noncritical

projection of the counselor’s own needs or experiences onto that of the

patient’s situation can be damaging or, at least, counterproductive.

Chapter 5 The Role of the Addiction Counselor

19
20
Chapter 6 The Individual Drug

Counseling Model

Goals and Objectives of Individual Drug Counseling

Addiction counseling addresses (1) the symptoms of the drug addiction and areas of impaired functioning that are related to it and

(2) the content and structure of the patient’s ongoing recovery program. Throughout the course of counseling, the addiction counselor

will:

1. Help the patient to admit that he or she suffers from the disease of

chemical addiction.

2. Point out the signs and symptoms of addiction that are relevant to

the patient’s experience.

3. Teach the addict to recognize and rechannel urges to use drugs.

4. Encourage and motivate the patient to achieve and sustain abstinence.

5. Monitor and encourage abstinence by using objective measures,

such as urinalysis and Breathalyzer® tests.

6. Hold the chemically addicted person accountable for and discuss

any episodes of use and strongly discourage further use.

7. Assist the patient in identifying situations where drugs were used to

cope with life’s problems and in understanding that using drugs to

cope with or solve problems does not work.

8. Help the addict to develop new, more effective problem-solving

strategies.

9. Introduce the patient to the 12-step philosophy and strongly encourage participation in NA, AA, and/or CA.

21
10. Encourage the chemically addicted person to develop and continue

with a recovery plan as a lifelong process.

11. Help the addict to recognize and change problematic attitudes and

behaviors that may stimulate a relapse.

12. Encourage the patient to improve self-esteem by practicing newly acquired coping skills and problem-solving strategies at home and in

the community.

The drug counseling sessions have a clear structure. However, within

the framework of that structure, the content of the discussion is largely

up to the patient. We make an effort to address effectively the patient’s

individual needs at any point in treatment while also recognizing the

commonality of many issues in addiction and recovery. People are indeed unique; however, the facets of a human problem like cocaine addiction usually follow familiar patterns. The validity of both realities

should be respected.

Stages of Treatment

The stages of addiction treatment described here are:

1. Treatment Initiation

2. Early Abstinence

3. Maintenance of Abstinence

4. Advanced Recovery

As with other stage theories of development, the stage theory of addiction recovery is only a model. Individuals pass through the stages at their

own pace, the stages are overlapping rather than discreet, and individuals may slip back at points and need to rework issues from previous

stages. This theory does not, however, discount the considerable usefulness of having a model of the typical process in mind so that the patient’s

place in his or her own recovery then can be compared with the model

for better understanding the patient’s process and the steps needed to

be taken to proceed.

Appropriate treatment for chemical addiction varies and is sensitive and

responsive to the changing needs of the patient throughout his or her recovery. The addiction counselor should understand that addiction treatment must be progressive, just as the patient’s recovery process is progressive. To provide optimal counseling, the counselor must be sensitive to the patient’s evolving needs in treatment. To ensure a progressive

approach to addiction treatment, the counselor must be prepared to

Chapter 6 The Individual Drug Counseling Model

22
address different topics in recovery, use different kinds of interventions,

and hold the patient to a different level of responsibility as he or she

works toward recovery.

In Each Session

Preparing for the

Session

The counselor should prepare for each session by checking the patient’s

recent urine results and recalling the major themes or issues from the

previous session. The counselor must understand the progressive nature of treatment and be familiar with the topics that are appropriate to

the patient’s current phase in recovery. In summary:

1. Check urine results.

2. Recall themes from previous session.

3. Prepare to discuss the topics appropriate to the patient’s phase in

treatment.

During Each Session At the beginning of each session, the counselor should inquire how

things have been going since the last session and whether the patient has

used any drugs. Reported drug use should be noted. If the patient relapses, the patient and counselor should analyze the relapse, determine

what precipitated it, and develop alternatives that can be used to avoid

relapsing again. This process will probably require the full session.

If the patient presents with an urgent, addiction-related problem like

family arguments or financial problems as a result of the addiction, the

counselor should address these problems in the session. Emphasis

should be on how these problems are related to the addictive behavior.

The counselor’s goal is to help the patient develop strategies for dealing

with the problems without turning to drugs. For example, the loss of

one’s job, the serious illness of a loved one, or severe relationship problems will require acknowledgment and some attention in the counseling session. However, the main purpose of the session is the promotion

of recovery from addiction, not the resolution of the patient’s other life

problems.

The counselor should always give the patient feedback regarding the

most recent drug screen results. If the urine test was positive for cocaine, the counselor should confront the patient with this information.

Even if the patient has admitted to recent use, the counselor should discuss the urinalysis result, so the patient is reassured that the counselor is

monitoring his or her efforts to abstain. If, however, the patient denies

any use even though the urine sample is positive for cocaine (which is

not uncommon), the counselor should view this behavior as most likely

Chapter 6 The Individual Drug Counseling Model

23
indicative of denial, underlying which might be feelings of shame. The

counselor will probably want to use themes of shame or denial in addressing this disparity.

A useful approach is discussing how the patient would feel and what it

would mean if he or she were using drugs. If the patient continues to

insist that there has been no cocaine use, the counselor probably should

just drop the matter and agree to disagree for the present. Continuing to

confront without moving the counseling anywhere probably is unwise

because the counselor risks severing the therapeutic connection. If the

patient insists that there is some type of laboratory error, the counselor

may be able to split the urine and have half analyzed with a different test,

or use a different screening procedure, such as a saliva test.

If nothing urgent must be addressed in the session, the counselor and

patient should discuss the addiction-related topic(s) most relevant to

the patient’s current needs in recovery. The topics central to recovery

from cocaine addiction, and the stage of recovery they are particularly

associated with, are described in the next section. No more than two

new topics should be introduced to the patient in a session. However,

any topics that have already been introduced to the patient can be reviewed, if appropriate.

To review, in each session, the counselor should:

1. Find out how the patient has been since last session.

2. Inquire whether the patient has used drugs since last session.

If the patient has used cocaine, analyze the relapse and develop

strategies to prevent future relapses.

If the patient has used other drugs, discuss why abstaining from all

drugs is important, particularly when one is attempting to recover

from chemical addiction.

3. Inquire whether there are any urgent problems that need attention

and, if so, deal with them.

4. Provide feedback about whether recent urine tests have come back

showing any cocaine use or not.

5. Discuss the recovery topic that is most relevant to the patient’s stage

in recovery and his or her particular needs in treatment.

Chapter 6 The Individual Drug Counseling Model

24
Chapter 7 Treatment Initiation

Patients often enter treatment with ambivalence about giving up their

drug use. Counseling begins with helping the addict decide to participate

in treatment and accept abstinence as a goal. The counselor can help the

patient recognize and understand the damaging effects of addiction, address his or her denial of the problem, and show motivation toward recovery. In this progressive treatment model, the patient’s ambivalence is discussed specifically in the first 2 weeks of treatment, although motivation

and commitment to recovery may be issues that are returned to throughout treatment.

The first two sessions of counseling should be devoted to introducing

the treatment program to the patient, obtaining a drug usage and treatment history, and developing the treatment plan with the patient. Because of their specific purpose in establishing the overall framework for

the provision of treatment, these sessions are described in some detail.

Counselors should follow the session agenda described. In addition to

the setting up of the framework for the treatment, the first two sessions

are important in fostering the patient’s motivation to become sober. Ambivalence and denial are likely to be relevant concerns in the early phase

of treatment. Because they are so fundamental to the recovery process,

the counselor should discuss them here or at any future point in the individual patient’s treatment.

Goals

1. Introduce the patient to the counseling program and its expectations. If the counseling will be time limited, point that out.

2. Obtain the patient’s history. Develop a treatment plan.

3. Help the patient to realize that he or she suffers from the disease of

addiction.

4. Help the patient to decide to break the addictive cycle.

5. Help the patient to see the benefits of a drug-free lifestyle.

25
Treatment Issues

1. Denial

2. Ambivalence

Denial Denial is defined as refusing to believe the reality about one’s life circumstances. It may be refusing to believe that one is addicted or refusing

to acknowledge that the losses one has suffered as a result of the addiction are significant.

Patients often enter treatment with some denial about their addiction,

so this behavior should be pointed out and explored early in counseling. In spite of evidence to the contrary, addicts may believe they still

can control their chemical use. They often do not believe that they

have the disease of addiction, and they frequently are ambivalent

about giving up their drugs.

A patient experiencing denial may exhibit some of the following erroneous beliefs:

1. Refuse to believe that he or she is an addict.

2. Think that he or she can solve the problem by “cutting down” on cocaine use, rather than eliminating it totally. Patients may also say that

they want to get their cocaine use back “under control.”

3. Refuse to believe that a secondary drug (alcohol, for example) is a

problem, as well as their primary drug of choice (cocaine, for example).

4. Refuse to believe that Alcoholics Anonymous or Narcotics Anonymous will be helpful, because he or she is “not like the people there,”

ostensibly because their drug problems are so severe.

5. Insist on continuing to spend time with “friends” who enable the patient’s use by agreeing that drugs are not a problem.

When the counselor recognizes that denial is interfering with the patient’s ability to successfully deal with the addiction, the counselor

should endeavor to get the patient to realize that he or she is not seeing

the truth about the addiction. Finally seeing the truth will foster motivation and promote a desire to change. The counselor may use confrontation, pointing out what the addiction has cost the patient, and encourage the patient to abstain from drugs temporarily if he or she truly is not

addicted.

Chapter 7 Treatment Initiation

26
Ambivalence Patients usually enter treatment with some ambivalence about staying

sober or making a commitment to treatment. The patient’s motivation

should be examined early in the counseling sessions.

Feelings of ambivalence often are present for the following reasons:

1. The patient associates drug use with some positive emotional

change.

2. Drug use may have been employed as a coping strategy for solving

problems, and the patient does not yet know of a better coping

strategy.

3. The patient may feel too weak or helpless to break the powerful cycle

of addiction.

A patient’s feelings of ambivalence should be explored so the counselor

can assist the patient to recognize the ambivalence and identify the underlying reasons. Understanding the patient’s reasons also will help the

counselor to direct discussion regarding motivation appropriately.

Motivation refers to how much the patient is impelled to act on the desire to become sober. A patient may enter treatment already somewhat

motivated because he or she recently “hit bottom” in some way. Such a

“bottom” may be losing one’s job or one’s spouse, draining one’s bank

account, or getting arrested. Although these consequential life events

may help to motivate the patient, they may not be sufficient. Additionally, the counselor should encourage and support the patient’s desire to become sober.

The counselor should discuss the patient’s ambivalence and motivation

to quit using and commit to recovery. Encouraging the patient to discuss

the pros and cons of using and focusing on the patient’s reported negative consequences of using may help to cement, or at least strengthen,

the patient’s desire to become abstinent. Having the patient identify the

personal benefits of a drug-free lifestyle, and particularly what he or she

really wants in life, helps to highlight the advantages of becoming sober.

Identifying patients’ individual goals for their life and talking about how

such goals can be attained can be empowering and lead patients to feel

more able to be proactive in making positive changes.

Introductory Sessions

Session 1 In the first session, the counselor’s goals are to establish rapport, review

the ground rules for participating in treatment, and begin to know the

patient. The patient needs to understand the expectations of the program and agree that they are important for successful treatment. Next,

Chapter 7 Treatment Initiation

27
the counselor should begin to take a detailed drug usage and treatment

history to allow the counselor to focus on the patient’s own addiction related concerns. The counselor also will want to find out recovery-related

activities in which the patient is involved (NA, religious program, etc.)

and what supports he or she has (supportive partner or family, etc.).

Session 2 The counselor should finish obtaining a thorough drug usage and treatment history that will culminate in the treatment plan, basically a contract established by the counselor and patient collaboratively. The plan

should identify the problems to be addressed in treatment and the desired goals. The primary problem identified always should be the addiction; other problems should be addiction related. In IDC, the drug-use

goal always should be total abstinence, not just abstinence from cocaine. The initial treatment plan is basic. Its purpose is to clarify the mutually agreed upon goals of the patient and counselor, with the patient

making a commitment to work toward recovery.

The counselor should inquire about the patient’s experience with

12-step groups and ask whether the patient already attends meetings, or

has previously but no longer attends, or has never heard of them. If unfamiliar with the 12-step approach, the patient should be introduced

briefly to the 12-step approach and meetings in the area. (The counselor

can provide lists of the local meetings.) All patients should be encouraged to attend meetings at least 3 to 4 times a week as part of his or her

plan for recovery. If agreed to, participation in self-help groups should

be listed on the treatment plan.

