i
ii

Acknowledgments

The development of this manual was supported, in part, by several research grants from the National

Institute on Drug Abuse. This manual was written by Drs. Alan J. Budney and Stephen T. Higgins

under Contract Number N-01DA4-2205 with the National Institute on Drug Abuse. Dr. Lisa Onken,

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 under the direction of Dr.

Higgins and colleagues at the University of Vermont. The development of this therapy model for treatment of drug abuse is built on the work of Dr. Nathan Azrin and colleagues who first developed the

Community Reinforcement Approach for treatment of alcoholism and Dr. Maxine Stitzer and colleagues who pioneered the use of contingency-management procedures in the treatment of illicit drug

abuse. The work of many others was also quite valuable as is acknowledged in the relevant portions of

this manual.

The assistance of many dedicated therapists and research assistants who participated in the clinical

trials of this therapy protocol is gratefully acknowledged and appreciated.

Disclaimer

The opinions expressed herein are the views of the author 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.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced without permission

from the National Institute on Drug Abuse or the author. Citation of the source is appreciated.

National Institute on Drug Abuse

NIH Publication Number 98-4309

Printed April 1998
iii

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 the most effective treatment approaches include both biological and behavioral components.

To ensure that treatment providers apply the most current science-based 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 specific

guidance on session content and how to implement these 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.

Foreword

Alan I. Leshner

Director

National Institute on Drug Abuse
iv

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v

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

Background ..................................................................................................................1

Psychosocial Interventions ........................................................................................1

Supporting Research .................................................................................................2

Use With Other Populations ..........................................................................3

Concurrent Alcohol Dependence ..................................................................3

Program Overview ......................................................................................................5

Lifestyle Changes ......................................................................................................5

Vouchers ....................................................................................................................6

Other Drug Abuse .....................................................................................................6

Treatment Parameters ................................................................................................6

Schedule ........................................................................................................6

Components ...................................................................................................7

Structure ........................................................................................................8

Clinical Approach ....................................................................................................... 9

Counseling Style ......................................................................................................9

Flexibility ......................................................................................................9

Empathy ........................................................................................................9

Active Involvement ....................................................................................10

Directive but Collaborative .........................................................................11

Social Reinforcement .................................................................................11

Counseling Techniques ................................................................................................11

Behavioral Techniques ...............................................................................12

Additional Resources ..................................................................................12

Progress Graphs .........................................................................................13

Counseling Structure ...................................................................................................13

Preparation ..................................................................................................13

Session Protocol ..........................................................................................14

Recent Problems or Crises ..........................................................................16

Contents
vi

Special Issues ................................................................................................................17

Absences ...........................................................................................................17

Tardiness .........................................................................................................17

Extra Sessions .................................................................................................17

Drug and Alcohol Use ......................................................................................17

Concurrent Treatment ......................................................................................18

Premature Termination ......................................................................................18

Documentation of Patient Contact ...............................................................................19

Clinical Supervision ......................................................................................................19

The Voucher Program ....................................................................................................23

Objective Monitoring ...................................................................................................23

Urinalysis Schedule ......................................................................................................24

Specimen Collection .....................................................................................................25

Laboratory Analysis ......................................................................................................25

Presenting the Results ...................................................................................................26

Intake ...............................................................................................................................27

Initial Contact ..............................................................................................................27

Screen Applicants .............................................................................................27

Schedule Intake ................................................................................................27

Intake Procedures ..........................................................................................................28

Assessment ........................................................................................................28

Self-Administered Questionnaires ....................................................................29

Program Description .........................................................................................30

Structured Interviews ........................................................................................31

Initial Treatment Session ..............................................................................................35

Get to Know the Patient ...................................................................................35

Provide Overview and Rationale ......................................................................37

Introduce the Voucher Program ........................................................................38

Describe Abstinence Contract ..............................................................38

Explain Urinalysis Monitoring..............................................................38

Explain Voucher Program .....................................................................39

Review Abstinence Contract ................................................................42

Priming .................................................................................................42

Problem List ......................................................................................................42

Practical Needs Assessment .............................................................................45

Appointment Book ...........................................................................................45

Significant Others .............................................................................................46

Disulfiram Procedures (if applicable) ...............................................................46

Collect Urine .....................................................................................................46

Schedule the Next Session ................................................................................46
vii

Early Counseling Sessions .......................................................................................47

Outline a Treatment Plan .......................................................................................47

Sessions One and Two ...........................................................................................49

Urinalysis Results ......................................................................................49

Complete Intake and Treatment Orientation ..............................................49

Introduce Functional Analysis and Stimulus Control ................................50

Assist With Practical Needs .......................................................................50

Use the Appointment Book ........................................................................51

Start To Develop the Treatment Plan .........................................................51

Discuss Areas for Change ..............................................................51

Prioritize Problems .........................................................................52

Set Specific Target Goals ...............................................................52

Follow Through ..........................................................................................53

Drug Avoidance Skills ..............................................................................................55

Functional Analysis ................................................................................................55

Components of Functional Analysis ..........................................................56

Triggers ..........................................................................................57

Behavior .........................................................................................58

Positive Consequences ...................................................................58

Negative Consequences .................................................................59

Conduct a Functional Analysis ..................................................................59

Self-Management Planning ....................................................................................63

Rationale ....................................................................................................63

Initiate Training ..........................................................................................64

Make the Plan .............................................................................................64

Drug Refusal Training ............................................................................................66

Rationale ....................................................................................................67

Refusing Cocaine and Other Drugs ...........................................................67

Components of Effective Refusal ..............................................................68

Practice Refusal Skills ...........................................................................................68

Homework .................................................................................................69

Lifestyle Change Components ................................................................................71

Time Management .................................................................................................71

Develop Time-Management Skills .............................................................72

Apply Time Management ...........................................................................73

Social/Recreational Counseling .............................................................................73

Rationale ....................................................................................................73

List Activities and People...........................................................................74

Set Goals and Assess Progress ...................................................................75

Facilitate Change ........................................................................................75
viii

Problemsolving .....................................................................................................76

Rationale ...................................................................................................76

Steps for Problemsolving ..........................................................................77

Recognize the Problem .................................................................77

Identify the Problem .....................................................................78

Brainstorm .....................................................................................78

Select Approach ............................................................................78

Evaluate Effectiveness ..................................................................78

Practice ..........................................................................................78

Vocational Counseling ..........................................................................................81

Rationale ...................................................................................................81

Set Goals ...................................................................................................81

Treatment Components .............................................................................83

Social-Skills Training ............................................................................................85

Assertiveness Training .............................................................................85

Rationale .......................................................................................85

Define Interpersonal Style.............................................................86

Assertiveness Skills ......................................................................88

Practice ..........................................................................................88

Set Goals and Assess Progress ......................................................88

HIV/AIDS Prevention ...........................................................................................88

Rationale ...................................................................................................89

AIDS Knowledge Pretest ..........................................................................89

Video and Discussion ................................................................................89

Pamphlets and Condoms ...........................................................................91

AIDS Knowledge Posttest ........................................................................91

HIV Antibody and Hepatitis B Testing .....................................................93

Provide Information ......................................................................93

Discuss Results .............................................................................93

Relationship Counseling .........................................................................................95

Session One ...........................................................................................................95

Introduce Relationship Counseling ...........................................................95

Introduction Exercise ................................................................................97

Relationship Happiness Scale....................................................................98

Daily Reminder To Be Nice ......................................................................98

Session Two ........................................................................................................102

Perfect Relationship Form ......................................................................103

Positive Requests ....................................................................................103

Session Three ......................................................................................................107

Communications Training .......................................................................109

Session Four ........................................................................................................109

Communications Training .......................................................................110

Sessions Five - Eight ...........................................................................................110
ix

Other Substance Abuse ..........................................................................................117

General Approach .................................................................................................117

Treatment Goals ........................................................................................117

Abstinence ....................................................................................118

Reduced Use .................................................................................119

No Intervention .............................................................................119

Concurrent Alcohol Use........................................................................................119

Abstinence ................................................................................................120

What Is Disulfiram? ......................................................................120

Medical Oversight ........................................................................120

Disulfiram Protocol ......................................................................121

Limited Alcohol Use/Safe Drinking .........................................................125

Patients Who Hesitate or Refuse ..............................................................126

Backup Agreement ...................................................................................127

Marijuana Use ......................................................................................................127

Other Psychiatric Problems ...................................................................................129

Depressive Symptomatology ................................................................................129

Evaluate Suicide Risk ...............................................................................129

Monitor Symptoms ...................................................................................130

Treatment ..................................................................................................130

Anxiety ................................................................................................................130

Relaxation Protocol ..................................................................................131

Relaxation Exercise and Practice .................................................131

Applications ..................................................................................132

Insomnia Protocol .....................................................................................132

Rationale .......................................................................................133

Sleep Diary ...................................................................................133

Sleep-Hygiene Rules ....................................................................135

Sleep Restriction and Stimulus Control ........................................136

Practice .........................................................................................137

Clinical Supervision ................................................................................................139

Weekly Clinical Staff Supervision ........................................................................140

New Cases ................................................................................................140

Active Cases .............................................................................................142

Counselor Treatment Team Meetings ...................................................................142

References ................................................................................................................145
1

Cocaine dependence remains an intractable U.S. public health problem that

contributes to many of our most disturbing social problems, including the

spread of infectious disease (e.g., HIV, hepatitis, tuberculosis), crime, violence, poverty, traumatic injuries, and neonatal drug exposure. Although the

overall number of cocaine users has decreased during the past decade, the

number of heavy users (once a week or more) has increased, along with

other disturbing trends such as increases in the number of cocaine-related

emergency-room admissions, deaths, and admissions to State-supported treatment facilities.

There is no consensus on how to treat cocaine dependence. No pharmacotherapy is available, but even if one should be developed, effective psychosocial treatments would still be necessary to address the multiple problems

common in this population. Research on psychosocial treatments for cocaine dependence has been relatively fruitful, and several effective treatments have been reported (Carroll et al. 1991, 1994a,b; Higgins et al. 1991,

1993a, 1994a, 1995.)

One such intervention, CRA + Vouchers, is the focus of this manual. This

treatment integrates a community reinforcement approach (CRA), originally

developed as an effective treatment for alcohol dependence (Myers and Smith

1995), with an incentive program (Vouchers) wherein patients can earn points

exchangeable for retail items by remaining in treatment and cocaine abstinent. This multicomponent treatment as a whole and several of its components have been demonstrated to be efficacious in controlled clinical trials

conducted with cocaine-dependent adults in outpatient clinics. Its applicability to younger individuals and in other settings has not been tested.

This manual provides the necessary guidance for therapists to implement

CRA + Vouchers as a whole as well as the individual components that are

effective as adjuncts to other treatments.

Background

Psychosocial Interventions
2

Our group has conducted five controlled clinical trials examining the efficacy of CRA + Vouchers. In two trials, CRA + Vouchers was superior to

standard drug abuse counseling in retaining patients in treatment and documenting clinically significant periods of continuous cocaine abstinence

(Higgins et al. 1991, 1993a). For example, in a 24-week study, more than 75

percent of those who received CRA + Vouchers completed 24 weeks of outpatient treatment compared to only 11 percent of patients who received drug

abuse counseling. Several months of continuous cocaine abstinence were

documented in the majority of patients treated with CRA + Vouchers versus

only 10 percent among those treated in a standard counseling group.

A third trial further assessed the reliability of the positive outcomes observed

with CRA + Vouchers and began to identify which of its several components

were clinically active (Higgins et al. 1994a). A 24-week, randomized trial

was conducted to assess the efficacy of the vouchers component. Cocainedependent outpatients were randomly assigned to receive CRA + Vouchers

or CRA alone. Patients who received CRA + Vouchers stayed in treatment

significantly longer and achieved greater durations of continuous cocaine

abstinence than patients assigned to CRA alone. A fourth clinical trial was

recently completed in our clinic, further supporting the efficacy of the voucher

program in promoting sustained periods of cocaine abstinence among patients enrolled in outpatient care.

Another component, wherein patients’ significant others were used to provide social reinforcement when the patient successfully abstained from cocaine abuse, was recently tested. Preliminary research suggested that this

was an effective intervention (Higgins et al. 1994b). However, a randomized

clinical study yielded no evidence to support the efficacy of this approach,

and it was discontinued.

In two of the trials with positive outcomes, followup assessments were conducted 12 months after treatment entry. In each trial, evidence supported the

greater efficacy of the complete treatment package (CRA + Vouchers) compared to drug abuse counseling or CRA alone (Higgins et al. 1995). For

cocaine-dependent adults, the efficacy of incentives for remaining in treatment and for providing objective evidence of recent cocaine abstinence has

received further scientific support. In a recent review of the scientific literature, 11 of the 13 studies (85 percent) on the use of incentives in the treatment of cocaine dependence showed positive treatment effects (Higgins

1996).

Supporting Research
3

CRA + Vouchers was developed and tested in Burlington, Vermont, a

small metropolitan area. To assess the generality of this treatment approach to large metropolitan areas, additional trials were conducted in

methadone-maintenance clinics located in Baltimore and San Francisco

with patients who abused cocaine while in treatment for opioid dependence (Silverman et al. 1996a; Tusel et al. 1995).

Only the voucher program was examined in these 3-month randomized

trials. Vouchers significantly increased cocaine and other drug abstinence,

thereby demonstrating the applicability of incentives for reducing cocaine

abuse to abusers residing in large metropolitan areas.

Several recent adaptations of the voucher program for use with special

populations also appear promising. One application was with schizophrenic cocaine abusers (Shaner et al. 1997). Another involves the use of

the voucher program to increase treatment retention, abstinence, and

participation in prenatal and postnatal care among pregnant and postpartum cocaine-abusing women (Kirby et al. in press).

We were surprised to learn that approximately 60 percent of our patients

were also alcohol dependent. Disulfiram (Antabuse) therapy, with clinic or

family supervision to assure medication compliance, is a standard component of CRA with alcoholics. Thus, we quickly adopted the practice for

simultaneously treating alcohol and cocaine dependence in these dually

dependent patients. In a chart review of these patients, disulfiram therapy

was associated with significant decreases in drinking and, unexpectedly,

cocaine use as well (Higgins et al. 1993b).

Carroll and colleagues subsequently reported results consistent with these

findings in a pilot clinical trial (Carroll et al. 1993). In that study, disulfiram therapy was compared to naltrexone therapy in a population of

outpatients who abused cocaine and alcohol. Patients were randomized to

receive one of the two medications as an adjunct to once-weekly psychotherapy. Disulfiram therapy resulted in reductions in drinking and cocaine

use that were three or more times greater than those with naltrexone

therapy. A larger, randomized trial on the efficacy of disulfiram therapy in

patients who abuse cocaine and alcohol was completed recently by this

same group and again, cocaine use was significantly reduced via disulfiram therapy (Carroll, personal communication).

Use With Other

Populations

Concurrent Alcohol

Dependence
4

BLANK PAGE
5

Cocaine dependence is a life-threatening problem characterized by behavior

patterns that make treatment entry, compliance, and lifestyle change very

difficult. Therefore, CRA + Vouchers providers are expected to make every

effort to facilitate treatment initiation, ongoing attendance, and behavior

change that will support a drug-free lifestyle. The general approach taken to

achieving this goal is perhaps best described as individualized, empirically

based, and behavioral.

Although patients are expected to be extremely active participants in the

treatment process, therapists should expect difficulties and noncompliance

with therapeutic activities. These problems should be defined for what they

are, problem behaviors in need of therapy, not as a reason to discharge patients from treatment.

Increasing cocaine abstinence is the primary goal of CRA + Vouchers. To

achieve and maintain abstinence, patients need to make major lifestyle

changes, particularly in four areas:

 • Family relationships

 • Recreational activities

 • Social networks

 • Vocation

High levels of satisfaction in a cocaine-free lifestyle are needed to compete

with the reinforcement derived from drug use and the drug-using lifestyle.

Therefore, increasing satisfaction in these areas is a major goal for reducing

the probability of continuing or resuming cocaine use.

Patients are assessed at intake in each of these areas, and individual treatment goals are developed by the therapist and patient together. Specific types

of counseling and skills training are provided on an as-needed basis, depending on each patient’s lifestyle change goals and the skills needed to

achieve those goals. Therapists are expected to

Program Overview

Lifestyle Changes
6

facilitate achievement of targeted goals through extensive outreach whenever necessary.

Urinalysis testing is used to measure the patient’s progress in achieving cocaine abstinence, which is the basis for receiving positive reinforcement (social and material) to further increase abstinence. Cocaine abstinence is difficult to achieve and may not result in sufficient, immediate natural rewards,

particularly in its early stages. The treatment program provides prompt reinforcement to keep the abstinence going as well as additional motivation to

abstain by using vouchers. The points accumulated under this system can be

spent for anything that contributes to the patient’s treatment goals. Purchases

are made by staff with the approval of the therapist.

Cocaine abusers frequently abuse multiple substances, and more than half

use alcohol and marijuana excessively or in conjunction with cocaine. CRA

+ Vouchers routinely initiates interventions to decrease other drug use, including disulfiram therapy when appropriate to help patients increase alcohol abstinence. The subject of other drug abuse is introduced at intake, and

therapy is started immediately, if appropriate.

Patients are always counseled that abstinence from all other drugs of abuse,

including alcohol, is the most direct and surest way to increase their chance

of success in dealing with their cocaine dependence. However, it is quite

common for cocaine abusers to not consider their alcohol or other drug use a

problem. The treatment philosophy of CRA + Vouchers in this regard is to

first and foremost provide patients with treatment for the problem for which

they sought help - cocaine dependence.

CRA + Vouchers is designed as a 24-week treatment program. During weeks

1 - 12, the therapist schedules two 60-minute individual counseling sessions

each week. Additional patient contacts in the form of brief phone calls or inperson sessions are employed as needed. During weeks 13 - 24, the therapist

schedules one 60-minute counseling session each week, depending on the

patient’s needs. Urinalysis monitoring is scheduled for three times a week

(e.g., Monday, Wednesday, Friday)

Vouchers

Other Drug Abuse

Treatment Parameters

Schedule
7

during weeks 1 - 12 and twice a week (Monday, Thursday) during weeks 13

- 24.

CRA + Vouchers includes a variety of skills-training components (exhibit

1), but not all patients need or receive all components. Training is tailored to

the needs of the individual and is focused on achieving and maintaining

cocaine abstinence. Patients are taught to identify their pattern of cocaine

use and to develop drug-refusal skills and strategies

Week 1: Treatment Plan Development/Goal Setting

Week 2: Functional Analysis/Sleep Hygiene (or Relationship

Counseling)

Week 3: Functional Analysis/Employment Counseling

Week 4: Employment Counseling/Functional Analysis (or Rela

tionship Counseling)

Week 5: Employment Counseling/Drug Refusal Training/HIV/

AIDS Prevention (or Relationship Counseling)

Week 6: Social/Recreational Counseling/Social Skills Training

(or Relationship Counseling)

Week 7: Social/Recreational Counseling/Social Skills Training

(or Relationship Counseling)

Week 8: Social/Recreational Counseling/Social Skills Training

Week 9: Sleep Hygiene/Employment Counseling

Week 10: Sleep Hygiene/Social/Recreational Counseling (or

Relationship Counseling)

Week 11: Relaxation Training (or Relationship Counseling)

Week 12: Relaxation Training/Review Treatment Progress/Set

Goals for weeks 13-24

Weeks 13-24: New Components are added or counseling continues to

focus on changes in the areas addresses during the first

12 weeks.