Chapter 7 Treatment Initiation

28

Sample Treatment Plan

Goals:

1. Abstain from use of all illicit drugs.

2. Attend all scheduled counseling sessions and submit to urine

drug screens as requested.

3. Attend at least three 12-step meetings a week and speak in at

least one meeting.

Patient’s Signature ________________________________
Chapter 8 Early Abstinence

The second stage in treatment of addiction is early abstinence. After the

patient acknowledges the need for treatment and shows at least a preliminary commitment to treatment, the counselor and patient must begin to

work on early abstinence issues.

These include:

1. Recognizing the medical and psychological aspects of cocaine

withdrawal.

2. Identifying triggers to drug use and developing techniques for avoiding these triggers.

3. Learning how to handle drug craving without using.

The counselor should encourage the patient to establish a drug-free lifestyle that involves participating in self-help groups to aid in one’s recovery, avoiding social contact with drug-using associates, and replacing

drug-related activities with healthy recreational activities. This period of

treatment lasts from the preliminary establishment of motivation toward abstinence to approximately 3 months into recovery, assuming the

patient makes reasonable progress.

The topics described here are particularly relevant to the needs of the

patient at this point in treatment. The order in which they are presented

is generally the order in which they often emerge as treatment issues.

But, the counselor should use discretion and address these issues as

they seem appropriate for each individual patient.

Discussions of these topics may be repeated as needed. The counselor

should base the relative emphasis placed on each topic on the patient’s

needs in recovery. No more than two topics should be introduced to the

patient in a session. However, in reviewing topics previously introduced, the counselor can address all appropriate topics. Although the

order in which they are presented and the relative emphasis are flexible,

all the issues identified here should be addressed in the counseling

sessions.

29
Goals

1. Teach the addict to recognize and avoid the environmental triggers

that lead to drug use.

2. Teach the addict to engage in alternative behaviors when he or she

experiences craving.

3. Help the patient to achieve and sustain abstinence from all drugs.

4. Urge the patient to participate in healthy activities.

5. Encourage participation in self-help groups.

Treatment Issues

1. Addiction and the associated symptoms

2. People, places, and things

3. Structuring one’s time

4. Craving

5. High-risk situations

6. Social pressures to use

7. Compulsive sexual behavior

8. Postacute withdrawal symptoms

9. Use of other drugs

10. 12-step participation

Addiction and the

Associated Symptoms

The counselor should review with the patient the concept of addiction

and the behavioral and medical/physiological symptoms of the disease.

When discussing symptoms, the counselor should focus on cocaine but

can include other drugs as appropriate.

The concept of addiction is that the behavior, or use of something, becomes compulsive, leaving the addict no control over the behavior. Because the addict has no control over this behavior, he or she will continue to use the drug despite the resulting impairment to physical and

emotional health, social and occupational functioning, and intimate

relationships.

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The behavioral symptoms of addiction include narrowing of one’s behavioral repertoire, predominance of the drug in the person’s daily life,

spending time achieving or recovering from drug effects, and continuing to use in spite of the severe problems associated with use. The counselor will review with the patient the specific symptoms of addiction that

he or she has demonstrated. The counselor will focus primarily on the

life-overwhelming nature of addiction and the importance of avoiding

abusable substances in order to provide the best chance for preventing a

relapse.

The medical/physiological symptoms also should be reviewed with the

patient. They can include increased pulse and blood pressure, anxiety,

paranoia, hallucinations, seizures, cardiac arrhythmias, cardiac arrest,

and cerebrovascular incidents (strokes). The relative risks for each of

these adverse effects will be reviewed. For example, anxiety and paranoia are much more common than seizures or cardiac arrest. The cocaine withdrawal symptoms of depression, low energy, and insomnia

will be described, along with the fact that these symptoms do not occur

in all cases.

If the patient’s route of administration of any drug used has included injection, and/or the patient has engaged in unsafe sexual behavior, perhaps impulsively when using cocaine, then infection with the HIV virus

is a medical condition that may co-occur with cocaine addiction. The

topic of HIV infection should be introduced here. The counselor must

assess the patient’s level of knowledge and sophistication about the

topic and present information at an appropriate level. If the patient has

engaged in high-risk behavior, or the counselor believes the patient may

have engaged in high-risk behavior even though he or she denies it, then

the patient’s risk factors or potential risk factors should be identified,

and behavioral changes to reduce risk should be encouraged at this

point.

The medical effects of other abused substances, including alcohol, also

should be reviewed if the patient has or has had problems with these

drugs.

People, Places, and

Things

People, places, and things are a way of designating the external triggers

that initiate craving or the urge for a drug. The patient must learn how to

deal with these triggers in order to achieve continued abstinence. This

topic is central to addiction counseling and usually requires repeated

discussion throughout treatment. First, the counselor should help the

patient to identify the people, places, and things that will trigger or lead

to a cocaine craving or urge. Then the counselor should point out that

the patient must avoid the people, places, and things that trigger craving

and have the patient discuss how he or she can avoid the triggers. The

patient should be encouraged to avoid those triggers that are possible to

avoid easily (for example, having one’s paycheck deposited directly or

Chapter 8 Early Abstinence

31
taking public transportation to and from work rather than drive through

a risky area). The patient and counselor should collaborate to develop

strategies to help the patient avoid or manage those things that are more

difficult to stay away from (for example, a drug-using partner or spouse

or a crack house on the block where one lives).

During an individual’s addiction, he or she has learned to associate cocaine use with people, including one’s dealer or other users; places, like

a particular crack house or corner; and things, especially money and

drug paraphernalia. The counselor should strongly encourage the patient to avoid those people, places, and things that were previously associated with drug use and assist the patient in developing strategies for

avoiding these triggers. These strategies may include having someone

the addict trusts handle his or her money, cutting up his or her automatic teller machine card, getting rid of drug “works,” i.e., paraphernalia (preferably with someone else’s help); staying away from certain

neighborhoods, blocks, or areas of his or her community; and avoiding

drug-using friends and family members. Triggers that cannot be avoided

altogether can sometimes be faced more safely in the company of another, non-using person, such as one’s sponsor or one’s spouse or child.

CASE EXAMPLE

A patient, Johnnie, reports that his cohabiting girlfriend, Lisa, has a serious cocaine problem. She is smoking about $25 worth of crack every

evening if she has the money. Johnnie reports that she often borrows

money from him, and she offers him some cocaine when she buys it. He

finds it nearly impossible to resist when she is using it around him. In addition, she often asks him to drive her to purchase it because they only

have one car.

Interventions

1. It appears that Johnnie’s girlfriend, Lisa, is a trigger for him. First, the

counselor should determine how serious and important this relationship is. If Johnnie says that he does not love this woman and is

not committed to staying in the relationship, then the optimal plan

may be to empower Johnnie to terminate the relationship or at least

to stop living with Lisa, so that he can make more effort toward his recovery.

2. If Johnnie feels committed to the relationship and to living together,

the counselor should find out how amenable Lisa is to participating

in treatment. The counselor first will want to discuss this matter with

Johnnie and then possibly invite Johnnie to ask Lisa to attend a couples session. The goal should be to get Johnnie to tell Lisa that it is

important to him that she participate in his treatment, either by deChapter 8 Early Abstinence

32
ciding to get clean and getting into treatment herself or at least by

supporting his treatment—by not bringing cocaine into their home,

using around him, asking him to get high with her, or asking him for

money or for a ride to pick up the cocaine. If she agrees to either option, that is a positive sign. The counselor also will want to help Johnnie be assertive about not lending Lisa money, or giving her rides to

where she buys drugs, and perhaps about holding her to her commitment, whatever it is.

3. The counselor will want to discuss Johnnie’s sexual relationship

with Lisa. First, does sex with her always involve cocaine use? Do they

have good sexual experiences without using cocaine? Obviously, if

sex typically involves cocaine use, this unhealthy situation must be

discussed in depth. The goal then would be to get Johnnie to recognize the danger of the situation and to try to abstain from drug use

when having sex. If that is not possible, then the counselor should

advise Johnnie to abstain from sexual experiences temporarily until

he has established some abstinence from cocaine. Also, the counselor should find out whether the couple practice safe sex and generally what they do or have done to minimize their risk of HIV exposure

via sexual transmission. Depending on the answer, the counselor

may want to teach Johnnie about safer sexual practices.

4. Lastly, the counselor may help Johnnie to identify healthy leisure activities that he and his girlfriend might enjoy together without using

cocaine. These could include going to movies or sports events, taking walks, or going shopping.

Structuring One’s

Time

If the patient has a chaotic, disorganized lifestyle, the counselor will

help the patient to identify what he or she does each day and help to

structure his or her days to encourage abstinence. People with drug-use

disorders often live in an impulsive and chaotic manner. Order and

structure can help to lessen the risk of relapse. One of the defining features of drug addiction is the priority that the drug assumes in the individual’s daily existence. Many addicts organize their entire daily routine

around obtaining, administering, and recovering from the effects of

their drug(s). Because of the time these behaviors require, many people

with a drug-use disorder experience a void, or a sense of loss, shortly after stopping the drug. They have spent so much time working for drugs

and associating with people, places, and things associated with taking

drugs that they have difficulty imagining what to do when they are not

using drugs.

The counselor must try to counteract this lifestyle, as well as restructure

the content of the addict’s daily activity, by trying to help organize the

patient’s daily routine. One way to help the patient achieve a better organizational pattern is to work out a daily schedule for the week, or until

the next session, and to review it. Structuring one’s time is an important

Chapter 8 Early Abstinence

33
aid to recovery, because having definite plans and staying busy helps the

recovering addict not to have excess free time, which is all too likely to

be spent thinking about using drugs. When newly recovering addicts

have too much free time, they are likely to recall the “good times” they

had using their drugs. This experience is called “euphoric memory” and

understandably tends to lead to desire for the drug.

Also, a structured life helps the patient to reduce residual physical symptoms from the cocaine use and to decrease negative emotional effects,

such as depression or boredom. The counselor will discuss how the patient spends his or her time and help the patient structure the time to

support abstinence. This structure should include getting up each

morning and going to bed at night at regular times, scheduling time for

12-step meetings at least 3 to 4 times a week, and including time for handling personal responsibilities and engaging in healthy recreational activities.

Sample

Schedules

Following are two sample schedules. The counselor can choose whichever one is more suitable for the patient’s lifestyle and needs. A schedule

form can be given for the patient to complete as homework prior to the

session, or the patient and counselor can complete a schedule together

and simultaneously discuss it during the session.

Planning a daily schedule together is helpful when the patient’s life is

very chaotic or organized primarily

around the drug addiction. With a

daily schedule, the counselor and

patient can look at the patient’s day

and identify the patient’s dangerous times and plan healthy activities

to fill those times. The counselor

also should remember to support

and encourage anything the patient

is doing that is positive, such as attending 12-step meetings, taking

care of his or her dog and getting

some exercise, attending counseling regularly. The issue of boredom, which is a common trigger for

patients, can be addressed at this

time, and ways to keep busy in order to reduce boredom can be encouraged.

Danny is unemployed, and his life is

very disorganized. The counselor

and Danny have been working on

getting him to attend his counseling

sessions regularly, two mornings a

Chapter 8 Early Abstinence

34

Danny’s Daily Schedule

7 am Wake up, get dressed

8 Walk dog

9 Counseling

10 NA meeting

11 Return home

Noon Lunch

1 pm

2

3

4

5

6

7

8 Watch TV or go out

9

10

11 Turn in if at home
week, and to attend an NA meeting every day. This approach is helping

Danny begin his day at a consistent time every morning. From the schedule, obviously Danny has too many empty hours in the afternoon and

evening, and boredom is likely to be a problem. Now the counselor and

Danny need to plan how he can fill some of these hours, perhaps by

working out, visiting a nondrug-using family member, going to school,

working part time or doing volunteer work, going to a second 12-step

meeting, or spending time with recovering peers.

Preparing a weekly schedule is helpful for the patient who has some

structure in his or her life, perhaps a job, but who has a particular time

that is very dangerous or a trigger for her. In Elaine’s case, she is pretty

responsible during the week, but Friday night through Sunday afternoon is a dangerous period for her, because her children’s father (they

are separated) takes the children. Also, Elaine feels stressed and burdened by the responsibilities of her week, and she needs to do something to relax and pamper herself over the weekend. Unfortunately,

many people turn to drug use to “nurture” themselves when they feel

very stressed by their daily life, because it is such a “quick fix” even

though it ultimately causes them to feel more stressed and unhappy.

Chapter 8 Early Abstinence

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Elaine’s Weekly Schedule

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

7 am 7 am 7 am 7 am 7 am

Get up Get up Get up Get up Get up

9–2 work 9–2 work 9–2 Work

12 noon 12 noon

NA meeting NA meeting

3 pm Pick 3 pm Pick 3 pm Pick 3 pm Pick Free time 3 pm Pick

up kids up kids up kids up kids up kids

4–9 Make 4–9 Make 4–9 Make 4–9 Make Kids are 4–9 Make

dinner, dinner, dinner, dinner, with dinner,

spend time spend time spend time spend time their father spend time

with kids with kids with kids with kids with kids

11:30 11:30 11:30 11:30 11:30

Turn in Turn in Turn in Turn in Turn in
In this situation, the counselor probably wants to acknowledge that

Elaine handles a lot of responsibilities well during the week and has little

time for herself. Then the counselor can discuss with Elaine how she

feels about her free time over the weekend and what she can do to avoid

drug use during this time. They can problem solve to identify things that

she can do to take care of herself during her free time over the weekends. Possibilities include joining a bicycling club, taking a dance class,

reading a good book, having her nails or hair done, or visiting a recovering friend or a family member.

Preparing a weekly schedule also is helpful if a patient in recovery seems

to be overscheduling himself or herself and cannot fit in a needed additional 12-step meeting or some personal time to relax. If a recovering patient seems to be overzealous and compulsive about keeping busy as a

way to stay clean, a weekly schedule can be a way to illustrate and discuss

this tendency.

Craving The counselor should discuss the concept of craving with the patient.

Craving is the strong desire an addict experiences for his or her drug of

choice, such as cocaine. Some patients may not identify with the word

craving but instead may use the word urge. Individuals appear to experience craving differently, but they usually describe physical and psychological symptoms. In the case of cocaine, these symptoms include heart

palpitations, rapid breathing, obsessional thinking about the drug, and

planning how one can get the drug or get the money needed to buy it.

Craving is thought to be due in part to biological factors and in part to

learning. Probably all cocaine addicts experience craving for cocaine.

The counselor must help the patient to understand and recognize what

craving or having an urge feels like. Recognizing craving will help the patient to maintain abstinence. The counselor should communicate to the

patient that he or she can experience and recognize a craving but choose

not to act on it in the usual, self-damaging way. Craving, however strong,

does not have to lead to drug use. One can just “sit the craving out,” and

it will pass. A useful analogy may be likening the craving to a strong

ocean wave. The wave will feel very strong when one is in the throes of it,

but it will wash over and pass. Also helpful is explaining that the strength

of cravings will decrease over time if the patient does not use, but if he or

she uses the drug, the craving phenomena will remain strong.

High-Risk Situations High-risk situations are those times that involve the people, places, and

things that trigger the addict’s cocaine craving. The counselor should

discuss situational triggers with the patient and help the patient to avoid

them if possible or learn to cope by developing the alternative responses

necessary to deal with these situations without using. This topic should

be largely a review of what the patient has learned about people, places,

and things in general but with an emphasis on the actual situations that

Chapter 8 Early Abstinence

36
recur in the patient’s own life and trigger a craving for cocaine. Learning

how to avoid these times or to develop alternative responses to whatever triggers the desire for cocaine is central to recovery from addiction

and bears regular repeating. The counselor will review with the patient

actual and potential “high-risk” situations that might occur and what can

be done to avoid them. Examples of high-risk situations are being offered drugs, being around a drug-using friend, or attending a social

function where drugs are available. The counselor should rehearse with

the patient alternative responses to exposure to these situations. Identifying such situations well in advance and rehearsing how one could

deal with such exposure should provide a better chance of avoiding a relapse from such exposure.

After the patient identifies his or her particular high-risk situations, the

counselor and patient should work together to develop strategies for

avoiding these situations. Other potential high-risk situations also

should be considered. The counselor should offer reasonable alternative responses to unavoidable high-risk situations, such as calling a

friend or talking to one’s partner or spouse. The patient should be encouraged to use the support of drug-free or recovering friends, family

members, and AA/NA/CA acquaintances.

Social Pressures

To Use

Many addicts report that their entire social life revolves around their addiction. Addiction limits the scope of their social interactions to the

point where all of their social contacts are with other addicts, usually

creating a lot of social pressure to use in order to remain within the

group. Addicts have to face this social pressure. Other addicts might not

want the addict to recover, because they are reminded of the failings and

liabilities of their own illness. They will put pressure on the addict who

is trying to break the cycle of addiction. This pressure may be blatant,

such as offering the recovering addict drugs or demeaning him or her for

trying to recover. Alternatively, they may use more subtle techniques,

such as mentioning previous “good times” involving drug use.

The counselor should ask the patient if he or she feels pressured by

peers to continue or resume using drugs. If so, the patient’s peer group,

the experience of the pressure, and the patient’s response to the pressure should be discussed.

The simplest resolution to this problem—the avoidance of all drug users—should be strongly encouraged. Recovering addicts who are feeling more dependent and greatly need to fill the void left by the drugs

may be lonely. The patient needs to realize that the people with whom

he or she was getting high were not true friends and begin to forge positive relationships with drug-free and recovering people. Participation in

AA, NA, or CA should be encouraged as a way of filling the void left by the

loss of drug-using peers. Establishing a new, recovering peer group

Chapter 8 Early Abstinence

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within the 12-step program creates positive social pressure to remain

abstinent that often is very helpful.

Compulsive Sexual

Behavior

Frequently, sexual encounters become associated with the use of cocaine, because many people believe that cocaine enhances sexual experience. In actuality, cocaine distorts the sexual experience so that it

eventually becomes an emotionally painful, compulsive quest to get the

best high or rush similar to the experience of using cocaine.

Many cocaine addicts have a problem with compulsive sexual behavior,

which should be addressed at various points in the addiction treatment.

In early abstinence, the first issue to address is whether sex or the potential for sex is a trigger for the addict. If the patient’s craving for cocaine or

any drug is triggered by sex, the counselor needs to encourage the patient to avoid those sexual stimuli that trigger craving. The counselor

should explore with the patient the sexual situations that lead to craving, as well. For example, the patient may prostitute to get drugs or meet

with a prostitute to get sex in exchange for drugs. Also, a patient may be

aroused by sexual experiences involving pornography or sexual paraphernalia, along with the use of cocaine. The patient needs to avoid such

triggers, and the counselor should help the patient to identify healthy alternative ways to fulfill appropriate sexual desires.

For some patients, the message in the beginning of treatment can be to

avoid sexual stimuli for a while. Later, when the patient is more stable,

the counselor and patient can work on establishing healthier means of

sexual expression for the patient. For other patients, asking them to abstain from sexual behavior for a while is not practical. In these cases, the

counselor and patient must ascertain what types of sexual behaviors are

emotionally affirming rather than compulsive. The patient should be encouraged to participate only in these more positive kinds of sexual experiences.

If the patient has participated in impulsive or promiscuous sexual behavior, information about HIV infection, safe sex practices, and the patient’s risk factors should be addressed.

Postacute Withdrawal

Symptoms

Some people, particularly those who have used cocaine in large

amounts over long periods of time, will experience long-lasting changes

in mood, affect, and memory. These changes may continue for days or

weeks after the cocaine use has been stopped. Anxiety and/or depression, often accompanied by difficulty in sleeping, are some of the symptoms that may occur. Other patients experience panic attacks that persist for varying time periods after episodes of cocaine use. Some complain of difficulties in short-term memory, such as alcoholics experience

after detoxification. Another problem is feelings of anhedonia or lack of

pleasure in life; the addict experiences depression or other symptoms of

Chapter 8 Early Abstinence

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a mood disorder that can persist beyond the period of acute detoxification. These symptoms are known as postacute withdrawal symptoms

(Gawin and Kleber 1986).

Other patients with cocaine addiction do not have any of these symptoms after stopping drug use. Those who have the symptoms usually experience them for a relatively short time. The drug counselor must be

aware of the symptoms of postacute withdrawal and discuss them with

the patient. The aim is to help the patient identify them if they occur and

to label them appropriately as symptoms that have resulted from cocaine use. The danger is that the patient will interpret the symptoms as

being fundamental problems with himself or herself that can be reversed or corrected by self-administration of cocaine or other drugs. The

counselor is to be very firm in telling the patient that such symptoms are

most likely a result of drug use rather than an independent disorder and

that they will be, in fact, made worse, not better, if cocaine is used.

Use of Other Drugs Frequently patients see themselves as being addicted only to their drug

of choice in spite of the fact that they frequently use another drug or

drugs as well. For example, if the individual is in treatment for cocaine

addiction, he or she may believe that alcohol or marijuana still can be

used nonaddictively. The counselor should strongly encourage the patient to accept the necessity, if he or she is to achieve full recovery, fortotal abstinence from all drugs (excluding, of course, any appropriately

prescribed medications).

The counselor must first find out what, if any, mood-altering substances

the patient is continuing to use. If the patient denies use of any

mood-altering substances, this topic should still be addressed briefly before discussing other issues. If the patient continues to drink alcohol or

use another drug, the counselor should engage the patient in a discussion of the pros and cons of continuing to use these drugs.

The counselor should also point out the following reasons for total abstinence:

1. Other drugs, such as alcohol, are likely to trigger a craving for cocaine.

2. An addict may transfer the addiction to the other drug and begin using it compulsively.

3. An individual who uses alcohol or marijuana, for example, will not

learn how to cope with daily stressors, relax, or have fun without the

use of mood-altering substances.

If the patient is particularly resistant to giving up use of his or her secondary drug(s) on a permanent basis, the counselor may be more sucChapter 8 Early Abstinence

39
cessful by avoiding the power struggle and encouraging the patient to

abstain temporarily (for the length of the time that he or she is in treatment), rather than directly confront the resistance. This issue then will

reemerge at a later point in treatment, giving the counselor and patient

another opportunity to discuss the importance of abstaining from all

mood-altering substances to achieve recovery.

CASE EXAMPLE

Bill likes to go to the local bar for a couple of beers and to play darts after

work sometimes. He says that the beer never gets him into trouble;

rather, he only has a problem with cocaine. He enjoys socializing at the

neighborhood bar and typically only has a couple of beers and then goes

home to his wife. However, after pressing Bill, the counselor finds out

that when Bill gets cocaine, he gets it from a contact at the bar. It is usually on the weekends, when he typically drinks more heavily than he

does on the weeknights, and then he meets up with his contact and they

go and buy cocaine. Bill is primarily a binge user, and in these binges, he

often spends $500 in an evening, a habit he cannot afford.

Interventions

1. This behavior is an example of denial. The counselor wants to help

Bill to see the link between the alcohol and the cocaine. One approach would be to confront the patient gently. The counselor

might say, “Well, it sounds like you don’t go and pick up cocaine until after you have had a few drinks at the bar. So, even though your

drinking doesn’t always lead you to pick up, in the instances (or at

least most of the instances) when you do pick up, you have been

drinking first.” Amazingly, patients often have never recognized this

connection.

2. The counselor might try to persuade Bill of the seriousness of this

problem by having a conversation about the magnitude of the financial difficulties he is getting himself into because of his cocaine use.

3. The counselor’s aim is to get Bill to change these damaging behaviors. The optimal change would be if Bill can agree not to go to the

bar and not to drink alcohol in addition to not using cocaine. If Bill

cannot imagine himself relinquishing this social outlet, a compromise might be that he could drink soda instead of beer while he is socializing, never carry more than $10 in his pocket, and not go to the

bar on weekends. If this type of compromise is established, which is

not ideal, the counselor must keep abreast of Bill’s progress with this

and press him to avoid the bar and abstain from all drugs if this compromise plan does not work.

4. Bill might respond to the recommendation that he carry less money

by saying that he does not need money in his pocket, because he can

Chapter 8 Early Abstinence

40
get cocaine on credit. The counselor would concede this truth but

remark that by choosing not to carry much cash, Bill is making it

harder for himself to buy cocaine and easier for himself to resist. Not

having the money right there will serve as a reminder that he has decided not to use (if indeed he has) and might just give Bill the extra

incentive he needs to leave the bar without picking up. If Bill has difficulty not carrying money because having money is closely associated with his sense of self-worth, then the counselor must be sensitive and really compliment Bill on taking a proactive approach to his

recovery by not carrying extra cash.

5. The counselor also will want to check into the status of Bill’s relationship. Is he spending time at the bar because of marital discord? If

he denies that and says his marriage is strong but hanging out at the

bar is what the men in his neighborhood do, then the counselor will

want to encourage him to make specific plans to spend quality time

with his wife in place of going to the bar. If, on the other hand, his

marriage is strained, the counselor will want to determine whether

marital discord triggers Bill’s cocaine use and will want to point out

that link.