Components

Exhibit 1.- Sample Schedule
8

for avoiding or coping with situations that are high risk for cocaine use (i.e.,

functional analysis and self-management planning). Skills training in other

areas (e.g., assertiveness, communication, relaxation) is also provided as

needed to help patients abstain from cocaine and other substance abuse.

The order in which these components are delivered may vary depending on

the needs and priorities of the individual patient. For example, functional

analysis training is usually scheduled for sessions two through four. However, if a patient has important practical needs (e.g., housing) that must be

addressed during these sessions, the therapist may assist in solving those

problems first.

The number of sessions used to address each problem is also flexible. For

example, one patient may receive four sessions of social skills training, while

another may receive only two sessions. Individualized treatment plans are

developed for patients based on their particular needs. The therapist and

patient come to a collaborative decision concerning which components will

be implemented during the program and the order in which they will be

delivered.

Treatment is delivered through individual counseling. Although each patient’s

treatment sessions will be somewhat different in content and focus of behavior change interventions, all sessions follow the same basic structure.

In general, sessions focus on the areas for change listed in the individual’s

treatment plan. During each session, the therapist and patient discuss progress

and problems in each targeted area. The specific goals are evaluated, and

plans of action are initiated. Sessions also focus on the development of behavioral skills important for gaining and maintaining abstinence. Behavioral rehearsal and role-playing are regular in-session activities when skills

training is scheduled.

Structure
9

While therapists must develop their own style of counseling, CRA + Vouchers therapists must also adopt certain guidelines to assure the integrity of the

treatment. The guidelines presented here are designed to facilitate adherence

to this treatment protocol. They reflect a treatment philosophy and

conceptualization of drug dependence that is consistent with scientific studies on determinants of drug abuse. Since this approach differs at times from

other perspectives on drug dependence, such as the disease model and selfmedication model, the counseling approach also differs in some respects.

Flexibility in appointment scheduling and goal setting is important for both

treatment retention and facilitating progress toward target goals. Particularly

in the initial stages of treatment, therapists must try to work around patients’

schedules and make counseling as convenient for them as possible. The

therapist’s attitude should reflect an effort to meet the individual patient’s

needs.

Some patients may be oppositional, disorganized, inflexible, or ambivalent

about participating in treatment. From a CRA + Vouchers perspective, such

characteristics are part of the drug-dependence problem and thus behaviors

that need to be changed over time. For example, therapists should -

 • Tolerate tardiness to sessions and try to have a full session

 • even when patients are late.

 • Tolerate patients who must leave early from sessions.

 • Be willing to meet patients almost any time of day.

 • Set up meetings out of the office if necessary.

With difficult patients, once an effective working relationship is established,

the therapist can begin to ask for more reasonable behavior regarding scheduling and regular participation. Improvements in these areas should become

an explicit part of the individualized treatment

Clinical Approach

Counseling Style

Flexibility
10

plan. Usually such a plan involves graded steps toward improvements (i.e.,

shaping by successive approximation).

Flexibility in goal setting is also very important. For example, if the therapist thinks alcohol abstinence should be a goal but the patient is unwilling to

accept that goal, a compromise is reached. Similarly, if the therapist thinks

that regular employment should be a goal but the patient voices strong resistance, it is put on hold. In general, therapists should express what they think

are optimal goals, but if patients are not ready to make these changes, their

positions are respected. The therapist’s goal then becomes helping patients

progress to the point where they may want to work on these goals. In the

meantime, alternative goals are set, and the issues that were met with resistance can continue to be discussed during the course of treatment.

Therapists must exhibit empathy and good listening skills. They should convey an understanding of the patient’s situation and its inherent difficulties.

In the initial stage of treatment, active listening skills can be used to help

develop an effective relationship and to facilitate goal-setting. As a general

rule, confrontation is strongly discouraged as a means of gaining compliance with therapeutic activities and goals. Rather, therapists should use their

professional counseling skills and appropriate behavioral procedures (e.g.,

prompts, shaping successive approximations, social reinforcement) to gain

treatment compliance.

For example, if patients are constantly late for appointments, therapists should

not lecture them on promptness or lack of motivation but, instead, facilitate

a discussion about the time demands of treatment and how they may conflict

with important or desirable activities. Therapists can then engage the patients in problemsolving and ask them whether changing the appointment

times or providing assistance with transportation would make it easier for

them to attend regularly.

Throughout treatment, empathy should be shown whenever patients are

ambivalent about or having difficulty making changes in any problem area.

Nonjudgmental feedback is used to help patients make decisions about specific goals or lifestyle changes. Therapists avoid making moral or value judgments and, instead, exhibit genuine empathy and consideration for the difficult decisions and behavior changes patients must contemplate.

CRA + Vouchers requires both therapists and patients to adopt an active,

can-do, make-it-happen attitude throughout treatment. Active problemsolving

becomes a routine part of the therapeutic relationship. Therapists do whatever it takes to help patients make lifestyle changes. This includes taking

patients to appointments or job interviews, initiating recreational activities

with them, scheduling sessions at different

Empathy

Active Involvement
11

times to accomplish specific goals, having patients make phone calls while

in the office, assisting them with appointments, and searching newspapers

for job possibilities or recreational events.

The therapist’s motto is “we can make it happen.” Therapists try to model

and in other ways facilitate this same attitude in patients. Patients should be

encouraged to be doers rather than talkers, and therapists must model action

behavior whenever appropriate.

One caution. Therapists must always use good judgment regarding their own

safety when planning outreach interventions. Some patients or their living

environments may present some cause for concern. In those instances, other

staff members should go with the therapist. If staff are still not comfortable

with the safety issues, the intervention should be postponed or canceled.

CRA + Vouchers treatment encourages patients to set lifestyle change goals.

Therapists guide the patients in setting appropriate and effective goals by

enlisting information and suggestions from them. Therapists are also expected to have ideas about specific behavior changes necessary for increasing cocaine abstinence and ways to implement such changes. However, therapists must be careful not to present their views in an authoritarian style that

makes patients feel that they are being told what to do. The task is to have

patients actively participate in the development of their treatment plan so

they feel that the plan is theirs.

Therapists should assume the role of both teacher and coach when helping

patients develop new skills and behavior patterns. They can provide expert

knowledge to help solve the problems for which the patients ask for help and

then coach, train, and encourage patients as they try to put these skills into

action.

Therapists should provide social reinforcement frequently for all appropriate efforts and changes exhibited by patients. They should take advantage of

all opportunities to help patients feel that they are making progress. This is

important because, for many patients, change will be slow and difficult. The

social reinforcement provided by therapists and clinic staff may be the only

source of reward and encouragement available to patients during the early

stages of the program.

Therapists using CRA + Vouchers must have a good understanding of behavioral principles as well as sound counseling skills. A good working knowledge of behavioral principles and their application will allow therapists to

effectively provide rationales for each treatment component,

Directive but

Collaborative

Social Reinforcement

Counseling Techniques
12

model appropriate skills, and serve as credible, competent professionals who

can help people with many difficult issues.

As patients try to take active steps toward specific lifestyle changes, therapists should not expect them to readily set appropriate goals, initiate goaldirected behavior, and maintain these new behaviors simply because a wellmeaning person encourages them to do so. Significant obstacles will arise

that will make the targeted lifestyle changes difficult to achieve.

For example, engaging in a new prosocial recreational activity may involve

interaction with nondrug users unfamiliar to the patient. The thought of entering this situation can produce anxiety and avoidance behavior. Similar

obstacles may arise when patients try to attend educational classes, go for

job interviews, or ask someone for a date. Explanations for noncompliant

behavior may include lack of the skills necessary to complete the task, avoidance due to a history of prior failure in similar situations, and loss of something valued by the patient if change is implemented, to name a few possibilities. The therapists’ responsibility is to maximize the probability that patients will carry through and achieve the desired behavior change. Behavioral procedures are the therapeutic tools used to increase the probability of

compliance with therapeutic activities and success in meeting goals.

Some of the most important and frequently used behavioral principles and

procedures that CRA + Vouchers therapists must master are -

 • Behavioral contracting.

 • Effective goal-setting.

 • Modeling/role playing.

 • Shaping successive approximations.

 • Self-monitoring.

 • Therapist prompting/monitoring.

 • The Premack principle.

 • Skills training (e.g., social skills, problemsolving, task analysis, re

laxation, time management).

It is beyond the scope of this manual to provide training or guidelines for

how and when to apply basic behavioral procedures that will help patients

meet targeted lifestyle change goals. Detailed protocols are provided for some

of the procedures that are primary components of CRA + Vouchers, but in

general, therapists must be experienced in applying behavioral procedures

or be supervised by someone who has

Behavioral

Techniques

Additional Resources
13

that experience. The following texts are recommended to help train and guide

therapists in basic behavioral principles and procedures.

 • Goldfried, M.R., and Davison, G.C. Clinical Behavior Therapy . New

York: John Wiley and Sons, 1994.

 • Meichenbaum, D., and Turk, D. Facilitating Treatment Adherence:

A Practitioner’s Guidebook. New York: Plenum Press, 1987.

 • Miller, L.K. Behavior Analysis for Everyday Life . Pacific Grove,

CA: Brooks/Cole, 1984.

 • Sulzer-Azaroff, B., and Meyer, G.R. Behavior Analysis for Lasting

Change. Fort Worth, TX: Holt Rinehart and Winston, 1991.

An effective way to demonstrate progress, or lack of it, to patients is to set

measurable goals and record progress on graphs. The most important would

be the cocaine urinalysis graph. This shows the cumulative number of cocaine-negative test results plotted as a function of consecutive tests conducted

to date in treatment. Clinic attendance can also be presented graphically.

Specific target behaviors can be recorded on graphs so that progress can

easily be viewed by both patient and therapist. For example, if the goal is to

make four job contacts each day, a bar graph with days of the week on the x

axis and number of job contacts on the y axis would be created, and a goal

line set at four would be drawn across the graph. If the goal is to spend 10

hours each week in social/recreational activities, a cumulative record, by

week, might be used to record progress.

The therapist’s primary role in each session is to gain active participation

from patients and to make sure the session stays focused on a preset plan.

The task may be made difficult if the cocaine abuser comes to sessions with

clinical issues other than those included in the treatment plan. To effectively

deal with such issues, the therapist must skillfully demonstrate appropriate

concern but not allow the session to lose focus. The session plan should be

followed in every session, except in extreme emergencies. The plan can be

structured to accommodate unexpected issues without necessarily altering

the preset goals for the session. The therapist’s task is to stay in control of the

session and ensure that adequate time is available to cover the designated

issues.

Therapists should prepare for each session by reviewing the rationale for the

component to be delivered as well as any didactic material to be presented.

Prior to each session, a therapy session checklist (exhibit 2)

Progress Graphs

Counseling Structure

Preparation
14

Session date ______________ Session date ______________

Cocaine use ______________ Cocaine use ______________

Other drug ______________ Other drug ______________

SO ______________ SO ______________

Primary behavior Primary behavior

_______________________ _______________________

Specific goals Specific goals

_______________________ _______________________

_______________________ _______________________

Secondary behavior Secondary behavior

_______________________ _______________________

Specific goals Specific goals

_______________________ _______________________

_______________________ _______________________

Secondary behavior Secondary behavior

_______________________ _______________________

Specific goals Specific goals

_______________________ _______________________

_______________________ _______________________

Secondary behavior Secondary behavior

_______________________ _______________________

Specific goals Specific goals

_______________________ _______________________

_______________________ _______________________

Exhibit 2: Therapy Session Checklist
15

is completed to ensure adequate preparation. The checklist provides the structure and guidance needed to stay focused on the task so that the treatment

goals are covered in each session.

The following protocol is followed for each session.

 1. First, the therapist reviews urinalysis results (using the graph) with

the patients and provides appropriate feedback. Any problems in the

area of drug abstinence are discussed. Active listening skills are used

to provide support, while encouragement and social reinforcement

are used selectively to support the patients’ efforts.

 • If the day’s urine sample is cocaine-negative, patients are con

gratulated and the behavior that helped them remain absti

nent is discussed.

 • f the day’s urine sample is cocaine-positive, patients are reas

sured that cocaine use is their reason for being in treatment

and that the treatment program is there to help with this prob

lem. A functional analysis of the most recent cocaine use is

conducted, and the therapist stresses the importance of un

derstanding the reasons behind that behavior so they can bet

ter learn to control their use.

 2. The therapist then reviews and evaluates progress on each treatment

goal . Graphs are updated and any problems are discussed. Active

listening skills are used to provide support; encouragement and so

cial reinforcement are used selectively to support patients’ efforts.

 3. If adequate progress is not being made, problemsolving and appro

priate behavioral procedures are used to resolve any difficulties that

may be interfering with achieving the targeted goals.

 4. After reviewing progress in each problem area, goals to be met by

the next session are set. Didactic teaching and rationales for new

behavioral targets are discussed with the patient.

 5. Skills training, behavioral rehearsal, and role playing are used as

scheduled and when appropriate.

 6. Out-of-office procedures can be implemented when warranted. For

example, if the week’s goal is to sample a recreational activity and

the therapist is to function as the initiator, then the patient and thera

pist go perform this activity. If the patients’ goal was to fill out em

ployment applications and they did not do so, then the therapist helps

them do so during the session.

Session Protocol
16

 7. Disulfiram compliance is reviewed and evaluated with patients who

are involved in that protocol. Any problems with the disulfiram therapy

are discussed and procedures implemented to resolve such problems.

Reinforcement and encouragement are provided for successful com

pliance. Similarly, the compliance procedures for taking disulfiram

at the clinic are followed with patients engaged in this protocol.

 8. A review of goals to be accomplished between this session and the

next, along with some words of encouragement, are the last things

that happen in a session.

Many cocaine abusers come to sessions each week with new or repeated

crises. How the therapist handles such crises is important for the effective

delivery of this treatment because CRA + Vouchers requires careful focus

and structure. Certainly, ignoring patients’ real life problems entails the risk

that they will view treatment as irrelevant to their own needs, which may

increase attrition. At least three options for handling crisis situations are available.

 • Therapists can use their counseling skills to try to tie these seemingly

unrelated issues back to the patient’s treatment plan by discussing

how the current treatment plan may help with the crisis.

 • Therapists can discuss the importance of these issues while carefully

explaining that these issues cannot be worked on until a period of

abstinence has been achieved. If the strategies currently being tried

are inappropriate or unsuccessful, a plan is discussed to better meet

the patient’s needs.

 • Sessions are divided so that 10 - 20 minutes are available at the end

of a session to discuss issues not directly related to the treatment

plan. This strategy is an effective way to meet the patient’s needs and

retain the structured protocol. Importantly, the therapist can use at

tention to the patient-specified issue as reinforcement for covering

the session plan (the Premack principle). A statement like the follow

ing can be very effective: “Yes, I can see why you are concerned

about this matter. Let’s try to get through some of our other issues so

we can reserve time to talk about this.” The order of events is impor

tant here. Attention to the new concern must come after going through

the planned activity.

If therapists feel that an intervention is necessary for the new concern, then a

behavioral approach consistent with the structure of CRA + Vouchers is used

to assist the patient. Referral to an outside source may be an option if the

problem is clearly in need of immediate attention and is not tied to drug

abuse. The clinical supervisor is consulted to help

Recent Problems

or Crises
17

resolve such issues. Trained therapists obviously must use their clinical judgment in dealing with such patient concerns. For example, one would not

implement the aforementioned strategy in dealing with acute suicidality.

If patients do not come for a scheduled session or urinalysis test, an immediate attempt is made to contact them by telephone to find out why they missed

the session. If patients do not have a telephone, a visit to their home is considered. Once contact is made, staff can encourage the patient to come to the

agency right away. If necessary, transportation arrangements to the clinic

are made. If this is not possible, the session is rescheduled as soon as possible. If patients cannot be reached for 2 days, an empathic letter of encouragement and concern is sent. All reasonable efforts should be made to retain

patients in treatment. When patients return after an absence, problemsolving

is conducted to prevent another similar absence.

Therapists should convey the attitude that sessions are important and patients should not waste time by being late. Assistance in helping patients

solve any problems that contribute to tardiness should be offered. However,

therapists should be careful to not punish attend-ance. Especially in the early

stages of treatment, praise is offered for coming to the clinic even though

late. If time is available, full sessions are conducted even if started later than

scheduled.

Some patients will request extra sessions, particularly in the beginning of

treatment. Therapists should try to meet such patient needs. Brief contacts

can be scheduled or phone check-ins used to provide the additional support

requested. The supervisor should be consulted to make decisions about how

long additional support will be provided and how to handle more needy

patients. Eventually, the goal is to reduce additional support and return to

regularly scheduled sessions.

Note that by making a request, the patient is indicating that extra sessions

are important (i.e., a potential reinforcer). Therefore, contracts could be written

wherein the therapist agrees to extra meetings contingent on the patient completing certain goals.

Therapists should terminate any session in which patients are under the influence of alcohol or other drugs. This should be done in a caring but assertive manner. Therapists should explain that they are unable to provide the

professional care that patients have requested when they

Special Issues

Absences

Tardiness

Extra Sessions

Drug and Alcohol Use
18

are under the influence. Patients are encouraged to return for the next session sober.

Patients should not be enrolled in other professionally delivered treatments

for alcohol or drug problems while enrolled in CRA + Vouchers. Multiple

treatments can cause confusion because different treatment approaches may

use different strategies. Patients may get mixed messages or may be unable

to focus their energies sufficiently to benefit from CRA + Vouchers if engaged in other treatments.

Attendance at AA (Alcoholics Anonymous) or NA (Narcotics Anonymous)

is often encouraged but not required. Some patients may choose to make

self-help group attendance one of their lifestyle change goals, and therapists

often recommend participation in AA or NA as a way to increase social interaction with sober individuals.

Treatment for other psychiatric disorders or behavior problems is often encouraged. An important judgment here is whether the problem directly influences cocaine use. If so, it must be addressed in the context of CRA +

Vouchers or through an appropriate referral. Clinical judgment must be used

to determine if the benefits of seeking additional treatment outweigh the

potential for such treatment to distract from the focus of CRA + Vouchers. If

the problem is mild and not directly affecting cocaine use, patients may be

encouraged to postpone additional services so they can focus their energy on

one problem at a time. Clinical supervisors should be consulted in these

cases.