12-Step Participation All patients who are treated for addiction are advised to participate in

one or more self-help groups. The most popular self-help groups are the

12-step groups, including Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA). The addiction counselor

must be familiar with the general 12-step philosophy and the 12 steps

and be able to review them, and the principles involved, with each patient. Reviewing these concepts will serve to familiarize the patient with

the 12 steps in a very general way and help the patient to apply the

12-step approach to specific aspects of his or her recovery program.

As the patient attends counseling sessions, the counselor will want to

monitor the patient’s participation in self-help groups. The counselor

should inquire about the patient’s participation in, and thoughts and

feelings about, 12-step groups and follow up by providing whatever further information or encouragement the patient needs about self-help

groups and the 12-step philosophy; for example, giving patients a current meeting list for their neighborhood or describing where the local

NA clubhouse is. Also, if the patient expresses some hesitancy about attending meetings because of the people, the counselor might assess

what kind of people the patient would be likely to be most comfortable

with and recommend that type of meeting. The counselor should explain to the patient that there are gay and lesbian meetings, women’s

meetings, nonsmoking meetings, medical professionals meetings, and

so forth.

Once the patient is attending 12-step meetings, sponsorship should be

discussed and encouraged. The role of a sponsor is to be a guide and a

Chapter 8 Early Abstinence

41
support person for the recovering addict. The sponsor will take a special

interest in the addict’s recovery and will draw from his or her own experiences in recovery and personal relationship with the 12-step program

to aid the addict in recovery. The patient should select a sponsor from

among the more advanced recovering individuals he or she has met in

the group. The sponsor should be someone who is working through the

program in a healthy way, has the patient’s respect, and has something

to offer the patient emotionally toward personal recovery. Also, if the patient is heterosexual, the sponsor should be the same gender to avoid

the complication of sexual attraction and the potential for sexual acting

out between sponsors and sponsees. Important to the patient’s recovery

is feeling that he or she can have an intimate relationship with the sponsor and that this relationship does not become sexualized. No specific

parallel rule applies if the patient is gay or lesbian; however, the principle remains the same. Recovery must not sexualize the sponsor-sponsee

relationship.

In reviewing the 12-step program, the counselor should emphasize the

importance of participating in self-help groups and also make the patient comfortable with the 12-step process, including sponsorship. Discussions about the 12-step program also will serve to introduce the idea

of continuous, even lifelong participation in a personal recovery

program.

Chapter 8 Early Abstinence

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Chapter 9 Maintaining Abstinence

The next stage of recovery is maintaining abstinence. The addict who has

achieved abstinence now works toward continuing the abstinent behavior—avoiding environmental triggers, recognizing his or her own

psychosocial and emotional triggers, and developing healthy behaviors to

handle life’s stresses. The patient now “practices” the drug-free lifestyle

begun in the previous stage of recovery. One of the key factors in preventing relapse to drug use is maintaining a recovery-oriented attitude by retaining a humble attitude toward the power of the addiction and not taking one’s abstinence for granted. Personal vigilance against relapse is paramount. Vitally important are continued participation in self-help groups

and honesty about feelings and thoughts that could lead one to a relapse.

Ideally, this stage of treatment begins at about the fourth month of treatment, assuming the patient has achieved preliminary abstinence in the

previous stage of treatment. The topics described here are particularly

relevant to the needs of the patient at this point in the recovery process.

The order in which they are presented is generally the order in which

they often emerge as treatment issues, but the counselor should use discretion and address these issues as they seem to be most relevant for the

individual patient.

The counselor may repeat discussions of these topics as needed. The relative emphasis placed on each topic is based on the patient’s individual

needs in recovery. To avoid confusion, and to avoid overload, no more

than two topics should be introduced to the patient in a session. However, in reviewing topics previously introduced, the counselor can address as many topics as relevant. While all the issues identified here must

be addressed in the counseling sessions, the order in which they are presented, and the degree of relative emphasis, is flexible.

Goals

1. Help the patient continue to maintain abstinence.

2. Make the patient aware of the relapse process, so it can be avoided or

reversed quickly.

43
3. Assist the addict in recognizing emotional triggers.

4. Teach the patient appropriate coping skills to handle life stresses

without returning to drug use.

5. Provide the opportunity for the patient to practice newly developed

coping skills.

6. Keep encouraging the behavior and attitude changes necessary to

make sobriety a lifestyle.

Treatment Issues

1. Tools for preventing relapse

2. Identification of the relapse process

3. Relationships in recovery

4. Development of a drug-free lifestyle

5. Spirituality

6. Shame and guilt

7. Personal inventory

8. Character defects

9. Identification and fulfillment of needs

10. Management of anger

11. Relaxation and leisure time

12. Employment and management of money

13. Transfer of addictive behaviors

Tools for Preventing

Relapse

Relapse prevention is an extremely important component of recovery.

After the patient has established some stability in abstinence, he or she

should start to develop skills to prevent future relapse to drug use. The

patient must learn how to manage negative or uncomfortable feelings

without using cocaine or other drugs.

Relapse prevention involves teaching the patient to recognize in

advance when he or she is headed toward a relapse and to change

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direction. A relapse does not begin when the addict picks up the drug—

it is a process that begins before actual use. With education, the patient

easily can recognize markers indicating imminent relapse. Indeed, the

recovering patient must become aware of these markers. Identified in

greater detail in the next topic section, these markers can most simply be

described as negative changes in attitudes, feelings, and behaviors.

Usually, patients can recognize examples of these negative changes in

their own lives and, thus, develop an understanding of the relapse process. Once the patient becomes aware of the nature of the relapse process, the next task is to develop the ability to intervene and change any

negative feelings or risky behaviors which occur. A relapse is caused by

failure to follow one’s recovery program. The task for the counselor and

patient is to identify early those situations where the patient is starting to

deviate from a healthy recovery plan and work to curtail and prevent the

deviation.

In advance of any relapse there is a need to set up concrete, behavioral

changes that the patient will need to make to get out of a relapse process

and return to a healthy recovery program. Such behavioral changes may

include going to meetings more frequently, spending time with people

who support recovery, maintaining structure in his or her lives, and

avoiding external triggers, such as going back to the neighborhood

where he or she obtained drugs.

Identification of the

Relapse Process

How to recognize relapse warning signs or the relapse process is usually

a very helpful skill to teach the patient and one that bears repeating.

Relapse is a common event following detoxification and can occur at any

time during recovery. Because relapse is a common, complex, and difficult occurrence, the addiction counselor should educate the patient

about the process of change associated with impending relapse. Particularly important is the recognition of the signals, events, or situations in

which the risk is especially high, so the patient sees the process of relapse for what it is and avoids it.

As described below, Gorski and Miller (1982) identified 11 steps that

will carry a patient toward a relapse. Teaching the patient the process is

not necessary if he or she can grasp more easily the simpler “changes in

attitudes, feelings, and behaviors.” The information presented below

should give the counselor a more complete understanding. The concepts should be presented to the patient in whatever way he or she can

best understand and use them.

Gorski and Miller’s steps are:

1. A change in attitude in which the patient no longer feels participating in the recovery program is necessary or a change in the daily routine or life situation that signals a potentially stressful life event.

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2. Elevated stress, as seen by overreactivity to life events.

3. Reactivation of denial, particularly as related to stress, as seen when

the patient is stressed but refuses to talk about it or denies its existence. This behavior is of great concern because of its similarity to denial of drug addiction or abuse.

4. A recurrence of postacute withdrawal symptoms, which are especially likely to occur at times of stress. They are dangerous because

the patient may turn toward drugs or alcohol for relief.

5. Behavior change. The patient begins to act differently, often after a

period of stress, as signaled by a change in attitude or daily routine.

6. Social breakdown. The social structure the patient has developed

begins to change. For example, she no longer meets with her sober

friends, or he becomes seclusive and withdrawn from his family.

7. Loss of structure. The daily routine that the patient has constructed

in the recovery program is altered. For example, he sleeps too late,

skips meals, or does not shave.

8. Loss of judgment. The patient has difficulty making decisions or

makes decisions that are very unwise. There may be signs of emotional numbing or overreactivity.

9. Loss of control. The patient begins to make irrational choices and is

unable to interrupt or alter them.

10. Loss of options. The patient feels stressed and believes that the only

choices are to resume drug use or to undergo extreme emotional or

physical collapse.

11. Relapse in which substance use is resumed.

The addiction counselor should become familiar with these signs and

review them with the patient so the patient can watch for these signals.

The counselor also should observe the patient closely for any evidence

that these signs are occurring. If they appear, the counselor should

point them out and help the patient address and reverse them. Reversing the process leading to relapse always involves recommitting

oneself to one’s recovery program by increasing attendance at 12-step

meetings, changing one’s living situation to a drug-free environment, or

taking positive action to resolve relationship, personal, or work-related

problems. The aim of the counselor is to help the patient return to a relaxed, organized, and symptom-free lifestyle; that is, one which is most

suitable, given the real constraints, for continuing recovery.

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CASE EXAMPLE

Sandy now has 31

2 months clean. If you were to ask her, she would tell

you she has 110 days, today. She is feeling really good about this, so

good in fact that she feels ready to return to work, which the counselor

supports. She is employed as a server in an exclusive restaurant, and her

bosses are pleased to give her the job back, because she is an excellent

worker. Soon she becomes quite busy at work, taking on extra shifts to

make additional, much-needed money, and she cuts back on her NA

meeting attendance. The daily structure she established in recovery is

dissolving. Because she is working late hours, she is sleeping late in the

morning, not eating regular meals, and not going to her health club,

which she enjoyed. The counselor becomes worried that Sandy has entered a relapse process and is on her way to picking back up. Sandy denies this behavior (which is the typical response) and tries to justify her

changed behavior by how important the job and the extra money are to

her now.

Interventions

1. The counselor will want to teach Sandy about the relapse process,

pointing out that the process begins long before the person picks up

and identifying those steps toward relapse that are relevant for

Sandy. In her case, the signs are a change in attitude (in that she no

longer prioritizes to attend as many NA meetings), elevated stress

(because she is overworking), reactivation of denial (because she

does not recognize the dangers of this new behavior pattern), behavior change (initiated by the return to work but progressing to include going out with work colleagues after hours), and loss of structure (because she is now going to bed late, getting up late, missing

meals, and not working out at her health club).

2. The counselor’s main intention here will be to break through the denial and get Sandy to see that she is heading down an unhealthy path

likely to lead to a relapse. The next step will be to get Sandy to recommit to her recovery program by reinstituting her positive behaviors.

The counselor should try to get Sandy to at least reinstate some

healthier behaviors, such as attending at least three NA meetings a

week, only working a certain amount of overtime, and making time

for herself to socialize with recovering peers.

3. If Sandy is resistant to accepting that she has entered a relapse process, the counselor may encourage Sandy to get feedback from her

sponsor or people who are in more advanced recovery. Sandy also

can be encouraged to learn from the mistakes of others. She may

know of peers who have had similar relapse processes in their recovery. The counselor can use this story to illustrate Sandy’s path.

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Relationships in

Recovery

Typically when addicts are active in their addiction, their primary relationship is to the drug. The chemically addicted person’s behavioral repertoire narrows, because the person spends so much of his or her time in

drug-related activities. Time and energy are spent on getting money to

buy the drug, obtaining the drug, using the drug, and coming down

from the drug. Because of this narrow focus, addicts tend to neglect

their relationships with nondrug-using people, and eventually some addicts do not even have relationships with sober individuals.

Positive, healthy relationships are an extremely important source of support during an addict’s process of recovery. The counselor should discuss with the patient his or her relationships and find out the nature of

these relationships. The counselor will want to determine whether the

patient has any positive family or social relationships that can be called

upon to provide support during the patient’s recovery. The counselor

also will be looking at whether the patient has many damaging or unhealthy relationships that will tend to hold him or her in the addiction.

Through discussion, the counselor can help the patient to identify unhealthy relationships and work toward changing his or her involvement

in these relationships.

Two types of unhealthy behavior, codependency and enabling behavior,

can contribute to a person’s continued abuse of drugs. The counselor

also should define enabling behavior and codependence and point out

such relationships in the patient’s life.