Therapeutic termination and referral should be considered for those cases in

which continued regular cocaine or other drug use places the patient in serious physical or psychological danger. During this time of HIV/AIDS and

other fatal consequences of cocaine abuse, treatment dismissal should be

made only after thorough and careful clinical assessment. However, when

the therapist and other clinical staff feel they have exhausted their skills and

efforts but the patient fails to progress, it is time for a referral.

Also to be considered are psychiatric reasons for termination and referral,

such as acute psychosis or severe suicidal ideation that requires hospitalization. Possible termination always needs to be balanced against recognition

that cocaine dependence is a life-threatening disorder characterized by ambivalence and risky behavior that can make progress in treatment difficult.

Therapists must guard against making referrals or dismissals merely because

of noncompliance. Cocaine abusers are at continuous risk, and a mandatory

referral or dismissal may exacerbate that risk if it results in

Concurrent Treatment

Premature

Termination
19

the patient not receiving any treatment. Such cases should be thoroughly

discussed with the clinical supervisor and other staff.

The discharge of patients who stop attending treatment should be preceded

by letters, phone contacts, and personal visits that convey a willingness to

continue treatment or to provide referral options for treatment elsewhere. In

the research on CRA + Vouchers, missing five consecutive scheduled urinalyses was a marker for termination from the program. This termination

rule has never resulted in the discharge of a patient who wished to remain in

treatment. Rather, it was used to provide a precise termination date for patients who simply stopped coming to treatment.

The following procedures are followed for documenting patient contacts.

 • Intake assessment is completed within 2 weeks of first meeting.

 • The treatment plan is completed within 1 week of the first meeting.

 • Session notes are completed on the Progress Note form (exhibit 3)

within 2 days of the counseling session. This form is designed to

help the therapist stay focused on the treatment plan and to evaluate

progress based on that plan. Note that the form is structured such that

all aspects of the treatment plan are reviewed, active goals are speci

fied, the measure by which to evaluate progress is designated, and

progress is assessed each session.

 • Notes from brief in-person and phone contacts are charted on the

Brief Contact form (exhibit 4).

 • All professional contacts are charted on the Brief Contact form.

 • Discharge summaries are completed within 2 weeks of discharge.

Clinical supervision should be a component of this treatment for two reasons. First, CRA + Vouchers requires intensive services that target specific

behavior changes. Unfortunately, many times CRA therapists may feel that

they are working much harder than their patients. Patients may be

noncompliant and refuse to follow through with many of the therapeutic

tasks the therapists have worked so hard to set up. This scenario does not

reinforce the therapists’ hard work. Thus, it can naturally lead to a decrease

in effort exerted by the therapist and foster

Documentation of Patient Contact

Clinical Supervision
20

Patient:_________________ Date:_____________ ________ Urinalysis review

 ________ Disulfiram review

Length of session: ________ Session: __________ ________ SO compliance review

 ________ Collect Happiness Scale

Urinalysis:______________ ________ Record time spent

Problem Area Goal Measure(s) Assessment

Status: A=Active; M=Maintenance; IN=Inactive; NP=No problem

_____ Alcohol/Drug

1. 1. 1. 1.

2. 2. 2. 2.

3. 3. 3. 3.

_____ Employment/education

1. 1. 1. 1.

2. 2. 2. 2.

_____ Family/social support

1. 1. 1. 1.

2. 2. 2. 2.

_____ Recreational/social activities

1. 1. 1. 1.

2. 2. 2. 2.

_____ Psychiatric

1. 1. 1. 1.

2. 2. 2. 2.

_____ Legal

1. 1. 1. 1.

_____ Medical

1. 1. 1. 1.

Homework:

Other comments: Changes in goals, missed sessions, schedule changes,etc.

Exhibit 3: Progress Note
21

Patient:_______________________ Date:_________________ Length: ____________________

Type of Contact (circle one): Phone In person Other agency

Note:

Patient:_______________________ Date:_________________ Length: ____________________

Type of Contact (circle one): Phone In person Other agency

Note:

Patient:_______________________ Date:_________________ Length: ____________________

Type of Contact (circle one): Phone In person Other agency

Note:

Patient:_______________________ Date:_________________ Length: ____________________

Type of Contact (circle one): Phone In person Other agency

Note:

Patient:_______________________ Date:_________________ Length: ____________________

Type of Contact (circle one): Phone In person Other agency

Note:

Exhibit 4: Brief Contact Forms
22

negative feelings and pessimism concerning treatment. A supervisor who is

not personally involved in administering the therapy can help the therapist

remain motivated, creative, and positive.

Second, cocaine abusers enrolled in treatment have multiple problems, some

directly related to cocaine and others that are not. Such patients often come

to treatment sessions with a new crisis each week - some serious, others not

so serious. These multiple problems and crises make it difficult for therapists to stay focused on the treatment plan. A supervisor can help therapists

sort through these issues and can provide the structure, support, and encouragement to remain focused on the primary goal of treatment, cocaine abstinence.
23

The voucher program is a contingency-management procedure that systematically reinforces treatment retention and cocaine abstinence, the primary

targets of CRA + Vouchers. Points are awarded for cocaine-negative urine

test results, and the number of points is increased for each consecutive negative urine sample (exhibit 5). Failure to submit a scheduled specimen is treated

as a cocaine positive. This procedure not only provides a reward for each

cocaine-negative test but provides a greater incentive for patients who maintain long periods of continuous abstinence. Stable patients are better able to

systematically work on the lifestyle changes targeted in the counseling sessions.

This system also recognizes that slips (use of cocaine) are highly probable

during treatment. To discourage slips, the value of the voucher reverts to its

initial value whenever cocaine use occurs. However, patients can regain the

higher voucher values by providing five consecutive cocaine-negative specimens. Points already in the patients’ accounts can never be lost.

Money is not provided directly to patients. Instead, vouchers are used to

purchase retail items in the community by a staff member. Items obtained

using the vouchers are quite diverse and have included ski-lift passes, fishing licenses, gift certificates to local restaurants, camera equipment, bicycle

equipment, and continuing education materials.

Therapists retain veto power over all purchases. Purchases are only approved

if, in the therapists’ opinion, they are in concert with individual treatment

goals related to increasing drug-free prosocial activities.

Regular objective monitoring of cocaine and other drug use via urinalysis

testing is an essential part of implementing CRA + Vouchers.

 • Objective monitoring is necessary for fair and effective implementa

tion of the incentive program and other behavioral contracts used in

this treatment. Such contracts are only effective

The Voucher Program

Objective Monitoring
24

if they are administered consistently and precisely. Reliance on selfreports would not be adequate for those purposes.

 • By the time illicit drug abusers enroll in treatment, family, friends,

employers, and others have often lost confidence in their veracity.

Lying almost has to be part and parcel of regular involvement in

illegal activities. Objective monitoring provides an effective means

for patients to reduce suspicion and rebuild respect among their sig

nificant others.

Objective monitoring keeps all interested parties, especially therapists, regularly apprised of the ups and downs in patients’ efforts to resolve their drug

abuse problem. Timely and objective evidence of patient progress is necessary for developing and revising treatment plans.

Urine specimens should be collected from all patients under staff observation according to a set schedule (e.g., Monday, Wednesday, and

Urinalysis Schedule

Negative urine specimens earn points that are worth approximately

$0.25 each.

During weeks 1-12 of treatment-

 • The first negative specimen is worth 10 points or $2.50 ($0.25

x 10 points)

 • For each subsequent, consecutive negative urine specimen, the

value of the voucher increases by 5 points (e.g. second = 15

points or $3.75, third = 20 or $5.00, etc.)

 • The equivalent of a $10 bonus is earned for three consecutive

negative urines in a week.

 • Positive specimens or failure to submit a specimen on schedule

resets the value of vouchers back to the initial $2.50

 • Five consecutive negative specimens after submission of a posi

tive speciment returns the value of vouchers to their level prior

to the reset

During weeks 13-24, the magnitude of the reinforcer is reduced to one

state lottery ticket for each cocaine-negative specimen

Exhibit 5.- Recommended Reinforcement Schedule
25

Friday during weeks 1 - 12 and Monday and Thursday during weeks 13 -

24.) All specimens should be screened for benzoylecgonine. Each week, one

randomly selected specimen is screened for the presence of other abused

drugs. Breath alcohol levels can also be assessed at the time urine specimens

are collected. Patients and therapists should be informed of the urinalysis

results as soon as possible after specimens are submitted.

The schedule is designed to optimize the probability of detection of cocaine

use. Frequent testing allows detection of almost any use of cocaine. However, it may also result in multiple positive tests from a single cocaine use

episode. This possibility cannot be avoided. Inform patients about this possibility at the start of treatment. Providing information about multiple positives in the beginning of treatment will greatly reduce controversy over the

results or the fairness of the voucher system.

Staff members who collect urine specimens need at least bachelors degrees

and should have received special instruction for several weeks by a trained

staff person in the collection and analysis of urine. Adequate precautions

must be taken to ensure against submission of bogus specimens. Some clinics have a same-sex staff member observe specimen collection; others monitor

the temperature of the specimen. A written copy of the rationale and procedures for specimen collection should be provided to all patients before they

enter the urinalysis component of the program.

After patients have read these materials, the staff member should ask if they

have any questions and whether they understand these rules. Taking time at

the outset to discuss the rationale and procedures for collecting specimens

and referring to them while collecting the first specimen can prevent later

confusion and problems. Patients who have any difficulty with these procedures should be asked to discuss their problem with the appropriate treatment staff.

Monitoring of cocaine use for clinical purposes can be accomplished by

testing for the presence of the cocaine metabolite, benzoylecgonine, in urine.

As a general rule of thumb, benzoylecgonine can be detected for up to 2

days following use of a psychoactive dose of cocaine. Longer intervals, up

to almost 2 weeks, can result from use of high doses of cocaine. Because

most specimens collected from patients enrolled in drug treatment are expected to be negative, immunoassays are recommended

Specimen Collection

Laboratory Analysis
26

or screening out negative samples (e.g., Braithwaite et al. 1995).

Because of cost and other factors, positive specimens are not regularly confirmed. Immunoassays for benzoylecgonine like the Enzyme Multiplied

Immunoassay Technique (EMIT) are very specific; that is, there is little reaction with other compounds that might produce a positive result. Also, in

the majority of cases, patients confirm the screens through self-reported cocaine use.

If your clinic policy is to regularly confirm positive specimens, experts recommend high performance liquid chromatography (HPLC) for clinical purposes and gas chromatography mass spectrometry (GCMS) for forensic purposes (e.g., Braithwaite et al. 1995).

Ideally, urine specimens should be tested immediately after collection while

the patients wait. If you have a drug-testing system in your agency, and all

testing is done by trained assistants, turnaround time can be very rapid (2 - 5

minutes). If your agency does not have laboratory capability, the results should

be presented to patients as soon as possible.

To be consistent with the CRA + Vouchers model, staff should adhere to the

following protocol when informing patients of their urinalysis results.

 • Engage in pleasant conversation with patients while waiting for the

results of the urinalysis.

 • If the specimen is negative for cocaine use (clean), give the patients

a voucher. Provide positive feedback to the patients and engage in

positive interaction for a few minutes.

“ Good job, Jim. You’re doing great. That’s three in a row. How’s

work going ? Great, keep it up. What do you have planned this week

end?”

 • If the specimen is positive for cocaine use (dirty), ask patients about

the amount of cocaine used and on what day. Record this informa

tion. Tell patients to speak to their therapist and immediately termi

nate the conversation. This is very important. Do not engage in pleas

ant conversation. Do not ask about what happened. Do not give thera

peutic advice. Merely refer patients to their therapist.

 • Inform the therapist of the urinalysis result as soon as possible.

Presenting the Results
27

Any person who expresses interest in receiving help for a cocaine problem

has taken a courageous step and should be treated accordingly. The therapist,

intake worker, or receptionist who has first contact with a prospective patient should do everything possible to facilitate entry into treatment. Staff

should provide timely assistance and be flexible in scheduling, empathic

when appropriate, and optimistic about the patient’s ability to change. Some

cocaine abusers may present for treatment with poor attitudes or seem demanding. It is important to expect such negative behavior and to label it as

part of the problem. This will help the therapist or intake worker provide the

friendly, respectful, and flexible treatment access required.

All initial contacts can be handled by a receptionist or clinician.

Conduct a preliminary screen to eliminate inappropriate applicants. For CRA

+ Vouchers , it is advisable to accept for treatment only those individuals

who -

 • Report cocaine abuse.

 • Are aged 18 years or older.

 • Reside within a reasonable distance of the clinic. This requirement

is due to the intensive nature of the intervention. Patients are ex

pected to attend the clinic a minimum of 3 days per week for urine

monitoring and counseling during the first 12 weeks of treatment.

Once the applicant contacts the clinic to request treatment (either by telephone or by walking in), every effort should be made to conduct the intake

interview as soon as possible. At least three studies show that scheduling

intake appointments with minimal delay significantly reduces the attrition

rate between initial contact and the intake appointment. Ideally, the intake

would be done the same day; if that is not possible, then try to schedule it

within 24 hours. The least accommodating

Intake

Initial Contact

Screen Applicants

Schedule Intake
28

schedule should be within 2 working days of contact, although occasionally

this process may take longer.

Inform eligible applicants that the first appointment takes approximately 3

hours to complete and explain what is involved.

 • Completion of various staff- and self-administered questionnaires

 • A brief overview of the program

 • An initial meeting with a therapist to begin developing a treatment

plan

Be prepared to be flexible on timing and scheduling. If the applicant cannot

stay for the complete intake, schedule another appointment as soon as possible to complete the process. However, a brief introductory meeting with a

therapist is recommended at the end of the initial intake session even if the

intake needs to be completed in a second session.

If applicants bring a spouse or partner to intake, it is important to make the

partner feel comfortable. However, the assessment interview is conducted

with the applicant only. Prior to and after the assessment, inform the partner

about the assessment and treatment process. If appropriate, raise the possibility of relationship counseling and encourage it at this time.

The intake session is one of the most important elements of the treatment

process. This may be the first treatment experience for many, and they may

feel uncomfortable or ambivalent about being there. Some patients may have

had an unpleasant treatment experience in the past and are wary of treatment

in general. It is important that patients are made to feel as comfortable as

possible during the intake process.

 • Be aware of the patient’s potential uneasiness and do everything pos

sible to make the initial meeting a positive experience.

 • Convey positive, can-do messages. The applicant should clearly hear

that, by working together, the applicant and clinic staff can resolve

problems that brought the individual to treatment.

 • Accommodate the need for brief breaks, food or drink, or need to

make a phone call.

It is important to collect detailed information on the severity of drug and

alcohol use, treatment readiness, current psychiatric functioning, medical

problems, employment, legal issues, and family and social problems. Following is a list of useful assessment instruments, in the order in which they

are typically administered by the authors; your clinic may choose to use

other instruments.

Intake Procedures

Assessment
29

The questionnaires described in this section are completed by applicants

prior to the interview. If there is any question about reading ability, take the

applicants to a private office and have them read several questions aloud to

see whether they can complete the forms without staff assistance. Persons

deemed capable of completing the forms should be given approximately 45

minutes to finish the ones described below.

If staff assistance is required, read the questions aloud in a private setting,

with care and positive regard for the discomfort poor readers may feel under

such circumstances. Reassure applicants that providing such assistance is

not unusual, because many individuals are unfamiliar with the words used in

such medical questionnaires.

 • Patient Information Form

A brief questionnaire should be used to obtain information on the

demographic characteristics of the applicants as well as their current

address and telephone number and the number of someone who will

always know their whereabouts. This information can be used to

contact patients who do not show up for treatment and to enhance

followup efforts.

 • Cocaine Dependency Self-Test and Cocaine-Related Consequences

Questionnaire

Adaptations of these forms can be used to efficiently collect useful,

specific information about the applicants’ pattern of cocaine use and

associated problems (Washton et al. 1988).

 • Michigan Alcoholism Screening Test (MAST)

This widely used, 25-item instrument lists common signs and symp

toms of alcoholism (Selzer 1971). Considering that most patients

entering treatment for cocaine dependence also use alcohol, and

greater than 50 percent meet diagnostic criteria for alcohol depen

dence, the MAST is useful for flagging patients with alcohol prob

lems.

 • Stages of Change Readiness and Treatment Eagerness Scale

(SOCRATES)

This instrument provides information on applicants’ perceptions of

the severity of their drug abuse problem and their readiness to en

gage in behaviors that reduce use (Miller and Tonigan 1996). It pro

vides a quantitative index of motivation to change, which may be an

important indicator of applicants’ willingness to comply with certain

treatment goals. Three versions of the SOCRATES that refer to spe

cific substances (i.e., cocaine, alcohol, and other drugs) are adminis

tered because the patient’s motivation to reduce substance use is likely

to be substance specific.

Self-Administered

Questionnaires
30

 • Beck Depression Inventory (BDI)

The BDI may be used to screen for depressive symptomatology (Beck

et al. 1961). It can be easily readministered on a regular basis to

monitor progress with patients who score in the clinical range at in

take. The mean BDI score of cocaine abusers entering treatment typi

cally falls in the clinical range of that scale. For most patients, BDI

scores drop precipitously after 1 or 2 weeks of cocaine abstinence.

However, that is not true for all patients. Therefore, it is important to

carefully assess and monitor depressive symptomatology and to in

tervene when symptoms do not remit.

 • SCL-90-R

This instrument may be used to screen for psychiatric symptoms to

help determine whether a more indepth psychiatric evaluation is

warranted. The SCL-90-R (Derogatis 1983) can be easily

readministered to monitor progress or change in psychiatric status.

When the self-administered questionnaires have been completed, they are

reviewed by the intake worker to make sure all questions have been answered. The information on the Patient Information Form is checked for

completeness.

A brief description of the CRA + Vouchers program and its philosophy should

be offered after completion of the self-administered questionnaires but before the structured interviews. The goals are to -

 • Orient applicants to what will happen in treatment.

 • Create an atmosphere of optimism about treatment outcome.

 • Make applicants feel hopeful about improving their life situation.

The intake worker should also explain that -

 • The program is confidential; everything discussed or written remains

private.

 • The program is specifically designed for persons who have prob

lems with cocaine.

 • The program lasts 24 weeks, with the first 12 weeks being fairly

intensive and involving counseling sessions at least twice a week

and urine testing three times a week.

 • If progress is being made, the last 12 weeks become much less inten

sive. Counseling sessions focus on lifestyle changes designed to help

patients make positive changes that will result in greater life satis

faction.

Program Description
31

The following is an example of a short description of what might occur during counseling.

“If you are interested in finding a job, the therapist will help you

with the job search, with developing a resume, and with transporta

tion and phone support if necessary. If you would like to go back to

school, we can help you obtain the applications, access funding and

assistance, and even take you to an interview if you need transporta

tion. If you are having problems in your relationship, relationship

counseling is available. If you don’t regularly participate in any fun

activities, we have many suggestions and may even take you to some

of these, like basketball, tennis, fishing, boating, and arts and crafts

classes.”