 Codependency occurs when another individual, perhaps the addict’s spouse or family member, is controlled by the addict’s addictive behavior. Codependents become codependent because they

have learned to believe that love, acceptance, security, and approval are contingent upon taking care of the addict in the way the

addict wishes. In their decisionmaking process, they allow the addict to define reality. Unfortunately, this excessively caregiving behavior tends to foster even more dependency on the part of the

addict. Some codependents are adult children of alcoholics or addicts and their codependent behavior is the result of growing up in

the environment of addiction.

 Enabling behavior occurs when another person, often a codependent, helps or encourages the addict to continue using

drugs, either directly or indirectly. Examples of individuals involved in enabling behavior are a spouse hiding the addict’s disease

from neighbors or their children by lying for the addict and a

so-called “friend” giving the addict money to buy drugs.

The counselor also will assist the patient to identify positive relationships with recovering or nondrug-using people who will be supportive

of recovery. The counselor should encourage the patient to call upon

these individuals for social support. If the recovering addict has no

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supportive relationships, he or she should be advised to use involvement in the fellowship in NA, CA, or AA to begin to establish supportive

relationships. Other positive social involvement should be encouraged,

such as with one’s religious organization or with a recreational organization.

CASE EXAMPLE

Johnnie, the patient we met earlier, is very ambivalent about his relationship with his cohabiting girlfriend, Lisa. He tells the counselor repeatedly that he does not love Lisa, and that they are living together mainly

because she had nowhere else to go. The problem is that Johnnie wants

sobriety, and Lisa is not ready to commit to recovery. She continues to

use cocaine around him in spite of his explaining that he wants to get sober and his asking for her support. However, he has not been able to follow through on what he and the counselor agreed: to separate from Lisa.

On a more positive note, Johnnie has been able to establish and maintain abstinence for 2 months now, and he really wants to continue working toward recovery. Johnnie says that his difficulty in breaking up with

Lisa is because she needs him so much. He says that she depends upon

him financially and for company and affection.

Interventions

1. The counselor wants to point out that Johnnie is being codependent

and enabling here, and in so doing he is tacitly supporting or encouraging Lisa’s dependency on the cocaine and on him. First the counselor will introduce Johnnie to these concepts and discuss them.

Johnnie is being enabling when he gives Lisa money to buy drugs or

otherwise makes it easier for her to obtain them. Codependent behavior is evident in the way Johnnie cannot separate himself from

Lisa and cannot insist that she not use cocaine around him.

2. The counselor should explore with Johnnie how his codependent

and enabling behaviors affect his recovery. The obvious conclusion

would be that these behaviors are undermining his recovery and

may potentiate a relapse. The counselor may need to point out how

they could potentiate a relapse and look at what the “cost” of relapsing would be for Johnnie at this point, since he has achieved some

abstinence.

3. Johnnie may find it helpful to discuss what his codependent and enabling behaviors are really doing to Lisa: promoting her addiction

and in turn damaging her rather than helping her, regardless of what

she thinks at the time. Johnnie should think about what his real motivation is concerning Lisa, and what he really wants for her and for

them as a couple.

4. The counselor should identify concrete steps for Johnnie not to take

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in the codependent and enabling behaviors and then support and

encourage Johnnie in taking these steps. Such steps might be to consistently be assertive with Lisa about not wanting her to use or bring

cocaine around him or to discuss with Lisa that he wants to separate,

and then talk with her to establish a specific plan for doing so.

5. The counselor should strongly encourage Johnnie to talk about this

situation in his 12-step meetings and perhaps begin to attend a

Codependents Anonymous (CoDA) meeting if he does not find the

resources he needs in his own 12-step meetings. Johnnie must get

the support of others who have had similar experiences in handling

this problem, and CoDA meetings or any 12-step meetings are probably the best resource.

Development of a

Drug-Free Lifestyle

Recovery is a lifelong process that requires the development of a

drug-free lifestyle, one of the most important objectives of treatment.

Addicts’ entire lives often are centered on several behaviors: getting

drugs, using drugs, and associating with others who use drugs. When addicts stop drug use, they often must establish new friendships, new social patterns, and new leisure activities.

If the patient has drug-free, supportive friends and family, he or she

should be encouraged to develop these relationships and perhaps participate in recreational activities with these people. If the patient reports

having no drug-free friends or family to whom he or she can turn, then

the patient should be encouraged to make new friends, which often only

can be done slowly—by becoming involved in new social groups, such

as religious, community, or other volunteer services.

Another part of developing a drug-free lifestyle is to establish a daily

schedule that one follows in a reasonably consistent manner. Daily

scheduling, and its advantages, should have been addressed earlier in

treatment and can be reviewed here. The counselor should find out how

well the patient can structure his or her life in a manner that supports abstinence and adhere to that structure. Reviewing the patient’s daily

schedule reinforces this structure and gives the counselor the opportunity to discuss with the patient deviations from the schedule. These deviations may involve “slips” or other emerging problems; thus looking at

them in counseling often is helpful in continuing to guide the patient

toward recovery.

If patients have achieved some healthy structure in their lives, the next

component of developing a drug-free lifestyle is identifying larger goals.

While remembering that sobriety is maintained “one day at a time,” at

this point in their recovery individuals may be ready to think about what

they want in their life in conjunction with recovery, such as going back to

school, changing careers, or saving to buy a house. The counselor and

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patient can examine how to work toward these goals within the context

of the recovering lifestyle.

Spirituality Spirituality, or healing the self, is an aspect of recovery related to the

12-step process but merits a separate discussion because of its importance in a successful recovery program. Spirituality is meant here in the

general sense of one’s having values and altruistic goals in life, rather

than in any specific religious sense. Patients are encouraged to relate to

a power that is transcendent and greater than they are. This “higher

power” is defined by the patient rather than the counselor and involves

connecting to a power that extends beyond the daily concerns of living.

One outlet for the expression of a connection to something greater

than oneself is found in participating in 12-step meetings, particularly

in doing volunteer service at them. Other opportunities to experience

and express this connection might lead to the patient becoming more

involved in his or her religion, in community affairs, or in charity work.

In either case, the patient is encouraged to reach beyond himself or herself as a way to find fulfillment and happiness. This experience of spirituality is a central part of participation in the 12-step groups. The addiction counselor’s role is to introduce and emphasize the idea and encourage the patient to follow through by his or her own efforts and by the fellowship of the self-help group(s) in which he or she becomes involved.

Shame and Guilt Addiction invariably produces feelings of shame and guilt that damage

the addict’s self-esteem. Shame and guilt are both negative feelings related to the experience of addiction, but shame differs from guilt in the

following way: Shame refers to negative beliefs about oneself; for example, one is a weak, worthless, or deficient person. Guilt refers to the belief that one has engaged in wrongful behavior, such as stealing to obtain

money for drugs. Because shame is about oneself and guilt is about

one’s behavior, feelings of shame are more profoundly damaging to the

self and more difficult to heal.

Addicts usually experience feelings of both shame and guilt over their

behavior even while in their active addiction. Individuals often feel

ashamed of themselves for becoming addicted and may not feel worthy

or deserving of recovery. They may have engaged in guilt-producing behaviors that are illegal and/or immoral, such as theft or prostitution to

get money for drugs. They may feel that they have emotionally injured

family and friends. They may have regrets about what they have lost,

such as their job, home, or family. If the addict feels ashamed or guilty,

continued addictive behavior may help the person escape temporarily

from these bad feelings. It also may serve as a way for addicts to hurt or

punish themselves. An addictive disease can become a downward spiral

in which the addict gets high to escape the pain that is the consequence

of getting high.

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The counselor should help the patient to identify and talk about any

feelings of shame and guilt. The counselor will want to show the addict

how the addictive behavior is not a true relief but actually contributes to

these painful feelings about oneself. Healthy, responsible living should

be encouraged as the way of restoring self-esteem and self- respect.

Counselors should point out that being a responsible spouse, employee, friend, or family member can promote improved self- esteem.

Making amends, or apologizing, to people one has wronged in one’s addiction is another way to restore self-esteem and self-respect. This apologizing can be done, if the patient so desires, whenever it is feasible and

will not be hurtful to the other person. Taking a personal inventory,

which is the topic of the next section, also helps to counteract the effects

of the shame and guilt of the addiction by giving the recovering person a

structure for facing up to and honestly taking account of the damaging

or bad behaviors engaged in during the active addiction. This inventory

leads to the possibility of making amends, which, in turn, can lead to letting go of the shame and guilt.

CASE EXAMPLE

Sandy, the recovering patient who seemed to be entering a relapse process, has relapsed. She feels so embarrassed and ashamed that she has

avoided two consecutive scheduled sessions. The counselor reaches her

by phone to discuss why she has missed the sessions, and she admits to

the relapse. She tells the counselor that she relapsed two weekends ago

after work with peers from her job. Since then, she has used twice, the

first time with the same peers and then 3 days ago by herself.

Interventions

1. The counselor empathizes with how bad Sandy is feeling and persuades her to come in for a session. Sandy attends the session, and

the first thing they do is process the relapse. They clarify specifically

what and how much Sandy used, which is important in the interest

of Sandy’s being entirely honest with herself and the counselor

about what happened. They identify what external events and internal thoughts and feelings led up to her use, how she felt, and what

she did afterward. They spend most of the first session analyzing the

relapse.

2. The counselor will want to communicate that they will work together to help Sandy get back on track. Further, the counselor will

want to encourage Sandy to recommit to her recovery, pointing out

that the counselor will support Sandy in resuming her recovery—she need not “go it alone.”

3. Finally, the counselor will want to frame the relapse as a learning exChapter 9 Maintaining Abstinence

52
perience, the analysis of which can teach Sandy how to avoid these

pitfalls in the future.

Personal Inventory Taking one’s personal inventory is a pivotal aspect of the recovery process, allowing the recovering addict to recognize what he or she has

been through and how he or she wants his or her life to be from this

point forward. If done truthfully and thoroughly, the inventory process

facilitates honesty with oneself and responsibility toward oneself and

others, in turn fostering greater self-acceptance. Although taking a personal inventory should be introduced at this point in treatment, the process should be repeated many times in recovery, so that each attempt is

done with increasing honesty and self-awareness on the part of the

patient.

The counselor should spend a full session talking with the patient about

the purpose, meaning, and procedures of taking a personal inventory.

The counselor should emphasize the importance of total honesty with

oneself in completing this task. The advantages to be gained via

increased self-knowledge and self-acceptance should be emphasized. If

the patient is involved with AA, NA, or CA, then taking a personal inventory should be a familiar idea. Therefore, the counselor and patient can

discuss the patient’s feelings about and preparations for this undertaking. If the patient is unfamiliar with the idea of taking a personal inventory, then the counselor can introduce and discuss the concept.

A personal inventory can be taken in several different ways. One way to

proceed is to ask the following questions of oneself and to write down

the answers.

1. How does my addiction affect me—physically, emotionally, spiritually, financially, in terms of my self-image, and so forth?

2. How does my addiction affect those around me—at home, at work,

financially, in social situations, as a role model for children, with regard to the safety of myself and others, and so on?

3. What character defects in me feed the addiction—insecurities, fears,

anxieties, poor self-image, lack of confidence, excessive pride, controlling behavior, anger, and others?

Character Defects After the recovering addict has learned to avoid the people, places, and

things that can lead to drug use and has established abstinence, he or

she may begin to recognize aspects of personality or character that are

obstacles to further recovery. Such obstacles are, in 12-step ideology,

“character defects.” They are typically recognized by the patient within

the process of undertaking the personal inventory discussed above. One

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outcome is that the individual notices qualities within himself or herself

that he or she might like to change.

“Character defects” are personality qualities that may impede recovery

from addiction or decrease the patient’s quality of life. These may either

have arisen as a result of the addiction or have existed previously and

contributed to the development of the addictive behavior.

The patient’s efforts to change such defects should be encouraged by

the counselor. The following process is recommended for working on

changing defects.

The patient should:

1. Identify problematic qualities in himself or herself, such as inappropriate anger, impatience, overconfidence.

2. Decide what qualities to change by assessing how much control he

or she has over the undesirable trait and by determining whether it is

in his or her best interest to change.

3. Make a commitment to work on changing the quality(ies).

4. Seek the help of others when it may be appropriate

5. Follow through on his or her commitment.

This process is the main approach to change in IDC, in a nutshell. Almost anything the patient seeks to change as part of recovery can be

looked at and dealt with using this process.

As a part of this process patients also should be urged to recognize the

positive qualities within themselves. Addicts often feel so much shame

and guilt that they have difficulty identifying positive aspects of themselves. In this case, the counselor should especially encourage patients

to identify good qualities about themselves and even to remind themselves of these positive things.