“We also provide coping skills training. If you have problems cont

rolling anger, we can help with anger management. If you have money

problems, we can assist you with financial management. If you have

difficulty with behavior problems with your children, we can assist

you directly or we can help you get some additional help. If you have

trouble relaxing, we can work on relaxation skills and stress man

agement.”

The intake worker also provides a very brief description of the Voucher program.

“You will also participate in our incentive program. When you pro

vide cocaine-free urine samples, you earn points that can be used to

support your goals. You can accumulate points to pay for activities

like going to the movies, joining a gym, taking a class, buying a fish

ing rod, and so forth. When you provide consecutive clean urines,

you earn bonus points. Staying clean for 12 weeks can earn you the

equivalent of nearly $1,000. Your therapist will tell you more about

these things after our interview.”

After this brief description of the program, the intake worker should give

applicants an opportunity to ask questions. Keep this interaction brief; the

therapist can provide more detailed information after the structured interview is completed. If applicants are still interested and wish to enroll in

CRA + Vouchers, escort them to a specified location to complete the structured interview.

 • Drug History

A structured drug history interview should be used to collect infor

mation on past and current substance use to determine the duration,

severity, and pattern of the patients’ cocaine and other drug use. The

accuracy of the patients’ reports of cocaine use (amount and fre

quency) is facilitated by the use of an effective technique for review

ing recent use called timeline followback (Sobell et al. 1988). Using

a calendar as a prompt, individuals are asked to recall, on a day-byday basis, when they used a particular

Structured Interviews
32

substance in the past week and the amount used on each occasion.

Grams are the best metric measurement for determining the amount

of cocaine used. The same assessment is conducted for the previous

3 weeks and as far back as is needed for diagnostic purposes. This

technique provides a good overview of the pattern of cocaine use

during the past 30 days. The interviewer should ask for as much clari

fication as possible to help obtain an accurate assessment of the ap

plicants’ substance abuse history.

 • The Addiction Severity Index (ASI)

This structured clinical interview is designed to provide reliable, valid

assessments of multiple problems common among substance abus

ers (McLellan et al. 1985). It gives a quantitative, time-based assess

ment of substance abuse as well as employment, medical, legal, fam

ily, social, and psychological functioning. The data obtained in this

interview are useful for developing treatment plans that include

lifestyle change goals. The ASI is also a useful instrument for assess

ing progress at followup points because it is time based and yields

quantitative composite scores for each problem area. Interviewers

must be trained on ASI administration to ensure that they conduct a

reliable ASI interview.

 • The DSM-III-R Checklist

Only the psychoactive substance use section of this semistructured

interview is administered to facilitate accurate diagnoses of substance

abuse and dependence (Hudziak et al. 1993). Special training in sub

stance use diagnostics is required. Particular care must be taken to

ensure accurate diagnoses, especially if a nonprofessional conducts

the interview.

 • Practical Needs Assessment

This form (exhibit 6) was developed to determine if the cocaine abuser

has any basic needs that may interfere with engaging successfully in

treatment (e.g., housing, legal, transportation, childcare, financial).

The interviewer asks specific questions and collects detailed infor

mation on each area of potential need. These are needs that may re

quire immediate attention and should be given priority in treatment

planning, since many cocaine abusers enter treatment with their lives

in chaos. The probability of engaging and keeping patients in treat

ment may be compromised if swift attention is not provided to basic

life problems.

After the interviews are completed, the intake worker should inform the applicants that they will be meeting with their therapist in a few minutes, after

a brief break (5 - 10 minutes). The intake worker should then complete an

intake summary sheet (exhibit 7) and give it and all
33

Housing

 • Does the patient have a place to live?

 • Is it satisfactory?

 • Does it place the patient at risk for cocaine use?

 • Does the patient have a phone?

 • Are there utilities in service?

 • Is any type of housing assistance needed?

Employment

 • What is the patient’s employmeny status?

 • Is this employmeny satisfactory?

 • Is cocaine use a risk on the job?

 • What services can be used to improve the situation?

Financial

 • Is the patient in trouble financially?

 • Is the patient in need of financial counseling?

 • What financial services are needed?

Education

 • Would the individual benefit from additional education?

 • Is the patient interested in obtaining more education?

 • re the patient’s expectations realistic?

Health

 • Does the patient have adequate health care?

 • Is the patient or the family in need of health services?

 • What health services could the patient use?

Legal

 • Is the patient in need of legal assistance?

 • What type of legal services would be helpful?

Childcare

 • Does the patient need childcare services?

 • What type of childcare would be helpful?

Transportation

 • Does the patient need transportation services?

 • What type of transportation would be helpful?

Assessment

List the areas/and or services that would benefit the patient.

______________________________________________________

________________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Exhibit 6: Practical Needs Assessment
34

Exhibit 7: Intake Worker Summary

Patient ____________________________ D.O.B. ___________________ Date _______________

 1.Current Drugs Used (list):

 2.Referred by:

 3.Presenting problem according to patient:

 4.Drugs patient wants help with:

 5.Pattern of use over last 6 months:

 6.Current DSM-III-R drug dependence (list):

 7.Current DSM-III-R drug abuse (list):

 8.Current DSM-III-R dependence/abuse : drug yrs used route pattern of use last 6 months (daily, w/friends, etc.)

 9.Past DSM-III-R dependence/abuse (list):

 10.Prior drug abuse treatment (list date/type):

 11.Employment (circle one): full part-time unemp.; type of work ___________ pattern last year:_____________

 12.Education completed (specify grade, Assoc., B.A., Voc. training):

 13.Marital status (circle one): single married divorced widowed live-in partner

 14.Children (circle one): yes no; ages:

 15.Current living situation (list persons in home):

 16.Legal status (ASI):

 Was entry into program forced through legal situation? yes no Is legal status related to drugs? yes no

 17.Medical issues (ASI):

 18.Psychiatric issues (ASI): Suicidal thoughts (circle one): yes no; Past attempts:

 19.MAST Score: 20.BECK score

 21.ASI Scores: _____ Alcohol:_____ Drug: _____ Medical: _____ Legal: _____ Fam/Soc: _____ Psych: _____
35

of the intake information to the therapist during a brief meeting to review the

case. Patients are then introduced to their therapist.

The purpose of the initial treatment session is to ensure that patients leave

the clinic feeling that treatment has begun and there is hope that they can

improve their life situation. In many ways, this is an orientation session (exhibit 8). The session should be used to establish rapport with the patient and

to provide a clear rationale for the CRA + Vouchers approach. By doing this,

patients will develop clear expectations about how treatment works and about

what is expected of them.

If the patient is pressed for time or tired from the intake procedures, this first

meeting with the therapist can be shortened and any unfinished business

completed in the next session. The most important goals of this meeting are

to build rapport, enhance expectations, and orient patients to the treatment

process.

Therapists should begin by introducing themselves and reviewing the purpose of the session.

“What I hope we can do is begin to get to know each other. I’d like to

start by briefly discussing the problems that brought you here. I know

you already discussed them in detail with the intake worker, but I’d

like to hear about your problems from you firsthand so I can get a

better feel for what’s going on. Then I’d like to give you an idea of

what to expect as far as your treatment goes. Please feel free to ask

questions or express any concerns you may have about the treatment

or any thing else. Hopefully, by the time we’re done, you will feel

like we have a chance to really help you with your problems. How

does that sound?”

Expressions of empathy and support from the therapist for the patient’s

situation are essential during this session. The intake information isused to

guide questions and express concern. The therapist can ask for clarification

of any information on the intake materials as a means of further understanding the patient’s problems and clearing up any ambiguities.

Therapists start this process by inquiring about drug and alcohol use and

associated problems.

“I can see by looking over your paperwork that you have come to the

right place. It looks like problems with cocaine use and to some ex

tent alcohol use are the primary problems. Is that right? . . . Can you

tell me a little bit about your cocaine use and how it led you to seek

help today? . . . I see you had some treatment in the past. Was it

helpful?

Initial Treatment Session

Get to Know

the Patient
36

. . . What did it involve? . . . What do you expect to get out of

treatment this time around? . . . Are you optimistic about your

chances for success? . . . Do you have any thoughts about what it

will take to get you to stay clean? . . . Tell me a little about the pros

and cons of your cocaine use. What are the positive aspects of

using? What are the negative aspects?”

Next the therapist moves to a similar mode of interviewing regarding other

problem areas.

“I see you do construction work. Is that full time? . . . How do you

like it? . . . Are you satisfied with that type of work as a way of

making a living?. . . Are there other types of jobs you are considering? . . . Does your current job pose any risks for using cocaine or

drinking? . . . Do you use drugs with your coworkers? . . . Are you

interested in finding another job or getting any additional training?

. . . Do you have a timeframe in mind for when you might do that? . .

.

“I see that you are married and have two children. How old are

they? How are they doing in school? . . . Any problems or concerns

with either of them? . . . Does you wife agree with you about that

problem? . . . Have you tried anything to help with that? . . . How

did it work? . . . How are you and your wife getting along? . . .That’s

too bad. It’s pretty common for us to hear about those types of

problems in this clinic. Is she willing to work with you on your

cocaine problem? . . . If she is, we’d love to have her come in. I’ll

tell you about how that might work in a few minutes.”

 • Get to know the patient

 • Provide an overview of and rationale for this treatment.

 • Initiate the vouchers program, including the abstinence contract.

 • Develop the problem list.

 • Review the practical needs assessment.

 • Provide an appointment book.

 • Discuss the role of significant others in the treatment.

 • Initiate disulfiram procedures, if needed.

 • Make sure a urine sample has been collected.

 • Schedule the next session.

Exhibit 8: Goals for the Initial Treatment Session
37

This type of questioning will promote a discussion and provide an opportunity for therapists and patients to exchange information relevant to treatment planning. Therapists can also assess the patients’ general level of functioning, gain an initial understanding of their history, and assess their attitudes toward treatment.

After reviewing the intake material and touching on the specific problem

areas, the therapist should explain the philosophy and goals of CRA + Vouchers. The overview should be phrased in a positive, confident manner and

draw on the empirical support for this approach in the treatment of cocaine

dependence. The therapist should describe how the treatment experience gives

patients an opportunity to move their lives forward in a positive and fulfilling direction. The therapist should be upbeat and optimistic when presenting

the overview. The overview includes the following.

“I’d like to tell you a little bit about the treatment you will be receiv

ing. This treatment can provide you with skills others have found

useful for overcoming cocaine abuse. Our main emphasis will be

on -

 • Getting you involved in new social and recreational activi

ties.

 • Beginning new employment or educational opportunities if

you want.

 • Helping you obtain more satisfaction from relationships with

family and friends.

“We have learned that, for people to stop cocaine abuse, they must

make significant changes in their lifestyle. Cocaine and other drug

use can develop a very powerful control over a person’s life. To stop

using drugs and alcohol, people must have something equally pow

erful to look forward to that will fill their time. That is why our focus

will be on helping you increase the satisfaction you get from things

in your life that have nothing to do with drugs or alcohol. We believe

that nondrug-related activities can compete against the powerful ef

fects of cocaine use and the activities associated with its use.

“Our program also provides incentives for you to abstain from co

caine. I’ll explain how that works in a few minutes. We will also

focus on teaching you effective ways to avoid relapse and to turn

down drugs when they are offered to you. We know that slips can

occur while you are in treatment, but that is no excuse for quitting

treatment. Ups and downs can be expected. However, we are not

giving you permission to use.”

“One important factor to keep in mind is that there are usually mul

tiple causes of cocaine abuse. Some people say it is genetic, others

say one’s family or the stress of our society is the cause, others say it

is like a disease, while still others say it is a learned habit that can be

unlearned with practice. It actually doesn’t matter how the problem

Provide Overview

and Rationale
38

got started. Once it exists, we must look at what needs to be done in

the here and now to solve the problem. Whatever the causes, it doesn’t

help to blame anything or anyone. We have to focus all our attention

and energy on the lifestyle changes that need to happen for you to

stop using cocaine.”

“We will help you to the very best of our ability. It will be hard for all

of us and I expect some tough times. We will be there for you during

the good and bad times; we will help you understand your cocaine

abuse and help you develop alternative activities. However, nobody

can change your life for you. We can and will try to assist you in

every way we can, but you will have to do the work of changing your

life.”

After describing the treatment program, the therapist should answer any questions the patients may have and then introduce them to the notion of therapeutic contracts via an abstinence contract. This involves a written contract

in which patients explicitly agree to abstain from cocaine use and to conform

to a regular schedule of urinalysis testing. The rationale for this contract is

based on the primary treatment goal of eliminating cocaine use. Exhibit 9 is

an example of a contract adapted from one reported by Crowley (1984).

Urinalysis monitoring is used as an objective marker of progress in achieving the goal of abstinence from cocaine. It is imperative that patients clearly

understand the rationale for this procedure, and it is the responsibility of

clinic staff to ensure that they understand. Below is a list of reasons for using

a urinalysis monitoring contract. These are shared with patients.

 • Urinalysis monitoring contracts have been used successfully to help

decrease many forms of drug use, including cocaine, opioid, and ben

zodiazepine use.

 • Urinalysis monitoring will help us stay focused on the primary prob

lem that brought you into treatment. We are not trying to catch you

being bad, but rather to catch you being good (i.e., not using co

caine). In this way, we as well as others in your life can reinforce this

desired behavior. We can provide incentives, praise, and other forms

of positive support when you don’t use drugs. In addition, urinalysis

monitoring will assist us in helping you learn more about the rela

tionship between cocaine and other drug abuse and certain conse

quences.

 • If you use cocaine during treatment, the urinalysis test will provide

us with that information and an opportunity to work on ways to help

you get back on track and prevent further use from occurring. Many

times, patients do not want to share the fact that they used cocaine

because of embarrassment, pride, or some other reason;

Introduce the Voucher Program

Describe

Abstinence

Contract

Explain

Urinalysis

Monitoring
39

however, such information is important for helping you learn more

about how to meet your goal of stopping cocaine use.

 • Many times, drug abusers have lost credibility with friends, rela

tives, and other persons in their lives by the time they arrive in treat

ment. Urinalysis monitoring can provide a way to prove that you are

doing well. This may be important, because once you start doing

well, any bad days or irritability may be perceived by others as an

indication of relapse. Urinalysis monitoring can provide reassurance

to those around you that you are continuing to do well. Thus, moni

toring can assist you in regaining credibility with family and friends.

It is imperative that the therapist take adequate time to discuss the rationale

and procedures related to the voucher system in the introductory session.

The following issues should be covered.

 • Purpose.

“The purpose of this incentive system is to give you a positive re

ward for staying in treatment and achieving your goal of not using

cocaine. It is also a way to increase your motivation to work hard on

this goal and to support you as you work toward making some of the

lifestyle changes important for increasing your life satisfaction and

maintaining cocaine abstinence.”

 • Examples of how to use earnings.

“The points you earn can be used to pay for things like taking a

person who does not use drugs to the movies or dinner but not to a

bar or party. The points can be used to take classes or get training in

some area that you would like to pursue as a career or hobby. The

points can be used to pay to develop regular hobbies or activities

like joining a gym, the YMCA, or dues for a photography or hiking

club. They can also be used for family activities like taking a child

for swimming lessons, to a State park, or to an amusement park.

With the approval of your therapist, any activities that promote healthy

behavior rather than drug use can be considered.”

 • How the points accumulate.

“The point system is designed to help you maintain periods of con

tinuous cocaine abstinence. The points increase each time you pro

vide a cocaine-free urine specimen. For example, the first clean urine

specimen you provide is worth $2.50 in points, the second $3.75,

and for each week with three consecutive cocaine-free samples, you

will receive bonus points worth $10.00. Thus, if you were clean for 6

consecutive weeks, one clean sample provided during Week 7 would

be worth $25.00. All in all, if you stay clean every week for your first

12 weeks in treatment and provide all urine specimens as scheduled,

you will have $997.50 worth of points that can be spent.

Explain

Voucher

Program
40

This is an agreement between ___________________(the patient) and

_______________(the therapist) to help the patient maintain abstinence from cocaine. By this

agreement, I direct my counselor to establish a schedule for collecting urine specimens from me

for 24 weeks. I will provide urine samples three times each week on a Monday, Wednesday, and

Friday during the first 12 weeks of treatment. During the second 12 weeks of treatment (weeks 13-

24), urine samples will be collected two times each week on a Monday and Thursday schedule. A

clinical staff member of my same gender will observe the urination. Half of each urine sample will

be submitted for immediate analysis and half will be saved at the treatment agency. Samples will

be assayed for a variety of drugs of abuse, including cocaine, amphetamine, opioid drugs, marijuana, and sedatives.

Each specimen collection requires 3.0 ounces of urine. If the quantity is insufficient for analysis,

that will be considered a failure to provide a scheduled sample.

If I travel out of town because of an emergency, I will inform my counselor in advance of leaving.

My counselor is authorized to verify such absences with ______________________. I If I require

hospitalization, my counselor will arrange to collect urine in the hospital. If I am sick and do not

require hospitalization, I will still arrange to produce scheduled urine specimens. If I have difficulty with transportation, or inclement weather makes it difficult to travel, I will work out (with the

assistance of the clinical staff) a way to get to the treatment agency. On certain major holidays, the

agency will be closed. My counselor and I will mutually agree to altered urine schedules on those

occasions.

If, for appropriate medical reasons, a prescription is written for a medication that is sometimes

abused, I will supply my counselor with copies of that prescription. The appearance of that drug in

the urine will not be counted as a relapse to drug use. I hereby direct my counselor to communicate

by mail or telephone with the prescribing physician or dentist when my counselor deems that

action to be appropriate.

Cocaine-Free Urines: For each cocaine-negative urine sample collected during weeks 1-12 of

treatment, points will be earned. Points are worth the monetary equivalent of $0.25, although they

are not exchanged directly for cash. A voucher stating the earned point value will be presented to

me following the collection of a cocaine-negative sample. This voucher will specify the number of

points I earned for that day, as well as the cumulative points earned to date and their monetary

equivalent.

During the first 12 weeks of treatment, the first cocaine-free urine sample will earn 10 points. Each

consecutive cocaine-free sample collected thereafter will earn another 5 points above the amount

earned before. For example, if 10 points are received on Wednesday for a cocaine-free urine sample,

Friday’s cocaine-free sample will earn 15 points, Monday’s will earn 20, and so on. As an added

incentive to remain abstinent from cocaine, a $10 bonus will be earned for each week of three

consecutive cocaine-negative urine samples collected at the agency. Assuming there are no cocaine-positive urine samples collected, the monetary equivalent of $ 997.50 can be earned during

the first 12 weeks of treatment. (continued)

EXHIBIT 9.- Sample Abstinence Contract
41

Since a major emphasis in the program is on lifestyle changes, primarily increasing activities that

effectively compete with drug use, the money earned on this incentive system must be used toward

social or recreational goods and activities agreed upon by myself and my counselor. A list of

acceptable uses of vouchers has been developed for this purpose and will be given to me. During

the second 12 weeks of treatment, the incentive program will be changed. Rather than earning

vouchers for cocaine-negative samples, I will be earning lottery tickets for clean samples.

For the entire 24 weeks of treatment, immediately after the urinalysis test results indicate that the

urine sample is cocaine-negative, the vouchers (weeks 1-12) or lottery tickets (weeks 13-24) will

be delivered. Following the presentation of each voucher, I will be asked if I would like to purchase any goods or services. Vouchers may be used at any time during the program. Earned vouchers cannot be taken away from me under any circumstance.

Cocaine-Positive Urines: All urine samples will be screened for drug use. A record will be kept of

all drugs screened positive, although this contract will be in effect for cocaine only. For each

cocaine-positive urine sample collected, I will not receive a voucher. In addition, the voucher

earned for the next cocaine-free urine sample will be reset to 10. To reset the voucher value to

where it was prior to the cocaine use, I must provide five cocaine-free samples in a row. The fifth

clean sample will then earn me the same monetary equivalent as that earned for the sample preceding the cocaine-positive one, and the system outlined above will continue to be in effect (i.e., each

clean sample will earn 5 points more than the previous one).

Failure to Provide a Urine Sample: Failure to provide a urine sample on the designated date

(without prior approval of my counselor) will be treated as a cocaine-positive sample, and the

procedures noted above will be in effect. Although the clinic may attempt to obtain the sample by

coming to my home (with my permission), cocaine-negative urine samples collected in this manner will not earn voucher points, nor will they reset my voucher value to 10. In effect, cocainenegative samples collected outside the treatment program (except in the case of hospitalization)

are neutral. If a sample is obtained from me outside of the program, and the sample is cocainepositive, it will be treated in the manner outlined above for cocaine-positive urine samples.

My signature below acknowledges that I agree to the urinalysis monitoring system outlined above.

This system has been carefully explained to me, and I understand the outcome of providing both

cocaine-negative and cocaine-positive urine samples while I am a patient at the clinic.

Patient: ________________________

Therapist: ______________________
42

“In this system, however, one cocaine use during the middle of treat

ment can cost you quite a few points/dollars. For example, if you are

clean for 8 weeks and then, during Week 9, you use cocaine, instead

of getting $32.50 for the next clean urine sample, you get only $2.50.

And instead of the next clean urine sample being worth $33.75, it is

only worth $3.75. You can see the system is designed to help you stay

clean for long continuous periods. However, because we recognize

that cocaine use during treatment may occur, there is also a proce

dure to encourage you to stop using if you do slip. If, following a

slip, you provide five clean samples in a row, the value of your vouche

rs returns to the level of points you would have achieved before the

slip.”

After answering any questions about urinalysis and vouchers, therapists can

hand patients an abstinence contract and ask them to follow along as they

read it aloud. Questions should be elicited from the patients, and therapists

should provide as much explanation as necessary. It is essential that patients

completely understand this contract, including the urine sample collection

schedule, reinforcement schedule, and process of voucher spending.

After reviewing the abstinence contract, all patients are provided with two

movie tickets or passes to some community recreational facility such as the

YMCA or YWCA. These incentives serve as a start toward having the patient engage in lifestyle changes deemed important for treatment success.

These passes are not contingent on a cocaine-negative urine specimen.

This procedure is called priming. It should be explained as an example of

what can be done with the vouchers earned for cocaine abstinence. Therapists should also use this as an opportunity to have patients begin the process

of planning and scheduling cocaine-free activities by discussing when and

with whom they plan to use the passes.

Therapists should make sure patients receive the passes before leaving the

clinic.

Next, therapists can switch the topic to the development of a treatment plan.

The problem list (exhibit 10 and exhibit 11) can help organize the areas that

will be worked on during treatment. Therapists should explain that the list

focuses on seven areas of life functioning:

 • Drug and alcohol use

 • Employment and support status

 • Family relationships

 • Social and recreational functioning

Review

Abstinence

Contract

Priming

Problem List
43

Date: _____________ Patient:__________________________________

Problem 1: Drugs/Alcohol

Problem 2: Employment/Support

Problem 3: Family

Problem 4: Recreation/Social

Problem 5: Psychological

Problem 6: Legal

Problem 7: Medical

Exhibit 10: Problem List Form
44

Date: _____________ Patient:__________________________________

Problem 1: Drugs/Alcohol

Problem 2: Employment/Support

Problem 3: Family

Problem 4: Recreation/Social

Problem 5: Psychological

Problem 6: Legal

Problem 7: Medical

Exhibit 11: Sample Problem List

Cocaine Use. Intravenous. 3x per week. Spends $250/week on cocaine

Drinks 6 beers about 4-5x a week. Drinks more when doing cocaine. DWI

2 months ago

Marijuana use daily. 1-2x per day, usually in the evening after work

Works construction job - irregular full time, work declines in winter and

sometimes other times.

Pay is fair - not enought to support family well.

Most guys on the job use alcohol and drugs.

Wife always angry at him for spending money and coming home high.

Doesn’t spend much time with his children.

Loses his temper frequently and yells at wife and children.

No regular prosocial activities. Most friends are drug users.

Likes to work out frequently.

Depressed mood.

Irritable most of the time.

DWI - on probation.

Assault charge - on probation.

Positive for hepatitis B and C.

3/8/98 Jim
45

 • Psychological status

 • Legal status

 • Medical status

Data from the intake assessment can be used as a guide during this discussion. (If the ASI is used, it assesses each of these areas.) Therapists can elicit

from patients the problems that they are experiencing in each area. After this

discussion, most of the important problems should be identified. This information can then be used in developing the patients’ treatment plans.

Therapists should also review the information on the patients’ Practical Needs

Assessment forms, which focus on such areas as housing, childcare services,

and transportation needs. Reviewing these areas with patients will follow

naturally from the data on the problem list. Any significant problems that

might impede treatment compliance or success should be targeted for intervention as soon as possible. For example, helping homeless patients find at

least temporary shelter would be an immediate priority. If they do not have

transportation or a ride to the treatment facility, transportation issues should

be discussed.

Hopefully, therapists can initiate some problemsolving and action as soon as

these types of issues are identified.

“You say you live about 5 miles from the clinic and don’t have a

driver’s license. Is there a bus route that goes near your home? . . .

No . . . Can your wife drive you here regularly? . . . She doesn’t have

a license either. . . . Do you have friends or relatives who drive who

are not active drug users? . . . Your sister? Can she give you a ride?

Why don’t we call her up and check it out? . . . It’s possible that if she

can drive 2 days a week, maybe we can help you with a ride on the

other day. What do you need to do to get back your driver’s license?

Have you filled out the reinstatement application? . . . Why don’t we

call the DMV now and have them send us an application? If we can

figure out how to come up with $50.00, we could get you back your

license as soon as next week.”

Assisting patients very early with problems like these can help tremendously

with treatment compliance in general. This type of aid also gives therapists

credibility as people who understand patients’ basic needs and can help make

things happen to change their lives.

Patients should be given a pocket-sized daily appointment book, and the

importance of scheduling activities and appointments should be discussed.

The rationale provided to the patient is that the goal of the program is to

develop new habits that include regularly scheduled

Practical Needs

Assessment

Appointment Book
46

 activities that are not related to drugs. Planning and scheduling those

activities is the best way to develop new habits.

Therapists should also stress the importance of bringing the appointment

book to the clinic for each therapy session. It can be a valuable tool in

helping patients stay focused on the behavior changes that are the core of

CRA + Vouchers. Therapists should continually emphasize this point and

prompt patients to bring it to all sessions.

If patients are involved in a relationship with a partner, discuss the possibility of relationship counseling and its potential benefits. A brief description of the content and structure of the counseling should be provided. If

patients agree, schedule an appointment for the first relationship counseling session. If partners have come to the clinic for this initial session,

therapists should discuss with them their potential role in treatment and the

benefits of participation.

Those patients who show evidence of alcohol abuse or dependence, or

who report that alcohol use interferes with cocaine abstinence, should be

offered disulfiram therapy. For example:

“You have indicated a few times today that your drinking causes

you problems and that you always use cocaine when you drink.

This is a fairly common experience among our patients. Because of

this relationship between cocaine and alcohol, we feel that it is

very useful and sometimes necessary for people with cocaine

problems to stop drinking. Staying free from alcohol allows you to

have a clear head, which you will need to resolve the difficult

problems of stopping cocaine use. Many times, if someone doesn’t

stop drinking, they find that even though they have good intentions

of staying clean from cocaine, they fail. Once they have a few

drinks, their plans go right out the window and they use cocaine.”

“We have found that an effective way to help people stop drinking

is by using a medication called disulfiram. Have you heard of it? . .

. We find that those patients who take disulfiram are much more

likely to achieve their goal of cocaine abstinence.”

Try to get patients who need this medication started on disulfiram in a

timely manner.

 The therapist should make sure that a urine sample has been collected

before the patient leaves the clinic.

Before the patient leaves the clinic, the therapist should schedule the next

session. Every effort should be made to hold the meeting as soon as possible. The next day is preferable.

Significant Others

Disulfiram Procedures

(if applicable)

Collect Urine

Schedule the

Next Session
47

Sessions One and Two should take place as soon after the intake meeting as

possible. It is essential to complete the assessment/orientation and start treatment while patients are motivated. Therapists should be flexible and willing

to schedule these early sessions at any time that is compatible with the patient’s

schedule. Prior to these two sessions, as with all sessions, therapists should

prepare by completing a therapy session checklist.

Prior to Session One, therapists should begin to develop a tentative treatment plan (exhibit 12) using the information collected during intake. The

final working version of this plan, however, should represent active collaboration between the therapist and patient. It is important that patients be involved in this process and that they agree to the goals and methods.

Achieving cocaine abstinence is always the primary focus of the treatment

plan. Thus, the plan should target areas for change that are directly related to

cocaine use, are likely to decrease cocaine use, or will reduce the probability

of relapse. Areas for change typically fall into the following categories: other

drug use, vocation, family relations, social relations, and recreational activities. Psychiatric, legal, medical, financial, or housing problems deemed likely

to interfere with achieving or maintaining cocaine abstinence should also be

considered.

The following steps are useful in this task.

 • Develop a list of lifestyle changes that are reasonable targets for the

patient.

 • List reasons for those changes that can be readily discussed with the

patient.

 • Prioritize targets for lifestyle change based on what is most urgent

for achieving initial cocaine abstinence. It is important to decide on

the order in which such changes should be attempted.

Early Counseling Sessions

Outline a Treatment Plan
48
49

 • Determine methods for achieving change in each of the targeted ar

eas. For example, if the goal is to find satisfying employment, the

method might be employment counseling, resume building, and so

cial skills training. If the goal is to enhance patients’ relationship

satisfaction, the method would be relationship counseling and com

munications training. If the goal is to increase prosocial recreational

activities with nondrug-using peers, the method might be social/recr

eational counseling, and social skills, relaxation, and time-manage

ment training.

Our research and that of others indicate that alcohol use and abuse are often

major obstacles to achieving cocaine abstinence. Hence, we routinely recommend a period of disulfiram therapy for all patients who meet diagnostic

criteria for alcohol abuse or dependence or who report that drinking is related to their cocaine use.

Therapists have a great many tasks to accomplish in Session One as well as

getting to know the patient better and developing rapport. It is unlikely that

all of these tasks can be completed in one session. Those that are not should

be carried over into Session Two.

 • Review the patient’s urinalysis results since the last meeting.

 • Complete anything not accomplished in the intake assessment ses

sion and review the rationale for behavioral treatment.

 • Introduce the concept of functional analysis of cocaine use and stimu

lus control procedures to help with initial abstinence.

 • Assist the patient with practical needs.

 • Use the patient’s appointment book to organize, plan, and schedule

activities.

 • Initiate or continue with disulfiram or relationship counseling proce

dures.

 • Begin to develop the treatment plan.

Therapists should review the urinalysis results with the patient and provide

appropriate feedback. (The voucher should have been supplied by the staff

person who reports the results to the patient.) Any problems in the area of

drug abstinence should be discussed.

Patients should complete any unfinished assessment instruments or interviews. If this is all the patients have time for, they should still meet with their

therapist. If time is limited, therapists should answer any new

Sessions One and Two

Urinalysis Results

Complete Intake

and Treatment

Orientation
50

questions that the patients have and offer some optimistic remarks about

treatment outcome.

In the early stage of treatment, it is important to teach patients to identify the

antecedents of their cocaine use so that they can actively prepare to deal with

situations that place them at high risk for drug use. We refer to this as functional analysis.

The therapist should provide an overview of functional analysis and stimulus control procedures to help the patient understand how these can be used

to avoid or actively cope with risky environments. In this context, the notion

of craving should be addressed. The following points should be made.

 • Having the urge or craving to use cocaine is normal for persons in

treatment for cocaine dependence.

 • These urges can be triggered by external environmental events or

internal states. Examples of external events are seeing a friend you

have previously used with, passing a certain bar, watching a TV show

about cocaine, or attending a party. Examples of internal states may

be memories of past use episodes, feelings of depression, nervous

ness or tension, or remembering the good effects of past uses.

 • Urges to use are time limited; they only last a few minutes or at most

a few hours. They usually become less frequent and less intense as

you learn how to cope with them.

 • Functional analysis is the procedure by which you learn to identify

triggers for craving and cocaine use so you can develop strategies to

avoid or prevent them from occurring and cope with urges if they

occur.

Therapists will probably not have time in Session One to fully introduce and

explain functional analysis. Before this session ends, however, therapists

should discuss potential triggers (e.g., high-risk situations) that may occur

before the next session and help patients develop strategies for dealing with

those situations. Concrete plans should be made to deal with these high-risk

situations before patients leave the clinic.

If practical needs such as housing or transportation are issues for treatment

attendance, these needs should be a primary focus of the first session. Therapists should do everything possible to assist patients in finding solutions to

these problems.

Introduce Functional

Analysis and Stimulus

Control

Assist With

Practical Needs
51

Have patients use the appointment book provided by your agency to schedule alternative activities or strategies for coping with high-risk periods or

situations. The next session should also be scheduled, and patients should

record the day and time in the book.

It is unlikely that a comprehensive treatment plan with specific goals and

methods can be completed in Session One. Nonetheless, the topic should be

introduced at the first opportunity. The therapist might say something like

the following.

“A treatment plan will allow us to write down the things you and I

think are important to accomplish and how we plan to go about try

ing to accomplish them. We will use the plan to keep us focused on

the task at hand, that is, making lifestyle changes that will help you

stop using cocaine and other drugs and also increase your satisfac

tion with other important areas of your life. The treatment plan will

be developed through a cooperative effort between you and me. It is

important that you think the goals we set are important and will help

you achieve what you want in life. My job in this process is to assist

you in coming up with meaningful, effective goals and to offer advice

based on my knowledge and experience with treating persons with

cocaine and other drug problems.”

Therapists should then present their ideas about which areas of the patients’

lives need changes. For each suggested change, it is important that the therapist provide a rationale that draws from the information collected from the

patient as well as from research findings and clinical experience. An open

discussion and exchange of ideas should then follow.

If patients are reluctant to participate, the therapist should prompt them for

their thoughts on each issue. To facilitate patient input, the therapist should

use phrases such as: What do you think? Do you have any thoughts on this?

Does this make sense to you? Do you think this is important? Is this type of

change possible?

It is important for therapists and patients to agree on which areas of life

present problems and should be changed. If patients disagree with the

therapist’s opinion, those areas should be dropped for now and discussed

later in treatment if they continue to pose problems.

Use the

Start To Develop the

Treatment Plan

Discuss Areas

for Change

Appointment Book
52

Next, therapists and patients together decide the order in which these problem areas should be addressed, always remembering that increasing cocaine

abstinence is the primary goal. Mutual agreement is important, and the therapist may need to compromise to achieve such agreement.

Specific goals should then be set for each problem area. It is important that

therapists provide the rationale for setting specific goals.

“Setting specific goals is important. They will help us stay focused

on the primary changes which we agreed are important for stopping

drug use and achieving a more satisfying life without drugs. Specific

goals also provide a way to measure progress. This can be very im

portant, because many times progress can be slow. You may feel you

are getting nowhere. In reality, you may be progressing and making

changes, but you don’t feel much different. Information about spe

cific goals will help us both see more clearly whether we are heading

in the right direction, even if the progress is slow.”

“This information could also show when you are not progressing as

we planned. This information could lead us to either reconsider the

goal or find other ways to meet the goal. Keeping track of progress

on spe cific goals also provides us with a reminder to reward or praise

you for the hard work you are doing. Lifestyle changes are often dif

ficult to make. We would like you to learn to pat yourself on the back

and take credit if you are doing well.”

These goals should be quantifiable so progress can be graphed. Targets for

change should be set in the priority areas listed in the treatment plan and

categorized as primary or secondary behavior change goals.

The primary behavior goal in most cases will be one that emphasizes change

in the highest priority area. Examples of typical goals might be -

 • Five job contacts per week or making an appointment with voca

tional rehabilitation if the patient is unemployed.

 • Engaging in three recreational activities each week during high-risk

times.

 • Spending 4 hours each week engaging in fun activities with a family

member or close friend.

 • Attending class one night each week.

 • Doing 2 hours of homework toward obtaining a GED.

 • Planning and following through with activities with a nondrug user

on nights cocaine is typically used.

Secondary behavior goals might include similar behavioral changes, but they

would not have the highest priority for achieving and

Prioritize

Problems

Set Specific

Target Goals
53

maintaining abstinence for that particular patient. A maximum of three secondary behavior changes should be targeted.

Therapists and patients should mutually decide on these goals. Basic principles of effective goal-setting should be followed.

 • Set goals relatively low at first so the patient can experience success

early in treatment.

 • Thoroughly analyze all possible barriers to achieving selected goals

so that unrealistic goals are not chosen.

 • Make sure the patient understands how a goal relates to the overall

treatment plan.

It is essential to maximize the probability that patients will carry through

and achieve the desired behavior change. The therapists’ responsibility is to

use the appropriate counseling style and behavioral procedures to increase

the probability of compliance with a targeted behavior. The graphs of patient behavior are especially useful because they visually demonstrate

progress or lack of progress.

The tentative treatment plan should be reviewed in the next clinical supervision meeting to obtain input from staff and supervisors. Suggested changes

to the plan may occur at that point, and therapists can discuss these new

ideas with patients during their next session.

Therapists should also prepare a therapy session checklist to help focus subsequent sessions. This should be updated regularly, because treatment planning is a process of constant reevaluation, assessment, and change, based on

objective indices of progress. Patients and therapists together should review,

discuss, and assess the treatment plan frequently as goals are achieved or

interventions fail, or as new information becomes available. These changes

should also be reviewed at the regular staff supervision meetings.