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Commonly Considered Character Defects

Inappropriate Anger Self-Centeredness

Lust Impatience

Overcriticalness Low Self-Esteem

Exploitativeness Overconfidence

Dishonesty
Identification and

Fulfillment of Needs

Addicts often do not know how to get their needs met without using

drugs. Because an addict becomes so focused on obtaining and using

drugs, he or she loses touch with other, more important needs. Over

time some addicts fail even to recognize their other needs, much less

meet them. The counselor will discuss this problem with the patient and

determine if this is or ever was a problem. If this is a problem area, the

counselor will encourage the patient to talk about the specific instances

in which it occurs or has occurred.

Failures to recognize one’s needs can be situational. Often the feeling

that one does not have the right to have his or her own needs met can occur in a particular context. Examples include relational rights and privileges that stem from involvement with one’s family or spouse.

The counselor should explain the following concepts to the patient and

encourage the patient to practice assertive behavior. Assertive behavior

is a skill that can be learned and maintained through frequent practice.

 Assertion is standing up for one’s personal rights and expressing

thoughts, feelings, and beliefs in direct, honest, and appropriate

ways that do not violate another person’s rights. The goals of assertion are communication and mutuality.

 Nonassertion amounts to violating one’s own rights by failing to express honest feelings, thoughts, and beliefs and consequently allowing others to violate oneself. It also can occur through

expressing one’s thoughts and feelings in such an apologetic, diffident, or self-effacing manner that others easily can disregard them.

Unfortunately, assertion is often, through conceptual error, confused with aggression.

 Aggression is standing up for one’s personal rights and expressing

thoughts, feelings, and beliefs in a way that often is dishonest, usually inappropriate, and always in violation of the rights of others.

The goal is domination and winning by forcing the other person to

lose. Winning is ensured by humiliating, degrading, or belittling

one’s opponent.

The counselor will encourage the patient to identify personal needs that

are not being satisfactorily met and, if appropriate, help the patient to

identify and try out the assertive behaviors to help get the needs met.

Giving patients the opportunity to rehearse repeatedly the assertive

communications and behavior they want to employ in problematic situations in their lives often is a useful intervention.

Management of

Anger

Many cocaine addicts have problems managing and expressing anger.

For some, drug use simultaneously both numbs and exaggerates emotions. Addicts often use drugs to suppress the anger that they feel, over

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time becoming numb to their true feelings. Because of the failure to recognize when one feels angry and to understand the reason for the feeling, this unacknowledged anger may explode. Addicts may also have

trouble dealing with their anger because, due to their addiction, they

may not have learned to express anger in a healthy, productive way.

They may have learned unhealthy ways to express their anger from their

parents or other role models. Further, addiction impedes the individual’s self-learning and emotional growth, so the recovering addict may

feel unable to deal with feelings. Also, addicts may be angry at themselves for their addiction but place the blame on others, so they misdirect their anger and vent it on those who are close to them.

The counselor should discuss how the patient experiences and expresses feelings of anger, including what things cause the patient to get

angry and how and with whom the patient expresses anger. Frequently,

managing anger is closely related to identifying and meeting needs. For

many, simply recognizing when one’s rights are being violated is the first

step in managing anger. Then, one can try to respond assertively and

avoid a less productive angry response. There are appropriate and inappropriate ways to express anger, and how the patient typically expresses

anger should be discussed. The counselor should help the patient to

identify more positive ways to express anger. Healthier ways of expressing anger may include assertive communications, possibly taking a

“time-out” from an argument and returning to the discussion later, or

having a physical outlet, like going for a run, lifting weights, or even hitting a pillow. The goal is for the patient to become able to manage feelings of anger more productively, without resorting to drug use or hurting oneself or others.

Relaxation and

Leisure Time

Relaxation, physical activity, and better nutrition contribute to a physically and emotionally healthy life. Involvement and improvement in

these areas is to be encouraged as part of the lifestyle changes a chemically addicted person has to make in order to progress toward recovery.

Recreation helps to support one’s recovery by providing relaxing activity that reduces stress and helps the patient to maintain a sense of balance in his or her life.

The counselor should discuss what kinds of healthy recreational activities the patient enjoys and, if necessary, encourage the person to resume

participating in them. If the patient does not currently participate in any

such activities, the counselor can help the patient to identify some leisure activities, new or old, that would be feasible.

Whenever possible, some form of physical activity should be undertaken

as part of one’s leisure time. In some cases, the patient should check

with his or her physician before starting any type of exercise, but this

step is less necessary if the patient is generally healthy and already engaged in some physical activity. Healthy exercise supports recovery in

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two ways. Engaging in physical activity helps to combat boredom, which

can be a major trigger for drug use. And it helps the recovering person to

feel better physically, which will hopefully lessen the severity of any

postacute withdrawal symptoms.

If the patient does not come up with suggestions for any physical activity

on his or her own, then the counselor should offer suggestions, including those on the following list.

A related area of recovery to emphasize is good nutrition. Addicts often

fail to eat properly either because the bulk of their time is spent in getting, using, and recovering from cocaine or because after supporting

their drug habit, they do not have the money to buy food. Additionally,

cocaine use temporarily suppresses one’s appetite, so if the addicted

person does not consciously try to eat well, he or she will tend to skip

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Physical Activity Suggestions

 Taking daily walks (in a pleasant area that will not trigger drug

craving).

 Window shopping (which essentially involves walking), as long

as the recovering person does not have problems with compulsive spending. The advantage to this type of walking is that in bad

weather, one can do this activity inside in a mall or shopping center.

 Fishing (many, predominantly male, patients enjoy this activity

but the counselor has to clarify that there must be no alcoholic

beverages on the fishing trips).

 Joining a local health club or YMCA or YWCA.

 Riding a bicycle, either to commute to and from work or other

places or just for pleasure.

 Taking one’s kids to the park and playing with them. For younger

children, this activity usually means taking them to the playground;

for older kids, helping them improve their baseball, basketball, or

soccer skills might be appropriate. These activities offer the additional advantage of giving parents and children valuable quality

time together, which is important because the addiction has usually

damaged familial relationships.

 Playing a sport that one used to enjoy, such as tennis, a summer

softball league, or “pick-up” basketball games at the neighborhood courts (as long as there is no alcohol or other drugs

involved).
meals because of not feeling hungry. Good nutrition helps the recovering person feel better physically by lessening the experience of postacute

withdrawal symptoms and rebuilds the body ravaged by addiction.

The counselor should discuss eating habits with the patient to determine

how aware he or she is about good nutrition. If the patient does not have

healthy eating habits, some nutritional suggestions should be offered.

The following are very basic suggestions for improving one’s nutrition.

Employment and

Management of

Money

Recovering addicts very often have problems maintaining employment

and managing money. Frequently, their drug use has caused them to be

irresponsible at work, which may have gotten them fired. By this point in

recovery, many addicts have thought about going back to work or seeking work. Many feel that they need to start working, so they can become

responsible people and support themselves and their families. While

these heightened inclinations for the patient to be more responsible are

to be encouraged, work situations themselves may cause major problems for the addict in recovery.

Although employment will add structure to the person’s life and may foster improved self-esteem, it is likely to be a significant psychosocial

stressor. To get a job, the patient may have to face fears of failing. Actual

failure, or even the associated fears, may result in further loss of

self-esteem. Employment is stressful for other reasons as well. The job

environment may be a source of stress because it is a situational trigger

for drug use. Such a situation would exist if the recovering person used

or bought cocaine on the job, and especially if peers use cocaine on the

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Nutrition Suggestions

 Patients should be encouraged to eat two or three healthy meals

a day and follow the Dietary Guidelines for Americans (USDA,

USDHHS 1990).

 Choose foods from the different food groups, including meat,

poultry and fish; dairy products; fruits and vegetables; and bread

and grains. Five fruits and vegetables daily are recommended.

 Many Americans eat too much processed sugar, too much fat,

and too much salt, which can contribute to common health problems such as diabetes, heart disease, high cholesterol, obesity,

and high blood pressure.

 Balanced, nutritious meals are better and more economical if

prepared at home rather than purchased at fast food restaurants.

 Eating more healthfully will give one more energy and help one

to feel better sooner in recovery.
job. Alternatively, an employee may have used drugs in the past to escape feelings of stress related to what he or she considered a highly

stressful job. In this case, the recovering person’s pattern may have been

to pick up cocaine after work every day or most days. Cocaine then

would be used ostensibly to help the addict unwind after the stressful

day at work.

These issues should be discussed with the patient in preparation for his

or her return to work or to the job market. If possible, the patient should

have ample time to focus on recovery before returning to work. The

counselor and patient must decide when the patient has been in recovery long enough to ensure that the return to employment will not trigger

a relapse to cocaine use.

Along with returning to work, patients must be able to manage their

money responsibly. Addicts in their active addiction phase are often irresponsible with money. For many addicts, having money is a powerful

trigger for cocaine use. If they have any money, they will buy cocaine.

Some addicts reach the point where they will spend all their money on

drugs and not have enough money to buy food or pay rent. Some cocaine addicts also engage in other forms of compulsive behavior with

money, such as gambling or compulsive spending.

The counselor should know from previous sessions whether money is

an important trigger for the individual patient. Whether money triggers

cocaine craving or not, the counselor should discuss money management issues prior to when the patient returns to work. If money is a trigger, the patient may be advised to put his or her money in the care of a

trusted person (often one’s mother). Obviously, any person the patient

wants to entrust with money should not be using drugs. Also, it may be

helpful to avoid having a card that allows him or her to withdraw money

from an automated teller machine. The physical act of going to the bank

and conducting the transaction requires time and planning and is not as

likely to lead to a drug run.

Transfer of Addictive

Behaviors

Addicts recovering from chemical addiction often believe erroneously

that recovery lies in transferring their addictive behaviors and may not

recognize this pattern as such. Addicts may become compulsively involved in other activities, such as work or exercise. The counselor

should warn the patient against transferring addictive behaviors, because compulsive behavior does not allow one to exercise free choice. It

may not be drug use, but it is compulsive behavior nevertheless and

therefore not within the individual’s control. The replacement of one’s

drug addiction with another compulsive behavioral pattern will not lead

to true sobriety in the long run.

The counselor and patient can examine the patient’s activities in recovery and find out whether the patient is prone to becoming compulsive in

Chapter 9 Maintaining Abstinence

59
his or her behaviors. So-called “workaholism” is a common compulsive

activity in recovery and can involve the patient working more than

full-time, spending a lot of spare time thinking about work, or spending

every waking moment in job hunting. Such behavior should be pointed

out to the patient as being compulsive and not beneficial to recovery.

To combat compulsive behaviors, patients should be encouraged to

make their recovery a first priority, to structure their days, and to make

sure that recovery-oriented activities have a prominent place in their

agendas on most days. The patient should be helped to identify and

meet personal needs. The importance of relaxation and participating in

leisure activities should be highlighted. The addicted person will greatly

enhance his or her chance to stay in a healthy recovery process if he or

she eats healthfully, exercises, sleeps well, avoids overscheduling and

overworking, and is able to relax.

There is one important exception to discouraging compulsive behaviors

in recovery: if the patient participates in AA, NA, or CA in a manner that

appears compulsive. If the patient identifies 12-step participation as the

major activity supporting recovery and feels that he or she needs to attend several meetings a day, then this activity should be supported by

the counselor. If a patient’s 12-step participation is indeed compulsive,

and he or she develops a dependency on groups rather than internalizing the important 12-step ideas, then this is a therapeutic issue for some

much later point in recovery. However, at this still-early point in recovery, the counselor’s best approach is to continue to support the participation with the hope that through exposure the patient will internalize

what he or she needs from AA, NA, or CA.

Chapter 9 Maintaining Abstinence

60
Chapter 10 Advanced Recovery

Advanced recovery is considered to continue throughout one’s life. Recovery from addiction is a change in lifestyle that includes maintaining abstinence as well as involving oneself in healthy relationships; getting good

nutrition, rest, and exercise; and working to resolve one’s personal problems with the goal of attaining a satisfying, fulfilling life. Having established this kind of lifestyle, the patient must now continue to lead it. In

this model, recovery is a lifelong process.

Ideally, in this time-limited model, counseling is concluding at the point

when the patient is entering advanced recovery. Theoretically, individual drug counseling is being terminated when the patient has established and maintained abstinence and been taught all the essential strategies for recovery and for living sober. At this point the patient is ready

to have greater independence and self-accountability in recovery. Also,

he or she should be ready to embark upon the higher level task of integrating recovery-oriented values into all aspects of life. Of course, in reality, patients will be terminating at different points in their recovery

process, particularly when the counselor is working with a time-limited

approach. In this model, tailoring the length of treatment to the individual’s needs is not possible.