Follow Through
54

Blank Page
55

In order to stop abusing cocaine, patients need to learn which people, places,

and things stimulate the desire for cocaine and how to either avoid or cope

with them. CRA + Vouchers teaches patients three interrelated ways to accomplish this:

 • Functional analysis

 • Self-management planning

 • Drug refusal skills

All patients are trained in functional analysis in the early stages of treatment.

Its purpose is to help them understand their drug use so they can effectively

problemsolve for ways to reduce the probability of cocaine use. The approach described here is based on the work of Miller and Munoz (1982) and

McCrady (1985). Functional analysis is used throughout treatment as needed.

For example, if cocaine use occurs, therapists should encourage patients to

analyze these events to determine how to avoid using in similar situations in

the future.

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

“We are going to focus on what is called a functional analysis of

your cocaine habit. It is the first step in developing control over outof-control behavior. Your cocaine use is triggered by certain events,

situations, and feelings, and maintained by short- and long-term con

sequences. Therefore, it is important that you begin by analyzing

your pattern of cocaine use. Once you have learned to analyze your

use, you will know how to rearrange your environment - the triggers

and consequences - and how to engage in positive alternatives to

cocaine or other drug use so that you can achieve total abstinence

from cocaine. When you have completed this process, you will have

taken a large step toward beating your cocaine problem.”

“There are four important points to keep in mind as you learn how to

do a functional analysis of your cocaine use.”

Drug Avoidance Skills

Functional Analysis
56

 • Other people with drug problems like yours have been able to learn

ways to stop using cocaine.

 • It is important to begin thinking of your cocaine use as something

that you have learned to do. Understanding exactly how your co

caine problem got started is not always necessary for learning how to

stop using. Blaming other persons or events for the problem also

does not help. What is important is that you begin to view your co

caine abuse as a problem that you can do something about. In other

words, you are responsible for your own behavior.

 • The goal of this treatment program is to help you learn how to stop

using cocaine and how to live a drug-free lifestyle. You will get the

most benefit from our program if we can help you stop your cocaine

use early so we can focus on helping you make other lifestyle changes

that will promote long-term abstinence from cocaine.

 • However, if you use cocaine during treatment, it is important that

you do not view it as a failure. It is common for persons trying to

stop their cocaine use to have slips. We will use these instances to

help you understand more about your cocaine use so you can more

effectively learn to stop using completely. In other words, you want

to figure out what happened in that situation and how you can pre

vent it from happening again in similar situations.

 • It will be important for you to work on these new skills between

sessions. Learning and practicing new skills and behaviors is neces

sary; talking about making changes is not enough to deal effectively

with such a difficult problem as cocaine dependence.”

After briefly describing and providing a rationale for using functional analysis, therapists should begin to teach patients about the specific components

of functional analysis. Such discussions can proceed as follows.

“A functional analysis allows you to identify the immediate causes

of your cocaine use. You have probably noticed that in certain situa

tions you use cocaine, while in other situations you do not. The situ

ation around us can powerfully control cocaine use, particularly if

we are unaware of its influence. Some of the situations that can influ

ence cocaine use are -

 • The people you are with.

 • The place you happen to be.

 • The hour or the day.

 • How much money you have.

 • How much alcohol you have consumed.

Components of

Functional Analysis
57

 • What you are doing besides using cocaine.

 • How you are feeling.

“The first step in understanding your cocaine use is to identify the

types of situations in which you are likely to use cocaine. Your first

assignment will help you identify these risky situations and what about

them makes you want to use cocaine. These are called triggers.

“You will also need to identify the consequences of your use. There

are two kinds of consequences: the immediate and often positive con

sequences, such as getting high or having fun; and the delayed, often

negative consequences, such as blowing all your money and being

unable to pay a bill or having an unwanted sexual encounter.

“As you identify triggers and consequences, you will discover that

there are certain patterns to your use. These patterns will become

important targets for intervention.”

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

A trigger is an event that occurs before a person uses cocaine and increases

the likelihood of using. Triggers can be -

 • Particular individuals.

 • Environmental settings.

 • A certain feeling.

 • A combination of these.

“Triggers can be quite obvious or they can be difficult to identify.

They should not be thought of as things that make you use cocaine,

but as things that increase the chance that you will use. Many times,

a trigger will lead to other responses, like thoughts about using and

the potential consequences of using, such as ‘cocaine will make me

feel better’ or ‘doing some cocaine will be lots of fun’ or ‘cocaine

will help me forget that.’”

Almost anything can be a trigger.

 • Being out at bars

 • Your job

 • An argument with a friend or family member

 • Withdrawal symptoms

 • Being at a certain friend’s house

 • Peer pressure to use

 • Being home alone

Triggers
58

 • Parties

 • Saturday night

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

use.

Thoughts

 • I can’t deal with this.

 • I need to get away.

 • I need to forget.

 • Using would be a blast.

Feelings

 • Anxiety

 • Depression

 • Anger

 • Frustration

 • Happiness

 • Loneliness

 • Elation

Cocaine use is one of several behaviors that could occur after a trigger. The

patients’ job is to learn new behaviors so they can either avoid the trigger or

refuse to turn to drugs.

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

 • Forgetting bad negative events or feelings.

 • Becoming more energetic.

 • Getting rid of depressed feelings.

 • Feeling less pain.

 • Feeling good.

 • An enhanced sexual experience.

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

Behavior

Positive

Consequences
59

The negative consequences of cocaine use are usually experienced some

time after using. These are the effects that interfere with life goals and are

usually detrimental to relationships, work, finances, health, mood, and selfesteem. They are probably part of the problem that brought the patient into

treatment. However, these delayed, negative consequences often occur so

much later that they have little influence on future cocaine use.

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

“The first step in doing a functional analysis of your cocaine use is

to identify situations that function as triggers. We have created a

form to help you get started.”

Give the patient the Discovering Triggers form (exhibit 13). Therapists should

work with patients to complete this form.

Next, give the patients a Functional Analysis form (exhibit 14) and go over

each component of the diagram. The following steps can be used to guide

this training.

“An easy way to identify and see your cocaine-use pattern is to use

these Functional Analysis diagrams. Think of the last time you used

cocaine. Write down your cocaine use in the box marked Behavior

on your Functional Analysis form.”

“Next, try to remember what you were doing just before you started

using cocaine. Can you remember who you were with, where you

were, what you were doing, or what time of day it was? Write these in

the Trigger box on your chart.”

“Before using cocaine the last time, what were you thinking and feel

ing? Were you saying anything to yourself? Write whatever thoughts

and feelings you remember in the box called Thoughts and Feel

ings.”

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

 • What happened after you used?

 • What were the effects of using cocaine?

 • Did your mood change?

 • Did you feel high?

 • Did you act differently?

 • What were your thoughts and feelings?

Negative

Consequences

Conduct a

Functional Analysis
60

Patient:___________________________________Date: ________________________________

1.List the places where you are most likely to use cocaine:

2.List the people with whom you are most likely to use cocaine:

3.List and times or days when you are more likely to use cocaine:

4.List any activities that make it more likely that you will use cocaine:

5.Do you think that you use cocaine when you are feeling certain ways? Read through the following

 list and mark the ones that are relevant to you. For those you have marked, list specific examples

 from your own experience.

6.List the places where you are unlikely to use cocaine:

7.List the people with whom you are unlikely to use cocaine:

8.List the times or days when you are unlikely to use cocaine:

9.List the activities you engage in when you are unlikely to use cocaine:

a.at the end of (or during) a tense day h.

b.when faced with something you fear or are

 anxious about

c.when you’ve failed to accomplish something

 you’d planned

d.when you feel you have been taken advan

 tage of

e.when you are bored

f.when you are in a social situation

g.when you feel bad about yourself

h.when you are depressed

i.when you want to feel energized or high

j.when you are faced with a tough problem

k.when you want to be friendly

l.when you wish your personality was different

m.others not listed here

Exhibit 13: Discovering Triggers of Your Cocaine Use

 Source: Adapted from Miller and Munoz 1982.
61

 Triger Thoughts and Fellings Behavior Positive Negative

Consequences

EXHIBIT 14.- Functional Analysis - Cocaine Behavior Form
62

Blew $50.Late to work next day.Wife won’t talk to me.

 Triger Thoughts and Fellings Behavior Positive Negative

Consequences

EXHIBIT 14.- Functional Analysis - Cocaine Behavior Form ( example)

Bob comes over toapartment

Looks like good stuff.Could really get high.I deserve a break

Do 1/2 gram, thenanother gram.

Got really high. Bob and Ihad a blast. Didn’t have todeal with wife.

After work, guys say,“Let’s go to the bar.”

I know I should gohome. I’m tiredand know that I’lldo some coke andthat will help.

Go to bar.Drink a few beers.Shoot 1/2 gram.

Had a blast.ReenergizedGood high.

Wife was mad.Blew $30.Arm is sore.

Saturday night.

Time to party.Feel like getting reallyhigh.Staying home will beboring.

Go over to Tom’sapartment.Get a few 6-packs.Buy an eight-ball.High till 3 a.m.

Good coke, but reallyhigh.Laughed a lot.

Blew $120.Arm sore.Missed kid’s game inthe a.m.Wife mad.
63

“Now make a list of the effects of your cocaine use over time since

you began using cocaine. How has it affected your relationships,

friendships, work/school, health, self-esteem, and so forth?”

“You will find that the lists you just made include some things that

make you feel good and some that make you feel bad. Write down the

good things in the Positive Consequences box and the bad things in

the Negative Consequences box.”

“You will probably notice that most of the positive consequences are

events or feelings that occur with cocaine use or soon after, while the

negative consequences occur some time after cocaine use, probably

a long time after. This is why cocaine use becomes such a powerful

habit that it is difficult to break.”

“Congratulations, you have just functionally analyzed your cocaine

use in that situation.”

Therapists should now help patients complete one or two more functional

analyses during the session. Patients should also be encouraged to complete

additional analyses for the next session, using the Triggers form to identify

other cocaine-use situations. Both the Triggers and Functional Analysis forms

can be completed as homework if the session time expires. However, if the

forms are not completed for the next session, be sure they are completed

during that session.

Therapists and patients next turn to developing self-management plans for

the various triggers identified in the functional analysis. Such plans will be

developed throughout treatment whenever initial plans fail or new triggers

are found. Therapists start by praising the patients for doing a thorough job

on the functional analysis task and then introduce the next step: learning

specific ways to deal with cocaine craving.

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

“Now that you have identified the triggers and consequences related

to your cocaine use, we are going to work on developing strategies

for dealing with the triggers. To do so, I will teach you a strategy

called self-management planning. This training involves learning how

to avoid the triggers or to replace them with other things that are less

risky. In addition, you will learn how to rearrange your environment

to reduce the likelihood of using cocaine.”

Self-Management Planning

Rationale
64

Before initiating self-management training, therapists should review with

patients their functional analysis forms. This review should include the following.

 • An explanation that external environmental events can often set off

drug use.

 • Categorization of triggers into places, people, time of day, activities,

feeling, and so forth. Give examples and relate them back to the func

tional analysis (after work, weekends, watching television, others

using, anticipation of sexual experience).

Therapists should then explain that there are three basic ways of handling

these triggers to reduce the risk of cocaine use.

“One way is to avoid the trigger; for example, take a route home that

is different from where you obtained cocaine in the past; avoid going

by your dealer’s house; don’t go into bars; and avoid certain people.

To do this successfully, you will have to engage in new or different

activities.”

“The second way to deal with triggers is to rearrange your environ

ment. For example, don’t keep cocaine or paraphernalia in the house,

and don’t carry money with you if you know you will be walking or

driving past places where you might be tempted to buy cocaine.”

“The third way of dealing with triggers is to develop some new cop

ing method or plan that will help you not use when you are in a

particular situation. For example, you experience a trigger such as

extra cash in your pocket. Instead of using the money for drugs, en

gage in some incompatible behavior. For example, you might call

your spouse or do some activity that you enjoy, like working out at a

gym or shopping for something special for you or your family.”

Using the patients’ Functional Analysis forms, therapists can ask them to

pick out a few triggers and then discuss how they might handle those triggers to reduce the chances of using cocaine.

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

 • Choose a trigger. Start with one that often leads to cocaine use. If

possible, choose a trigger that is likely to come up in the near future,

before the next session, so the patient will be prepared to deal with it.

 • Brainstorm and write down a list of potential strategies for either

avoiding the trigger, rearranging the environment so the trigger does

not occur, or identifying a new coping method for dealing with the

trigger when it does occur. Any and all possibilities should be writ

ten down. Therapists should encourage patients

Initiate Training

Make the Plan
65

Trigger Plans +/- Consequences Difficulty

1. a.

b.

c.

d.

e.

Exhibit 15: Functional Analysis - Cocaine Behavior Form

 (1-10)
66

to be open to any ideas no matter how difficult, easy, simple, complex,

or crazy they sound. If needed, therapists should model brainstorming

by suggesting many possibilities, some outrageous, some impossible to

do, and some simple.

 • Together, therapists and patients should consider the overall effects or

consequences of each proposed strategy for dealing with the trigger and

write these down.

 • Therapists should then ask patients how hard they think it will be to

carry out each strategy using a scale of 1 (not very difficult) to 10 (ex

tremely difficult).

 • After considering all the potential strategies, their consequences, and

their perceived difficulties, one strategy should be selected.

 • Therapists then ask patients to rehearse the chosen strategy. For example,

if the plan is to avoid passing by an old friend’s home, have the patient

plot a different way home. If the goal is to arrange to be at a safe person’s

house during a high-risk time, have the patient role-play calling this per

son to arrange to be there. Better yet, have the patient actually call that

person during the session to arrange this get-together.

 • Plans for handling two or three triggers should be completed in the ses

sion until therapists feel that the patients understand how to do self-man

agement planning.

 • Set a goal for patients to complete additional Self-Management Plan

ning Sheets during the week. If they are not completed by the next

session,they should be completed during the session.

 • Set a goal for patients to carry out at least one of the plans before the next

session. Discuss what situations might be coming up this week and re

view the plan again before patients leave the session.

Drug refusal training is included in most patients’ treatment plans. As many as

one-third of substance abusers relapse as a direct result of social pressure from

friends to use. Most cocaine abusers who are trying to quit continue to have

some contact, either planned or inadvertent, with friends or acquaintances who

are still using. Turning down cocaine or opportunities to go places where cocaine is available will be much more difficult than most patients anticipate. The

ability to refuse cocaine or other drugs when offered is a special case of

assertiveness.(The structure of this training is adapted from McCrady 1986 and

Sisson and Azrin 1989.)

Drug Refusal Training
67

When initiating drug-refusal training, therapists begin by explaining why

this will be important to the patients.

“Drug refusal training can be very important in helping you achieve

a substantial period of abstinence and for maintaining that absti

nence. We are going to practice ways to refuse cocaine or to refuse to

go to places where cocaine is available. The ability to effectively say

no in these situations will help you feel in control when faced with

situations that are tempting and to which you may previously have

said yes automatically.”

“Our experience is that patients usually underestimate the difficul

ties encountered when trying to refuse or avoid cocaine. You may

feel that you will have no problem saying no, or that no one will ask

you if they know you are trying to quit. However, previous patients

have found that, if they do not prepare themselves to deal with these

situations, good intentions do not always lead to effective refusal.

What we and our patients have found to be helpful is to plan and

repeatedly practice using specific refusal skills for handling highrisk situations that may arise.”

“We have developed a training protocol that is designed to teach or

remind you of some effective ways to say no when opportunities arise.

An important component of this training is for you to be creative in

anticipating many of the situations that may come up in the followi

ng months. We have developed some examples that we feel are typi

cal of what many cocaine abusers face, but each person has a unique

set of circumstances. This training will benefit you most if you in

clude situations relevant to your life so that we can rehearse how to

handle them.”

Therapists then initiate a discussion and provide information concerning how

patients can learn to effectively refuse cocaine. Some important concepts

and instructions are presented as follows.

“Remember that those persons who offer you cocaine or alcohol are

not thinking of your best interests. They may be your friends, but

once you have decided to quit, it is important for you to consider

anyone who asks you to use cocaine or go party as a pusher. They

must be discouraged - politely, if possible, but firmly.”

“Saying no is the first and most important part of your refusal re

sponse. There are different ways of saying no that are appropriate in

different situations. Different people say no in different ways. It is

important to feel comfortable, which means that you have to develop

your own style. When working to develop your style, it is important

to keep a few goals in mind.

 • Your primary goal is to refuse or turn down cocaine.

Rationale

Refusing Cocaine

and Other Drugs
68

 • Your secondary goals might be to -

 • Reinforce your commitment to not use.

 • Feel good about yourself for doing it.”

“When creating your own refusal style, a few basic components of

your refusal responses will increase the likelihood that they will be

effective.

 • No should be the first thing you say.

 • Tell the person offering you drugs or asking you to go out not to ask

you now or in the future if you want to do cocaine. Saying things like

‘maybe later,’ ‘I have to get home,’ or ‘I’m on medication’ just make it

likely that they will ask again.

-Body language is important.

-Making good eye contact is important; look directly at the person

 when you answer.

 • Your expression and tone should clearly indicate that you are seri

ous.

 • Offer an alternative if you want to do something else with that per

son. Make sure that it is incompatible with cocaine use (taking your

children for a walk or to the park, going to work out).

 • Change the subject to a new topic of conversation.

Next, therapists help patients begin to develop personal refusal styles. Basic

examples of saying no are provided.

 • No, thank you.

 • No, thank you, but I’ll have some coffee or something to eat.

 • No, I’m not using anymore; it is causing me too many problems.

 • No, I’ve got a cocaine problem, so I’m not using anymore.

Therapists then help patients construct at least three typical scenes in which

patients have had or may have difficulty refusing cocaine. Examples of such

situations are friends stopping by with cocaine, friends calling on the telephone, running into friends while shopping, special occasions, parties, or

leaving work. The situations that they choose should be very specific. That

is, they should include specific people, specific times of day, and so forth.

Components of

Effective Refusal

Practice Refusal Skills
69

Therapists and patients then role-play two or three of these situations. Before starting, therapists remind patients of the components of effective refusal and the goals for the situation. A list of these components is provided

for the patient to refer to before and during refusal practice attempts (exhibit

16).

For each situation, therapists first have the patients function as themselves,

with the therapist acting as the person offering cocaine. After each trial, constructive feedback is given. Therapists continuously refer to the components

and goals of effective refusal when giving feedback. Examples or alternatives are given as needed. Problems with some of the patients’ tactics are

pointed out if they seem ineffective. Following the feedback, the role-play is

repeated. When patients experience a lot of trouble, therapists reverse roles

with them and model an effective response.

Second, therapists have patients act as the person offering drugs, and the

therapists act as the patient. The same procedures are followed. Therapists

initiate a discussion of how it feels to be in the different roles: What is hard?

What is easy? What feels comfortable? What does not?