Termination

The counselor should plan to discuss the patient’s thoughts and feelings

about ending treatment in the final active treatment session. The impending termination should be mentioned several sessions prior to the

last one in order to give the patient the opportunity to think about the

treatment experience. In the final treatment session, the counselor

should ask the patient to summarize his or her overall experience of the

treatment process. If possible, the counselor should recognize and compliment the patient’s achievements in recovery. A major goal is to identify the gains made through treatment. Another central goal is to recognize the areas still needing work and to plan how the patient will continue to work on them independently. The counselor should encourage

the patient to establish a personal commitment to continue in his or her

own recovery process. To this end, the counselor should urge the patient to specify the steps to be taken to establish his or her own recovery

61
process. The importance of continued participation in self-help groups

should be emphasized. Finally, the counselor should create the opportunity for the patient to discuss feelings about ending the counseling

relationship.

Treatment Booster Sessions

Following completion of the active treatment phase, patients can benefit from continuing to be seen by their counselors. They can use what

they have learned in the active phase of treatment and bolster that learning with less frequent booster sessions and continued participation in

self-help groups.

In the original research program, patients were seen once a month for 3

months for booster sessions. There was no empirical reason for choosing this particular length of time, so practical considerations should govern the choice of how long to continue the booster sessions. In the final

booster session, the counselor should revisit the termination issues that

were discussed at the end of the active phase of treatment.

The purpose of booster sessions is to provide continuing support for the

recovering individual, to encourage participation in a personal recovery

program, and to ensure that the person has assistance available if any

problems with maintaining abstinence should arise. The subject matter

discussed in the followup sessions should continue to be addiction-related and often will involve the repetition of earlier topics with a

new and higher level of understanding and integration.

Goals of Booster Sessions

1. Provide a reminder to the patient of his or her commitment to

recovery.

2. Offer support and feedback to the recovering person.

3. Help the individual develop a personal program of recovery.

4. Be available if a relapse or similar crisis should arise.

Chapter 10 Advanced Recovery

62
Chapter 11 Dealing With Problems That

Arise

Dealing With Lateness or Nonattendance

Patients are repeatedly urged to arrive for all sessions promptly, to call if

they are going to be late, and to call at least 24 hours in advance if they

must cancel a session. If a patient fails to fulfill these obligations, the

counselor will confront him or her about it in the session.

If a patient arrives late for a session, the consequence of that action is to

have a shorter session, because the counselor will, and should, end the

session on time. Repeated missed sessions without appropriate cancellations and rescheduling may eventually result in dismissal from the

treatment, which should be made clear to the patient. In the original research program, administrative termination of treatment occurred only

after 30 consecutive days of nonattendance, so patients were actually

given many chances to participate before being terminated from treatment for nonattendance.

Patients are requested to arrive “clean” for all visits. If a patient arrives

for a session obviously intoxicated, the counselor should remind the patient of his or her responsibility not to be high or intoxicated at sessions

and reschedule the session. Clinicians should use personal judgment

about how best to handle an individual event. For example, if a patient

arrives for a session mildly under the influence but not intoxicated

(blowing a low positive on a Breathalyzer®), the counselor must decide

whether to continue with the session or reschedule. This situation is

quite different from one in which the patient appears to have used just

prior to the session, for example, in the parking lot.

Denial, Resistance, or Poor Motivation

Denial and questionable motivation are central themes in the beginning

phase of addiction treatment. They are addressed in the initial sessions

of counseling and are repeatedly addressed, as needed, throughout the

course of treatment. The major strategy is to “chip away” at the patient’s

denial by pointing out the addictive behaviors and the actual conse63
quences of addiction and by appropriately confronting the patient on

the blindness of his or her denial.

Resistance is not a concept that is directly addressed as such in this addiction counseling model. In addiction counseling, much of resistant

behavior falls within the concept of denial and is addressed in that way.

For example, it would be denial if the patient refused to give up alcohol

(when cocaine is the drug of choice) or avoid drug-using friends because

of denial or minimization of the severity or consequences of the addiction. Another approach to dealing with resistance is to view it as the addict’s willfulness which can be overcome by surrendering one’s will to

one’s “higher power” in recovery—the meaning of the 12-step suggestion to “turn it over” or turn one’s will over to a “higher power.”

Regarding motivation, patients often express ambivalence at some point

in treatment. Several strategies may be used, including encouraging patients to review the pros and cons of getting sober or explore fully the

consequences of their addiction. Patients may also be asked to identify

specifically the benefits of sobriety in their life. Essentially, these issues

are reviewed continuously throughout the early period in treatment.

Strategies for Dealing With Crises

If the patient presents with an urgent, addiction-related problem like

marital dissolution or financial problems as a result of the addiction, the

counselor should try to address the problem. Emphasis should be placed

on how the problem is related to the addictive behavior. Considerable effort should be taken to help the patient develop strategies for dealing with

the problem in a manner consistent with recovery, including identifying

how to obtain appropriate assistance from social services.

If the patient presents with a true crisis, such as having spent all of his or

her money on a cocaine binge, and as a result, feeling suicidal, the counselor should address this issue immediately. The counselor may have to

organize a team effort among the appropriate treatment staff to provide

any medical or psychiatric services that the patient requires in order to

remain safe.

Dealing With Relapse

If a relapse occurs, the counselor and patient should use the session immediately following the relapse to identify and process the events,

thoughts, and feelings that precipitated the relapse. This step is called

relapse analysis.

Relapse to drug use is a common occurrence that can be emotionally

devastating to the patient. The counselor must communicate to the

Chapter 11 Dealing With Problems That Arise

64
patient that a relapse to drug use does not mean that the entire treatment program has been a failure. Recovery is definitely not all or nothing. There is a residual savings. When patients relapse, the counselor

will want to convey to them that they have lost their “clean time” but not

the knowledge and experience gained during their recovery. The counselor should educate the patient about relapse and about the importance of taking corrective action rather than being overcome by feelings

of depression or failure. Most episodes of drug use can be managed

without seriously interrupting the treatment program. They can be used

in a positive and educative way to strengthen the recovery process. In

dealing with a relapse, the counselor should use the general principle

that relapse is caused by failure to follow one’s recovery program. Thus,

the counselor should identify where the patient deviated from his or her

recovery plan and help the patient to recommit to the recovery program.

Levels of Severity of Relapse

Relapse can be viewed as having three levels of severity, which determine the appropriate therapeutic response. The counselor must understand the three types of relapse and the appropriate interventions to be

used in each case. The counselor should communicate to the patient

that any level of resumption of drug use is still a relapse, necessitating

analysis of the process and recommitment to one’s recovery program. In

other words, a “slip” still is a relapse. The levels of severity are to assist

the counselor in determining the appropriate action to be taken.

Slips The least severe type of relapse is a “slip,” a common occurrence that involves a very brief episode of drug use associated with no signs or symptoms of the dependence syndrome, as specified using the DSM–IV criteria (American Psychiatric Association 1994). Such an episode can serve

to strengthen the patient’s recovery if used to identify areas of weakness

and point out solutions and alternative behaviors that can help prevent

future drug use from occurring.

Several Days of

Drug Use

The next most severe type of relapse is when the patient resumes drug

use for several days, and the use is associated with some of the signs and

symptoms of addiction. In such a case, the counselor probably would

want to intensify treatment temporarily, which can be effective. We have

found that intensified contact will usually reinstitute abstinence. The

patient should be encouraged to review what happened and learn from

the experience how to avoid a relapse in the future. The patient also

should be encouraged to recommit to his or her recovery program.

Chapter 11 Dealing With Problems That Arise

65
Sustained Drug Use

With Resumption of

Addiction

The most serious form of relapse is a sustained period of drug use during which the patient fully relapses to addiction. Often a patient who relapses to this extent also will drop out of treatment, at least temporarily.

In this case, if the patient returns to treatment, he or she may need to begin treatment with a detoxification phase, in either an inpatient or outpatient setting. The decision to detoxify a patient as an inpatient or an

outpatient should be made conjointly by the treatment staff involved.

Their decision should be based on the severity of the relapse, the particular drugs used, the availability of social support, and the presence of

unstable medical or psychiatric conditions.

Chapter 11 Dealing With Problems That Arise

66
Chapter 12 Counselor Characteristics

and Training

Ideal Personal Characteristics of the Counselor

Addiction counselors must exhibit good professional judgment, be able

to establish rapport with most patients, be good listeners, be accepting

of the patients (i.e., not have a negative attitude toward working with addicts), and use confrontation in a helpful rather than an inappropriate

or overly punitive manner. Competent addiction counselors also must

be personally well organized enough to be prompt for all sessions and to

maintain adequate and appropriate documentation.

For clinical purposes, the model presented here can be used easily by

skilled counselors in the field. It is not intended to serve as an alternative

to a formal educational experience. Rather, it is intended for use by

counselors who already have gained some experience in the area of addiction treatment. To prepare for the original research study, counselors participated in several 2-day training workshops that they typically

enjoyed and found helpful. Therefore, we would recommend a formal

training experience, if possible. When such an experience is not possible, reviewing the manual carefully and participating in ongoing supervision still can be helpful.

For research purposes, formal training and certification by recognized

experts from the Training Unit at the University of Pennsylvania/Veterans Affairs Medical Center is necessary. In addition, ongoing supervision based on the adherence scale is required to ensure consistency in

this particular model as well as high quality patient care.

Educational Requirements

In the field of drug counseling, experience is viewed as at least as valuable as formal education, so the range of formal education is broader

than in clinical psychology, for example. Generally the range of education is high school graduate to doctorate, with the majority of counselors having a bachelor’s or master’s degree in social work, counseling

psychology, or other human services field.

67
Credentials and Experience Required

Counselors are required to have a minimum of 3 years of experience in

addiction counseling and be knowledgeable of and use the 12-step

model. Professional certification for addiction counselors is available

from different State organizations as well as from a national organization. For example, in Pennsylvania one can be credentialed as an Associate Addiction Counselor (AAC) or a Certified Addiction Counselor

(CAC) through the Pennsylvania Chemical Addiction Certification

Board (PCACB). Professional certification and affiliations are encouraged but not mandatory. Since extensive experience is a requirement for

certification, many counselors work in the field for a while and then become certified.

Counselors in Recovery Themselves

Many counselors in this field are either in recovery themselves or have a

family member who was addicted. Our view is that an indepth knowledge of addiction and the tools for recovery and an ability to empathize

with the patient are essential attributes of an effective addiction counselor. One way, but not the only way, to acquire this knowledge and ability is to be in recovery oneself. If a counselor is in recovery, he or she

should be relatively emotionally healthy and stable. In practice, a minimum of 5 years in recovery should be required. In a setting that employs

multiple counselors, the optimal situation is to have recovering and

non-formerly addicted counselors, because this mix tends to foster the

greatest amount of learning from one another.

Chapter 12 Counselor Characteristics and Training

68
Chapter 13 Supervision

Training and Supervision

Ongoing supervision is a necessary and important part of counselor

training and support. A problem sometimes seen in the addiction field is

a lack of adequate supervision. Also, counselor stress and burnout are

commonplace. This constellation of phenomena—lack of adequate supervision, stress, and burnout—are seen frequently.

The ultimate goal of supervision is to enhance the quality of patient care.

Two primary foci help to achieve this goal. First, it is centrally important

to provide support and encouragement for the counselor and to promote the opportunity for counselors to expand their skills. Second, it is

important for the supervisor to have the opportunity to review the clinical status of the patients and to offer suggestions or corrections.

The format of supervision in this model is for each individual counselor

to have a supervisor and to meet with that supervisor once a week to review counseling sessions. We recommend that the individual counseling sessions be audiotaped and some of them reviewed by the supervisor. The supervisor should listen to a certain percentage of the sessions

in their entirety and then rate them for adherence to the counseling

manual. Then feedback can be given to the counselor, based on his or

her adherence to the model of addiction counseling, as well as other relevant clinical issues.

Use of the Adherence Scale

This manual is accompanied by an adherence scale (see Appendix II) to

assess the counselor’s level of adherence and compliance in providing

addiction counseling based on this model. The adherence scale has two

primary uses: training and supervision, which is important in clinical as

well as research programs, and measurement of treatment

differentiability, which is particularly important in research studies comparing different models of treatment. Here, we discuss only the clinical

use of the adherence scale.