Patients may have difficulty with some components. Teaching the components one or two at a time may be a useful method for helping them develop

effective refusal skills. Therapists should model the components that they

have difficulty with by using role reversal.

 • No should be the first thing you say.

 • Tell the person not to ask you now or in the future if you want to

do cocaine.

 • Use appropriate body language:

 • Make good eye contact; look directly at the person when you

answer.

 • Your expression and tone should clearly indicate that you are

serious

 • Offer an alternative (if you want to do something else with that

person) that is incompatible with cocaine use.

 • Change the subject.

Exhibit 16: Components of Effective Refusal
70

Therapists should remind patients that the most important thing in developing effective refusal skills is practice. Weekly practice goals are set. For

example, two high-risk situations can be identified, and patients can practice

these scenes each day between sessions. If the patients have partners to practice with, this can be scheduled either during or outside of the session. If

patients do not have anyone to practice with, they can either practice aloud

in front of a mirror or write down a refusal scenario with responses and

bring it to the next session for practice.

In addition, therapists should ask patients to identify situations during the

next week in which they may be confronted by a pusher. These situations

should be rehearsed in session, and therapists should contract with patients

to practice this refusal scene daily and to refuse in that real-life situation.

Homework
71

An essential part of the treatment for cocaine abuse involves helping patients change their lifestyles. To accomplish this, they may need new skills,

new information, or steady prodding. The therapists’ task is to identify, with

patients and based on the initial assessments, the types and areas of assistance required. Then patients acquire the skills needed to mold themselves

into the kinds of people they want to become. This chapter outlines a number of skills-training components in the areas most commonly addressed by

cocaine abusers in treatment:

 • Time management

 • Social and recreational activities

 • Problemsolving

 • Vocational satisfaction

 • Social skills

 • HIV infection prevention

These components are provided as needed. Other types of skills training

(e.g., anger management) should also be available.

The substantial lifestyle changes needed to achieve and maintain abstinence

from cocaine require that patients make productive use of their time. They

must learn to plan and schedule events and activities so they have little idle,

high-risk time available. Many patients do not keep regular schedules, and

some express resentment at the suggestion that this might be helpful. However, planning and scheduling activities increase the likelihood that patients

will follow through with treatment goals and activities. Thus, time-management training is provided to most patients.

Therapists can introduce the idea of time management in the following manner.

Lifestyle Change Components

Time Management
72

“This part of your treatment involves learning to plan, schedule, and

prioritize the events and activities in your life. Solving your cocaine

problem requires making many substantial changes; it is important

to develop efficient ways to do this. Some patients say they don’t like

to plan or they like to be spontaneous, but if they don’t find a way to

schedule and organize their lives, they eventually become over

whelmed and don’t achieve their goals. It is important to spend time

on this issue in treatment.”

The importance of writing down and scheduling appointments and activities

should be reviewed at each session. Therapists should inform patients that

this practice can increase followthrough with plans and goals, reduce stress,

help avoid missed appointments, increase awareness of accomplishments,

and help organize and prioritize plans.

The first step is to make sure that patients have the appointment books provided during the first session. Since patients often lose these books, an effective alternative is to give them photocopies on a week-by-week basis. The

next step is to show patients how to effectively use the appointment book.

Therapists should stress the importance of establishing a regular pattern of

using the book. Suggest that patients get their books out each morning at a

regular time.

“Planning is usually done best first thing in the morning or at the

end of the day. There are many advantages to planning in the morni

ng when you are fresh. Having just thought about what you have to

do, you can move easily to getting it done. With the day’s priorities

clearly in mind, you will be less likely to be sidetracked as you go

along. Also, you can review any scheduled activities for the day.”

Patients should make a list of what they would like to accomplish that day or

before the next therapy session. Therapists should then point out how all the

items on a list are not of equal importance and introduce the ABC system of

prioritizing (Lakein 1973). In this system, therapists ask patients to write a

capital “A” beside those items on the list that have a high value, a “B” for

those with medium value, and a “C” for those with low value. Items marked

A should be those that yield the most value.

“You will get the most out of your time by doing the A’s first and

saving the B’s and C’s for later. By taking account of the time of day

and the urgency of the items, you can even break them down further

so that A items become A-1, A-2, A-3, and so on. How detailed you

get depends on you and the number of activities on your list.”

After the prioritizing is complete, therapists should help patients make realistic plans and schedules and enter them in the appointment book.

Develop TimeManagement Skills
73

The priority given to each item guides where and when it is written. At first,

patients may try to place more into their schedules than they can possibly

accomplish. Also, some make poor choices about which activities to schedule when. Here, therapists need to guide and teach patients about efficient,

realistic time-management planning.

Patients should be encouraged to make a separate “To Do” list each day. As

they complete each activity, they should cross it off the list. Then, at the end

of the day, they will be able to check on how many items have been completed. It is important that this list be on a single piece of paper rather than

jotting down items on miscellaneous scraps of paper. Patients should be encouraged to keep the list in their appointment books so it is accessible and

useful.

Therapists should ask patients to practice these time-management procedures (i.e., daily scheduling and keeping daily lists) during the coming week.

Have them choose a specific time of day to do this. Patients should also be

instructed to bring their appointment books and daily lists to each session.

Therapists should encourage daily and continuous use of these procedures

throughout treatment and help problemsolve any difficulties that patients

may have in completing the exercises. Emphasis is placed on making this a

daily routine for the next few months and perhaps for many years to come.

If patients do not comply with these exercises between sessions, therapists

should always try to have them use the appointment book and make daily

lists while in session. This repeated in-session exercise may help reinforce

between-session compliance.

This component of CRA + Vouchers focuses on developing interest and participation in recreational and social activities that are pleasurable for the

patient and do not involve cocaine or other drug use. The goal is to increase

participation in social activities that may serve as alternatives to cocaine

use.

Therapists should provide a rationale for working on lifestyle changes in

social and recreational areas.

“Many times, when cocaine or other drugs become a regular part of

someone’s life, they either stop doing many of the nondrug activities

they used to enjoy, or they never start or develop any regular recre

ational activities. For example, many drug abusers, like anyone else,

used to play sports, work out or exercise, go on hikes, go out to the

Apply Time

Management

Social/Recreational Counseling

Rationale
74

movies, visit relatives, and so forth. But as drug use increases, it

gradually replaces these other activities.”

“Social and recreational activities are important in most people’s

lives. They provide -

 • A source of enjoyment that can be looked forward to after a stressful

day at work or taking care of the kids.

 • A way to decrease boredom when you have free time.

 • A way to feel physically healthy.

 • An outlet for developing a skill that makes you feel good about your

self.

 • A chance to be with people you like to develop friendships.”

“These activities can play a very important part in becoming and

staying drug free. When you give up using drugs, you have to do

something else during the times you were using. If the things you do

are not satisfying or enjoyable, or you don’t do anything but sit around

and feel lonely or bored, you are more likely to use drugs.”

“Developing satisfying, regular social and recreational activities is

difficult for many people who are trying to quit cocaine. Sometimes it

is hard to -

 • Find anyone to do things with who is not a drug user.

 • Think of things you would like to do that are affordable.

 • Fit activities into your schedule because of work or family responsi

bilities.

 • Become motivated to start something new.”

“This is why we have a specific treatment component to assist pa

tients in developing a regular schedule of social and recreational

activities.”

The first step in social/recreational counseling is to develop a list of potentially reinforcing activities that patients are interested in pursuing. Therapists should gather possibilities from patients by asking about -

 • Current activities.

 • Activities enjoyed in the past.

 • Things patients have always wanted to do, but have never done.

Therapists could also use the Leisure Interests Checklist (Rosenthal and

Rosenthal 1985) to assess the patients’ interest in various activities. This

checklist can be administered either in-session or as an assignment between

sessions. As with any assignment, if the checklist is not

List Activities

and People
75

completed as scheduled, it should be completed during the next session.

Once possible activities are identified, therapists and patients should attempt

to categorize activities by amount of interest, cost, others’ involvement, time

commitment, likelihood of engaging in the activity, and whether it is physical or sedentary.

An important goal for most patients is to increase time spent with nondrugusing persons and discontinue interaction with drug abusers. Thus, the next

step is to create a list of persons who might participate in activities with the

patient. This can be very difficult, because patients will often report that

they don’t know anyone who is not a drug user or alcoholic; this is rarely

true. With gentle prompting by therapists about extended family and old

acquaintances, patients can usually name at least one safe person to target as

a contact.

If patients are unable to identify anyone, therapists should move on and come

back to this issue later. Finding safe people has high priority, since establishing a social network of nonusing friends or family members can play a substantial role in the achievement and maintenance of cocaine abstinence. As a

last resort, clinic staff may accompany patients who are trying out a new

activity as a way to establish interest and increase the probability that they

will ask a nondrug-using friend to participate in the future.

Therapists and patients should agree upon goals for directly participating in

a particular activity, taking the necessary steps toward participation, or increasing the time spent with nondrug-using persons. Behavioral techniques

for effectively setting goals and shaping behavior can be applied here. These

goals should then be incorporated into the treatment plan and systematically

worked on throughout the course of treatment. Progress should be assessed

in each session and any problems or changes in goals dealt with at that time.

If patients express fears about doing certain activities or meeting people,

therapists should assess the extent of the problem and offer to help with

problemsolving, social skills training, behavioral rehearsal, or another appropriate procedure. If applicable, therapists should encourage the use of

vouchers from the incentive program to pay for these activities. Also, if significant others are participating in treatment, they can help involve the patients in new activities.

Therapists can also help in this area by providing patients with listings of

local activities, recreational facilities, continuing education classes, and other

community resources and activities. In essence, the therapist

Set Goals and

Assess Progress

Facilitate Change
76

or another staff member can function as a source of information about available social/recreational opportunities in the community. This means therapists will need to review local newspapers, bulletin boards, and radio advertisements and make contact with community agencies prior to sessions.

For patients who seem unable to sample social activities, therapists might

use scheduled sessions to initiate such behavior. For example, therapists could

take patients bowling, shopping for crafts, to the YMCA, to play tennis or

basketball, or to a museum.

Achieving cocaine abstinence and making substantial lifestyle changes involve finding solutions for many problems. Some patients may have so many

problems that even minor problems seem overwhelming. For example, a

straightforward goal like going to a job service center to meet a therapist and

signing up for assistance may require solving a number of problems. The

patient may not have readily available transportation, childcare may be

needed, or the only available appointments may conflict with other important activities.

For many patients, their cocaine abuse has resulted in either avoidance of

such problems or making impulsive decisions that are not in their best interest. Such poor problemsolving behavior usually results in negative consequences that increase the severity of existing problems or create additional

problems. Thus, an important component of CRA + Vouchers is skills training in effective problemsolving. The method is similar to that used by Monti

et al. (1989) in the treatment of alcohol dependence. The goal of this training

is to teach patients to identify, analyze, and find solutions for the many problems they will face in their efforts to stop cocaine use and make lifestyle

changes.

Therapists should provide a rationale for this component.

“Persons trying to recover from cocaine problems often find them

selves confronted by difficult situations. These situations become prob

lematic if you do not have an effective response for them. Cocaine

abusers are likely to encounter several types of problems.

 • Finding themselves in situations where they have used cocaine and

other drugs in the past

 • Having to deal with social pressures

 • Craving drugs or relapsing

Problemsolving

Rationale
77

”Some common problems are encountered in making positive lifestyle

changes.

 • Having difficulty finding the time to participate in social activities or

hobbies

 • Lack of transportation

 • Problems with childcare

 • Job-related issues

 • Family pressures

 • Legal problems

“Effective problemsolving requires that you recognize the fact that

you face a problem situation and resist the temptation either to re

spond to your first impulse or to do nothing. If you don’t find good s

olutions, your problems can build up over time, and the pressure

may eventually get to you and trigger cocaine use. We have a pro

gram for helping you become a better problem solver. To become

good at this skill usually takes some time and a lot of practice.”

At this point, therapists should introduce the basic steps for prob-lemsolving.

 • Recognize the problem

 • Identify the problem

 • Brainstorm

 • Select the approach

 • Evaluate its effectiveness

Therapists should review several questions that patients can ask themselves

to become more aware of problem situations. The following are some sources

of clues that a problem exists.

 • Your body (e.g., tension, craving)

 • Your thoughts and feelings (e.g., worry, depression, loneliness,

 • irritability)

 • Your behavior (poor work performance, not meeting responsibilities

in your family, with friends)

 • Your reactions to other people (e.g., irritable, lack of interest, isola

tion)

 • Others’ reactions to you (e.g., avoidance, complaining)

Steps for

Problemsolving

Recognize the

Problem
78

Patients need to learn to clearly label or identify a problem once they realize

that something is wrong. They should collect as much information and as

many facts as possible to help clarify the problem. For example, if patients

are upset about their current job and are considering quitting, the therapist

could work with them to clearly identify what is problematic about the job.

Questions such as the following could be asked.

“Do you get along with your coworkers?”

“How is your relationship with your supervisor?”

“Have you received any negative feedback or evaluations?”

“Is the pay high enough? Have you asked for a raise?”

More and more detailed questions should be posed as therapists focus on the

problem.

It is important to develop a number of solutions to a given problem, because

the first one that comes to mind may not be the best. When brainstorming,

list all possible solutions but do not evaluate them yet. Patients should be

encouraged to list ridiculous as well as serious solutions, the most difficult

as well as the easiest solutions, and the “worst” solutions as well as the

“best” solutions.

The next step is to select the most promising approach. Therapists should

help patients evaluate each potential solution and identify the most probable

outcomes for each possible solution. Be sure to consider both positive and

negative outcomes and both long- and short-term consequences. Also evaluate the difficulty of implementing each solution. The decision on which solution to try first is made after considering both the ease of implementing the

solution and the potential for a positive outcome.

Once a solution is chosen, therapists should discuss the next step, evaluating

its effectiveness. Here, emphasis is placed on the need to evaluate and try

again if the solution is not effective. Also, it is important that therapists help

patients determine how they will know if it is effective. Determining this

ahead of time helps patients be more realistic and perhaps optimistic about

finding effective solutions to problems.

Therapists next provide several problemsolving

Identify the

Problem

Brainstorm

Select

Approach

Evaluate

Effectiveness

Practice
79

Procedure

Gather information: Recognize that a problem exists. Is there a problem? You get clues from your body, thoughts, feelings, behavior, reactions to other people, and the ways that other people react to you. Think

about the problem situation. Who is involved? When does it happen?

Exactly what takes place? What effect does this have on you?

Define the problem: Describe the problem as accurately as you can.

What goal would you like to achieve? Be as specific as possible. Break

it down into manageable parts.

Brainstorm for alternatives: List all the things that a person in your

situation could possibly do. Consider various approaches to solving the

problem. Even list alternatives that seem impractical. Try taking a different point of view, try to think of solutions that worked before, and

ask other people what worked for them in similar situations.

Consider the consequences: Look at each of your alternatives in turn.

What things could you reasonably expect to result from taking each

action? What positive consequences? What negative consequences are

long-term? Which are short-term? Which do you think you could actually do?

Make a decision: Which alternative is the most likely to achieve your

goal? Select the one likely to solve the problem with the least hassle.

Do it! The best plan in the world is useless if it isn’t put into action. Try

it out.

Evaluate its effectiveness: Which parts worked best? Reward yourself

for them. Would you do anything differently next time? After you have

given the approach a fair trial, does it seem to be working out? If not,

considerwhat you can do to beef up the plan or give it up and try one of

the other possible approaches. Remember that when you’ve done your

best, you have done all you can do.

continued

Exhibit 17: Problemsolving Worksheet
80

Practice Exercise

Choose a problem that may arise in the near future. Describe it as accurately as you can. Brainstorm possible solutions. Evaluate the potential outcomes. Prioritize solutions.

Identify the problem situation:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Brainstorm a list of possible solutions: Pros: Cons:

_________________________________ ___________________ ___________________

 ___________________ ___________________

 ___________________ ___________________

_________________________________ ___________________ ___________________

 ___________________ ___________________

 ___________________ ___________________

_________________________________ ___________________ ___________________

 ___________________ ___________________

 ___________________ ___________________

_________________________________ ___________________ ___________________

 ___________________ ___________________

 ___________________ ___________________

Exhibit 17: Problemsolving Worksheet
81

Satisfying, gainful employment or career activities can play an important

role in achieving and maintaining abstinence from cocaine and other drugs

of abuse. Therefore, vocational counseling is an important component of

CRA + Vouchers. The procedures are based on those outlined in Azrin and

Besalel’s “Job Club Counselor’s Manual” (1980). We have adapted it for

use in individual rather than group settings. Counselors providing this vocational component will benefit from familiarizing themselves with the Job

Club manual.

A job counselor is available to work with patients throughout the week, and

therapists use Job Club procedures in individual counseling sessions when

appropriate. This counseling focuses on helping unemployed patients locate

work and on improving the employment situation of patients who consider

their jobs unsatisfactory or have jobs that place them at high risk for continued drug use.

The rationale for making positive changes in this area is straightforward.

Therapists initiate a discussion about the role of a satisfying vocation in the

short- and long-term maintenance of drug abstinence.

“In drug abuse treatment, one of the predictors of long-term success

is stable, satisfying employment. This relationship between abstinence

and employment satisfaction exists because -

 • When you work at a job you like, you are unlikely to use cocaine

while working.

 • You are less likely to jeopardize that job by coming in late or missing

work because of late-night partying.

 • The job makes you take pride in and feel good about yourself.

 • The job provides you with the financial means to access other

 • positive things, such as social and recreational activities, and desir

able housing and transportation.

 • Sometimes the job also provides a source of social support, friend

ship, and social activities that are unrelated to drug use.”

The primary goal of vocational counseling is to assist patients in finding

satisfying employment or in taking steps toward the development of a meaningful career. Similar to other components of CRA + Vouchers, therapists

first conduct a thorough assessment and then collaborate with patients to set

behavior-change goals. For example, many patients have difficulty initiating job-seeking behavior. Thus, in the spirit of the Community Reinforcement Approach, therapists can take patients to fill out applications or provide job leads for those patients who do not take the initiative. The goals of

vocational counseling vary depending

Vocational Counseling

Rationale

Set Goals
82

on the individual patient’s situation. Below are examples of goals that are

typically set in the vocational counseling component.

For the unemployed patient:

 • Make eight job contacts per week.

 • Develop a resume

 • Send out two resumes with a cover letter each day.

 • Go to the job service twice a week.

 • Enroll in a job training program.

 • Enroll in a vocational exploration program.

 • Take a job-skills-related class.

 • Collect and consider information on educational possibilities.

For the patient who works “too many” hours or has an irregular schedule:

 • Keep work to 35 - 50 hours each week.

 • Establish a more regular schedule.

 • Explore alternative work schedules.

For the patient working in a “high risk for drug use” environment or the

dissatisfied employee:

 • Consider a job change.

 • Submit applications for alternative employment while continuing to

work.

 • Modify the work environment to reduce risk of drug use or improve

working conditions.