The scale is designed to target and make explicit the specific kinds of

69
interventions that are central to addiction counseling. Counselors are

rated, on 7-point scales, on the frequency and quality (which are interpreted as adherence and competence) of relatively specific types of interventions recommended in the manual. Counselors should be clear

about what types of interventions they should be employing if they are

using this approach. The scale also identifies types of interventions that

should not be used because they are not theoretically consistent with

this approach. Furthermore, the adherence scale is intended to guide

trainers or supervisors in their duties supervising other addiction counselors. To this end, fairly specific instructions also are provided for how

to rate the interventions correctly.

Although the adherence scale identifies the types of interventions that

are necessary to conduct good addiction counseling as described by this

manual, not every type of intervention highlighted should be employed

in every session. Patients do differ from one another. Different issues

arise for individual patients at different points in treatment, and as various life events impact on the treatment. The adherence scale lists the

repertoire of interventions that addiction counselors will be making in

the string of counseling sessions. But, overall, the patient’s individual

needs in treatment should influence how and in what sequence these interventions actually are done.

The adherence scale, developed based on the IDC approach has been

evaluated with regard to its psychometric properties (Barber et al.

1996). There was satisfactory interjudge reliability, which indicates that

the scale can be used reliably to assess adherence and competence for

IDC techniques.

Also, there was a fairly high level of internal consistency within the five

main and two secondary subscales: monitoring drug use behaviors, encouraging abstinence, encouraging 12-step participation, relapse prevention, educating the client, miscellaneous, and things that should not

be done. This finding supports the grouping of items into subscales,

which then creates an easier way of understanding the theoretical types

of interventions in this model.

Substantial correlations between adherence and competence imply that

experts in the field thought that counselors who made better use of the

interventions identified in the manual also were more skillful in their

counseling style in general. This finding suggests that the IDC model incorporates many of the valuable ideas and interventions in the area of

addiction counseling. Further, it probably suggests that skilled addiction counselors will be fairly comfortable employing this approach because it is consistent with what good counselors generally try to do.

Finally, the adherence scale has shown good discriminant validity, implying that experts in the field can distinguish this model from other

treatment models, including cognitive therapy and supportive70
expressive psychodynamic therapy. For the original research, we compared these different treatments for cocaine addiction and determined

that IDC was particularly effective.

Chapter 13 Supervision

71
72
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Woody, G.; Barber, J.P.; Butler, S.F.; Daley, D.; Salloum, I.; Bishop,

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Appendix: Adherence/Competence

Scale for Individual Drug Counseling (IDC) for

Cocaine Dependence

D. Mercer, N. Calvo, I.D. Krakauer, and J.P. Barber

University of Pennsylvania

Counselor No: _______________________________________ Patient No:_________________________

Session No:__________________________________________ Session Date:_______________________

Rater:_______________________________________________ Date Rated: ________________________

Please rate the counseling session using the scale below. For each item, rate both the frequency (how much

the counselor engaged in the described behavior) and the quality (how competently the counselor carried

out the behavior) on the blanks to the left of the item. When rating quality, be sure to take into consideration the context of the session and the timeliness of the intervention. Use the 7-point rating scale below

for both ratings.

Frequency: Quality:

1: did not occur at all 1: extremely poor, possibly detrimental to patient

2: passing comment, briefly touched on 2: poor (vague, critical, judgmental)

3: some, mentioned, briefly discussed 3: mediocre (implicit, rambling, poor focus)

4: moderate level of frequency 4: acceptable

5: pretty frequent 5: good quality

6: very frequent 6: very good quality

7: exceptionally frequent 7: excellent quality

If the behavior described in an item did not occur at all, rate frequency 1 and rate quality according to how

detrimental the exclusion of the intervention was to the patient. If it was extremely bad that the counselor

did not carry out the intervention, rate quality 1; if it was acceptable that the counselor did not carry out the

intervention (it was not necessary in the context of the session, or the patient carried it out spontaneously)

rate quality 4; and if it was excellent that the counselor did not carry out the intervention, rate quality 7. Do

not use a rating of “not applicable” for either frequency or quality.

Copyright 1995 77

1234567

Low Moderate Very high
MONITORING DRUG USE BEHAVIORS

Frequency Quality

______ ______ 1. Monitoring cocaine usage

Give a frequency rating of 4 (or above) if this occurs and a rating of 1 if it does

not. A frequency rating of 4 may be given even if the counselor does not explicitly

ask about cocaine use (i.e., “Have you used any drugs at all since we last met?”).

A lower quality should be given in this instance, however. To receive a high quality rating, the monitoring must be done at the beginning of the session.

______ ______ 2. Monitoring other drug/alcohol usage

Give a frequency rating of 4 (or above) if this occurs and a rating of 1 if it does

not. Rate quality according to how completely and competently it is covered. To

receive a high quality rating, the counselor must do a full drill at the beginning

of the session and establish the date of last use.

______ ______ 3. Monitoring craving

At least one specific question must be asked to get a rating of 4 or above. Sample

questions: “Did you want to use this week?” or “Did you have any cravings/urges

this week?”

______ ______ 4. Monitoring high-risk situations (situational triggers)

The situations must be explicitly tied into drug use to get a rating of 4 or above.

______ ______ 5. Monitoring emotional triggers (feelings that can lead to drug use)

The feelings must be explicitly tied into drug use to get a rating of 4 or above.

Sample question: “Have those feelings led you to pick up?”

______ ______ 6. Monitoring withdrawal or postacute withdrawal symptoms

This must occur specifically within the context of a discussion on withdrawal/postacute withdrawal symptoms. To receive a rating of 4 or above, specific monitoring questions must be asked.

ENCOURAGING ABSTINENCE

Frequency Quality

______ ______ 7. Helping the client structure his/her time

To get a rating of 4 or above, the counselor must offer plans or suggestions or discuss concrete ideas.

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______ ______ 8. Discussing current employment and/or money management

______ ______ 9. Discouraging drug and alcohol use

If only implicit, do not rate frequency above 4.

______ ______ 10. Discussing client compliance or resistance to treatment

This should be concrete, referring to the treatment plan and whether the client is

doing what s/he agreed to do (i.e., meetings, group therapy, abstinence, phone

calls, etc.).

______ ______ 11. Helping the client to develop healthy social skills and/or recreational

activities

______ ______ 12. Encouraging personal responsibility for recovery

______ ______ 13. Reviewing consequences of drug/alcohol use

This refers to past or progressing consequences, rather than future or possible

ones. Also, consequences should relate directly to the client.

______ ______ 14. Discussing issues of spirituality

ENCOURAGING 12-STEP PARTICIPATION

Frequency Quality

______ ______ 15. Monitoring attendance at 12-step groups

Includes frequency of attendance and type of group.

______ ______ 16. Encouraging attendance at or involvement in 12-step programs

Includes suggesting that the client get a sponsor, attend more meetings, attend

different types of meetings, etc.

______ ______ 17. Discussing specific steps and 12-step philosophy (i.e., steps, philosophy,

traditions, and slogans)

______ ______ 18. Examining client’s concerns about or resistance to any aspect of the

12-step program

______ ______ 19. Discussing sponsor-sponsee relationships

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RELAPSE PREVENTION

Frequency Quality

______ ______ 20. Discussing stressors and how they influence recovery

Stressors refer to any ongoing external situation to which the client must adapt

(e.g., employment, relationships, kids). The counselor must specifically tie the

stressor into recovery (e.g., “Does that make you want to use?” “What can you do

instead of using?” “How does this affect your recovery?” “Has this led you to use

in the past?”) to receive a rating of 4 or above. If the patient complains but the

counselor does not respond, F=1. Frequency reflects the presence of discussion,

and quality reflects the helpfulness of discussion.

______ ______ 21. Confronting denial and ambivalent feelings

______ ______ 22. Processing most recent relapse

This includes the people, places, and things of the relapse (i.e., what happened

when the relapse occurred).

______ ______ 23. Addressing relapse symptoms

This should occur in the context of relapse prevention and includes identifying

specific relapse symptoms. Changes in thoughts, attitudes, and behaviors count

as relapse symptoms.

______ ______ 24. Establishing concrete behavioral changes to get out of the relapse

process

Includes questions, such as “How can you interrupt it?” and “What can you do

differently?” as well as interventions, such as formulating safety or crisis plans.

An actual relapse does not have to have taken place; change in attitude, behavior, and thinking counts here as part of the relapse process.

EDUCATING THE CLIENT

Frequency Quality

______ ______ 25. Teaching about drug triggers

______ ______ 26. Teaching about withdrawal and postacute withdrawal

______ ______ 27. Teaching about the process of addiction/chemical dependency

Includes talking about the stages of addiction, tolerance, diagnostic criteria,

etc., in a didactic manner that is informative and declarative.

______ ______ 28. Teaching about the relapse and/or recovery process

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______ ______ 29. Teaching about high-risk sexual behaviors (especially HIV-related ones)

and/or the cocaine-sex connection

MISCELLANEOUS

Frequency Quality

______ ______ 30. Dealing with anger (how to acknowledge the feeling and express it

appropriately)

If this behavior does not occur (F=1), rate quality low only if it is clear that the

patient does have feelings of anger that need to be addressed. If the patient explicitly states that s/he is angry and the counselor ignores it, rate F=1, Q=1. If

the patient implies that s/he may be angry (e.g., describes a situation in which a

person would typically be angry) and the counselor ignores it, rate F=1, Q=3. If

the patient does not mention anything in the session that indicates there may be

anger issues, rate F=1, Q=4. For F > 1, the counselor must offer concrete suggestions for how to deal with anger to receive a quality rating of 4 or above.

______ ______ 31. Discussing management of postacute withdrawal symptoms (e.g.,

encouraging good nutrition, good sleeping habits, and physical exercise)

To receive a rating of 4 or above, the counselor must suggest concrete behavioral

changes tailored specifically to the patient and her/his circumstances.

______ ______ 32. Addressing other compulsive behaviors (i.e., gambling, sex, overworking,

eating, thrill-seeking).

If this behavior does not occur (F=1), rate quality low only if it is clear that the

patient does have a compulsive behavior that needs to be addressed. Quality

ratings depend both on the counselor’s response and the degree to which a problem seems to be present. If the patient explicitly states that s/he has a problem

with a compulsive behavior and the counselor ignores it, rate F=1, Q=1. A rating of F=1, Q=4 is equivalent to N/A, meaning that the counselor does not address the problem, and there does not seem to be a problem to discuss. As Q approaches 1, it becomes more obvious that there is a problem. For Q > 4, the therapist must address the problem, and Q approaches 7 as the intervention becomes more helpful.

______ ______ 33. Discussing specific unhealthy relationships

______ ______ 34. Discussing family issues (codependency, enabling, alcoholism, etc.)

This item only refers to family issues that are related to drug use and/or other

negative behaviors. The focus must be on the way that these issues affect the patient. The counselor must explore the ways in which family issues relate to recovery for Q > 4.

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THINGS THAT SHOULD NOT BE DONE

For these items, only frequency should be rated.

Frequency

______ 35. Pointing out client’s dynamic themes in relationships

______ 36. Interpreting aspects of the client’s relationship with the counselor

______ 37. Identifying client’s dysfunctional cognitions about addiction

Refers to the cognitive model in which the therapist identifies the dysfunctional

cognitions and then engages the client in a cognitive process of developing cognitive coping strategies.

______ 38. Encouraging client to use cognitive coping strategies

SUMMARY

Quality

______ 39. Overall performance as an IDC counselor

A rating of 4 means that the counselor was an acceptable IDC counselor. A rating below 4 means that the counselor was unacceptable in some way—s/he did

not adhere to the IDC manual, exhibited inappropriate behavior, was a poor

counselor, etc. A rating above 4 means that the counselor was an especially

good IDC counselor.

______ 40. Overall judgment of the level of difficulty presented by the patient

How difficult do you think this patient was to treat? If the patient was easy, rate

her/him low (1, 2, or 3). If the patient was difficult, give a high rating (5, 6, or 7).

A rating of 4 means that the patient was of about average difficulty.

1 = not difficult at all 7 = extremely difficult patient

TREATMENT MODALITY

Y/N Confidence

______ ______ 41. Is this an Individual Drug Counseling session? (Y/N)

How confident are you of your answer?

1 = not at all confident 4 = fairly confident 7 = absolutely certain

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______ ______ 42. Is this a Cognitive session? (Y/N)

How confident are you of your answer?

1 = not at all confident 4 = fairly confident 7 = absolutely certain

______ ______ 43. Is this a Supportive-Expressive Psychodynamic session? (Y/N)

How confident are you of your answe?

1 = not at all confident 4 = fairly confident 7 = absolutely certain

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