 • Enroll in a career exploration class.

 • Enroll in job-skill or alternative career-related educational classes.

By the end of the first session of vocational counseling, therapists and patients should have set a long-term goal (e.g., full-time employment as a secretary) and specific, short-term attainable goals (e.g., five job contacts per

week, employment with a temporary agency, enrollment in a computer skills

class). These goals should be monitored and changed, as needed, until patients achieve their long-term goal. In this respect, vocational counseling is

typically an ongoing component throughout treatment.
83

 The following vocational counseling services are provided to patients by

either the Job Club counselor or the therapist.

 1. The therapist encourages patients to treat the job search as a fulltime job. The suggested timeframe for this is to spend half of each

workday looking for job leads and setting up interviews and the other

half going to interviews. Patients are to continue with this schedule

each day until they find a job.

 2. The therapist advises patients to systematically contact friends, rela

tives, and acquaintances for job leads.

 3. The therapist provides standard scripts and forms to follow when

making contacts with potential employers, for writing letters, for

making telephone calls, and for keeping records.

 4. The therapist provides the supplies and services necessary for a job

search. Patients should have access to a work area, telephone, com

puter, photocopier, postage, and newspapers.

 5. The therapist encourages patients to seek job interviews and applic

ations for jobs that are not advertised. For example, the patient could

call all the manufacturing plants, all the car dealerships, or all the

haircutting establishments in the yellow pages.

 6. Patients are encouraged and taught to use the telephone as the pri

mary means for obtaining job leads. This is a more efficient method

than letters or visits.

 7. The yellow pages section of the telephone book is used to make lists

of potential employers.

 8. The therapist helps patients learn how to promote strengths other

than work skills (i.e., social and personal skills). These skills can be

highlighted in a resume when making job contacts as well as during

interviews. In addition, the therapist helps patients identify and list

marketable work-related skills that were not necessarily acquired

during previous employment.

 9. The therapist helps patients learn how to make the most of unsuc

cessful job contacts, that is, learn how to ask that source for other job

leads.

 10. Patients learn to recontact a potential job source following an inter

view. This can help demonstrate their interest and enthusiasm for the

job to the employer. Also, after an unsuccessful contact with a very

desirable job source, patients learn to call that

Treatment

Components
84

employer back after a period of time in search of future opportunities.

 11. The therapist helps patients learn how to arrange transportation to

job sites that are difficult to get to for whatever reason.

 12. Patients are encouraged to contact previous employers for jobs or

job leads.

 13. Patients are encouraged to get open letters of recommendation from

multiple sources. These can be used when submitting applications or

when interviewing to expedite the employer’s decision.

 14. The therapist helps patients build an effective resume.

 15. The therapist provides advice and instruction on how to effectively

fill out an application (e.g., emphasize personal skills).

 16. The therapist provides training on how to effectively present yourself

at interviews.

 17. The therapist provides a list of effective behaviors that should occur

during an interview. After each interview, the list is reviewed and

feedback provided.

 18. Patients who cannot find a job in a reasonable amount of time should

be encouraged to place a job-wanted ad in the newspaper. This ad

emphasizes personal skills and the type of work the patient is seek

ing.

 19. The therapist encourages patients to create a structured job-seeking

schedule. A datebook or form is used to schedule each day’s activi

ties.

 20. Patients engage in recordkeeping using such things as job lead lists,

call-backs, and progress notes.

 21. The therapist encourages patients to contact job supervisors rather

than personnel staff. Sometimes the supervisor has an important role

in making hiring decisions.

 22. The therapist instructs patients in how to discuss handicaps (e.g.,

physical limitation, prison record) with a potential employer and how

to turn them into strengths.

 23. The therapist encourages patients to consider a variety of jobs so

they do not restrict themselves to the extent that they do not find

employment.
85

 24. The therapist provides continued assistance until a job is obtained.

Social-skills training is provided to patients who report or demonstrate difficulties in -

 • Meeting nondrug-using peers.

 • Interacting with coworkers or roommates.

 • Attending social activities because they feel uncomfortable in social

settings.

 • Expressing their feelings or asserting themselves in an appropriate

way.

The goal is to help patients learn how to better handle interpersonal situations so they can experience more positive reinforcement and fewer negative, aversive effects from social interactions. The particular skill area to be

addressed depends on the patient’s needs (e.g., anger management, anxiety

in social situations, initiating pleasant conversation). Effective procedures

for social-skills training with alcoholics and drug abusers have been outlined by Chaney (1989) and Monti and colleagues (1989).

This chapter provides a detailed protocol for assertiveness training to illustrate the structure of a skills-training protocol. Most patients will benefit

from help in this area, since studies have shown a relationship between lack

of assertiveness and drug use.

Assertiveness training is appropriate for patients who tend to be either too

passive or too aggressive in social situations. Because of these tendencies,

these patients are unable to effectively obtain what they want in certain situations. As cocaine abusers try to make positive lifestyle changes, their ability to effectively communicate their needs becomes important in developing

alternative, nondrug reinforcements. Assertiveness training is one method

for increasing positive experiences and decreasing negative experiences in

social settings. Our procedures for implementing assertiveness training are

based on those outlined by Alberti and Emmons (1982) and McCrady (1986).

 Therapists should tailor the rationale for assertiveness training to the needs

of the patient.

“Your functional analysis showed that at least one of your triggers is

your inability to handle certain situations. Your positive consequences

from cocaine use included feeling free to express yourself, more

Social-Skills Training

Assertiveness Training

Rationale
86

relaxed, less depressed, and more powerful. If you can learn to deal

with these unpleasant situations and to create these positive feelings

without cocaine, you will have a much better chance of remaining

drug free.”

“Learning how to be assertive will enable you to act in your own

best interest, to stand up for yourself without experiencing excessive

anxiety, to express your feelings honestly and comfortably, and to

exercise your personal rights without denying the rights of others.”

Learning and practicing assertiveness skills typically take two to four sessions. Therapists should begin by defining assertiveness for the patient: what

it is, what it is not, and the results of assertiveness and its alternatives. Descriptions and consequences of passive, aggressive, and assertive behaviors

should be discussed with patients. Help patients recognize which styles they

tend to use, when they use them, how they affect them, and how they can act

assertively in more of these situations. Point out that assertive people can

also choose to be passive or aggressive if the situation requires it.

The following points about each interpersonal style should be integrated

into the discussion.

 • Passive behavior causes you to -

 • Deny yourself or your rights.

 • Avoid expressing feelings.

 • Feel hurt and anxious.

 • Allow others to choose for you.

 • Fail to achieve your desired goals.

 • Aggressive behavior causes you to -

 • Accomplish goals at the expense of generating hatred and resent

ment in others.

 • Express feelings and promote self-enhancement, but usually hurt

others in the process.

 • Minimize others’ worth and put them down.

 • Make choices for others, and deny them their rights.

 • Assertive behavior enables you to -

 • Express your feelings honestly.

 • Achieve your personal goals.

 • Respect the feelings of others.

Define

Interpersonal

Style
87

• Clearly express your needs (what you want).

• Tell the other person why you want it.

• Balance the negative with the positive. That is, if you have to be

critical or say something that implies blame, express something

positive first. For example, “I know you have really tried to be supportive and understanding of my problem in the past, but lately I feet

like you have been on my case constantly.”

• When expressing your feelings or needs, try to use “I” statements.

For example, you could say “I am angry because I feel like nobody

cares about my feelings,” instead of “You make me feel awful.”

• Try not to express feelings or need with “you” statements. They

usually cause the other person to act defensively and strike back.

• Acknowledge the other person’s rights and feelings in the matter.

For example, “I know it is hard for you to always check in with me

first, but that would make me feel much better, less anxious, and more

valued.”

• Try to be as specific as possible when describing your needs and

any changes that you request. For example, “I would feel much better

if you would not say ‘I told you so’ when I make a mistake at work. If

you could just tell me I made a mistake, I would be happy to fix it.”

• When responding to a request, try to sound strong and definite. For

example, you might say “No I do not want to do that, I have important

plans that I need to attend to,” rather than “I don’t think so, I don’t

really feel much like it today.”

• Speak loudly and firmly. Your message should be said with authority but not hostility. You want to convey that you mean business.

• Respond promptly. This lets the other person know that you have

thought about this and are sure of yourself.

• Make good eye contact. Look at the other person when you speak

and when you listen. Again, this promotes the impression that you are

serious about your message.

• Your body gestures and facial expressions should be consistent

with your message. For example, don’t smile if you are angry.

Exhibit 18: Being Assertive
88

 • Improve how you feel about yourself.

In summary:

 • Passive: You are hurt by not getting what you want.

 • Aggressive: The other person is hurt and may seek revenge.

 • Assertive: Neither person is hurt, and both get what they want.

Therapists should give patients the Being Assertive handout (exhibit 18) and

encourage a discussion of each point.

Therapists and patients now choose two situations from the patients’ Functional Analysis in which patients would benefit from being assertive. Behavior rehearsal and role-play are used to practice assertive responses in the

two situations. Therapists should give feedback after each attempt and have

the patients practice two or three times.

After patients have made significant progress during rehearsal, therapists

and patients collaborate in setting a between-session goal for either rehearsing assertive responses or actually attempting assertiveness in a specific situation.

At the next session, progress is reviewed. Problems are discussed, and feedback and social reinforcement are given by the therapist. Additional roleplaying and rehearsal of either the same targeted situation or a new situation

occur in this session. Again, appropriate between-session goals are set for

practicing assertive behavior. This process of goal-setting, evaluation, and

practice continues until the patients meet their goals.

At least one or two sessions during the early stages of treatment should be

devoted to HIV/AIDS education and, if warranted, counseling on the needs

and risk behavior of the patients.

The following tasks should be accomplished in this component.

 • Patients complete an AIDS knowledge test (pretest).

 • Patients watch and then discuss a video on HIV and AIDS.

 • Patients are given copies of HIV/AIDS pamphlets and condoms (if

desired).

 • Patients complete an AIDS knowledge test (posttest).

 • Patients are given information about being tested for HIV antibod

ies and hepatitis B and C.

Assertiveness

Skills

Practice

Set Goals and

Assess Progress

HIV/AIDS Prevention
89

The rationale for HIV infection counseling can be provided to patients by

the therapist as follows.

“We will take time during your treatment to provide education on

HIV, the AIDS virus, and other diseases commonly associated with

drug abuse, like hepatitis B and C. The most common way these dis

eases are spread among drug users is needle sharing. Injection drug

users are more likely to contract HIV or hepatitis B or C than are

intranasal users or smokers of cocaine. However, even users who do

not inject are at increased risk because these diseases are also spread

by sexual activity. If you associate with other drug users and have

intimate contact with one who injects or has had sexual contact with

an injection user, you are placing yourself at risk for getting these

diseases. It is important for you to have the knowledge you need so

you can protect your health as well as the health of other people you

love or associate with.”

Next, patients are given an AIDS knowledge test to complete in session. A

sample test is shown in exhibit 19. The purpose of assessing knowledge of

HIV transmission is to assure that there is no confusion about how one can

contract the virus and, more importantly, to ensure that patients recognize

the behaviors that place them at risk for transmitting or becoming infected

with the virus.

When patients have finished the questionnaire, therapists should review each

item and answer any questions the patients may raise. Therapists should

ensure that ample time is given to the discussion of incorrect answers and

that any misconceptions the patients have are clarified. Supervisors should

ensure that therapists themselves have the correct information.

After the pretest, patients should be shown an AIDS education video. In the

discussion after the video presentation, therapists should add or emphasize

the following information.

 • Explain that HIV infection is now growing fastest among injection

drug users and their sexual partners. Although gay men were the first

to become infected in this country, the virus has now spread to the

entire community. Almost 25 percent of AIDS cases have involved

injection drug users, their sexual partners, or babies born to these

individuals. Moreover, more than half the women with AIDS in the

United States are injection drug users or sexual partners of such us

ers.

 • Make certain patients understand that HIV infection leads to AIDS,

and that AIDS is a fatal disease in which the body can no longer fight

off infections and malignancies (hence the name, acquired immuno

deficiency syndrome).

Rationale

AIDS Knowledge

Pretest

Video and Discussion
90
91

 • Review the three ways that HIV can be transmitted: (1) through sexual

contact with an infected person, (2) through blood (as in needle shar

ing), and (3) from infected mothers to their babies. Explain that HIV

is transmitted most efficiently through blood, and that sharing needles

and other drug paraphernalia that might be bloody is an easy way for

the virus to get from one person’s system into another’s.

 • Emphasize that people who are HIV infected do not necessarily look

sick and may not know they are infected. You cannot tell by looking

at people whether they have the virus. People can carry the virus and

not get sick for several years, but they can still infect others.

 • If patients are currently injection drug users, point out that the only

totally safe thing to do is to stop injecting drugs. If they continue to

inject drugs, they should use new needles or clean them after each

use. Explain the steps for appropriate syringe cleaning and provide

them with a handout reviewing prevention tactics (exhibit 20).

 • Unprotected sexual intercourse with the exchange of body fluids

(blood, vaginal fluids, semen, pre-ejaculatory fluid) is also an effi

cient means of giving or receiving the virus. Sex can be made safer

(if the partner’s HIV status is unknown) by using latex condoms and

a spermicide that contains the ingredient nonoxynol-9 with every

sexual encounter, whether it is oral, vaginal, or anal.

 • Point out that alcohol and other drug use contribute to risk because

they can suppress the immune system, and they impair judgment in

ways that can lead to increased risk taking, such as injection drug use

and unsafe sex.

After viewing the video and discussing HIV infection, therapists should give

patients currently available pamphlets on HIV/AIDS.

Therapists should then tell patients that condoms are given away free by the

clinic and where to find them (some agencies leave them in the restrooms).

If patients are hesitant about asking their partners to use them, this will need

to be worked out in session. Role-playing these uncomfortable situations

will be especially useful.

At the beginning of the session following the AIDS video and discussion,

patients should retake an AIDS knowledge test in session to ensure that they

fully understand and remember what they were taught. Again, the completed

test should be reviewed and discussed.

Pamphlets and

Condoms

AIDS Knowledge

Posttest
92

All drug abusers should be aware of the potential for acquiring HIV infection and AIDS from sequentially using (sharing) injection equipment and paraphernalia and through sexual activity.

 • Persons with a negative HTV antibody test should be counseled to reduce their risk of acquiring HIV

 infection through sharing injection equipment by the following means:

 • Abstain from any further use of drugs by injection. This eliminates any new risk of bloodborne

infections. Drug abuse treatment should be sought to aid in stopping drug use.

 • Do not share injection equipment with anyone. This further protects the drug user from con

tracting HIV infection. Care should be taken not only with needles and syringes but also with

cotton balls, cookers, wash bottles, or any other materials possibly containing blood.

 • If you continue to share injection equipment, disinfect between uses. While it is not foolproof,

boiling needles and syringes for 15 minutes is one way to sterilize equipment between uses;

however, boiling plastic equipment may alter the shape and utility of the syringes. Cleaning i

njection equipment with disinfectants, such as bleach, does not guarantee that HIV is inacti

vated. DISINFECTANTS DO NOT STERILIZE EQUIPMENT. However, consistent and thor

ough cleaning of injection equipment with disinfectants such as bleach should REDUCE trans

mission of HIV if equipment is reused or shared.

 • To maximize the effectiveness of cleaning, needles and syringes should be flushed with water,

preferably soon after use, before blood has time to clot in the needle and syringe. Continue f

lushing until the equipment is at least visibly clear of blood and debris. The use of soapy water

and agitating (tapping, shaking, or “plucking”) the equipment while cleaning may be helpful in

removing blood and debris. The equipment should then be FILLED with fuil-strength house

hold bleach for at least 30 seconds of contact before again rinsing with water. Even apparently

clean equipment should be bleached before use unless it is known to be sterile. Bleach, which is

highly corrosive, may alter the usefulness of the equipment.

 • Infected persons should be counseled to prevent further transmission of HIV by the following

 means:

 • Inform prospective drug-using partners and sexual partners of their infection so they can take

appropriate precautions. Clearly, abstaining from drug injection and sexual activity with an

other person is one option that would eliminate any risk of HIV transmission by those routes.

 • Protect a partner during any drug use by taking precautions, as suggested above.

 • Since reinfection and/or infection with another strain of HIV may contribute to disease progres

sion, HIV-infected drug users should refrain from reusing or sharing injection equipment to

protect their own-health as well as that of others.

Source: Adapted from Centers for Disease Control and Prevention 1986.

Exhibit 20.–Recommendations to Prevent HIV Transmission

Through Shared Drug Injection Equipment
93

Patients manifest varying degrees of acceptance of HIV counseling and tests.

Some patients are highly motivated to learn their serostatus, while others

may be wary or suspicious. Still others may not perceive themselves to be at

risk for HIV infection and consider the test unnecessary. The therapist’s role

is to -

 • Improve the patient’s self-perception of risk.

 • Support behavior change already attempted.

 • Negotiate a risk-reduction plan.

 • Support decisionmaking about the antibody test.

 • Help patients who test positive to deal with the results.

If patients express interest in being tested, provide them with the names of

one or more testing facilities and their addresses, telephone numbers, and

hours of operation. Also explain the agency’s testing procedures, including

confidentiality or anonymity policies, and the procedures for and time involved in getting the test results.

Therapists should volunteer to meet patients at a place of their choosing (a

parking lot, a park, the mall) to discuss the test results. If the results are

positive, contact tracing can be done if patients so choose. These persons

will be informed that someone (the patient will not be identified) they have

had sex with or shared needles with during the recent past has tested positive

for HIV. They will be given information about what this means for them and

how to get tested themselves.

HIV Antibody and

Hepatitis B Testing

Provide

Information

Discuss Results
94

Blank Page
95

With those who are married or involved in a romantic relationship, CRA +

Vouchers focuses on reciprocity relationship counseling. Therapists train

couples in the use of general communication skills and the application of

those skills to developing behavioral contracts to improve the quality of their

relationship. These procedures are based on those outlined by Azrin et al.

(1973) and Sisson and Azrin (1989). Interested readers should see those

sources and Meyers and Smith (1995) for more information on this approach.

The schedule generally consists of one session each week for 4 weeks and

then one session every 2 - 4 weeks for the remainder of treatment, for a total

of eight sessions. Each session is about 1 hour long, and many of the major

problems in the couple’s relationship may be discussed.

The couples sessions replace individual sessions. Therefore, discussion of

urinalysis results should be the first topic addressed. If disulfiram is being

used, the Disulfiram Assurance Procedure should also be followed in the

office.

During the first relationship counseling session, therapists should provide

an overview of this therapy and explain that the primary objective is to make

both individuals more satisfied with their relationship.

“As you well know, an important area of your life that is negatively

affected by cocaine problems is your relationship with your partner.

Those close to the person with the problem are typically most af

fected by the problem. Many partners of cocaine abusers have tried

many times to help their mate stop using. Strategies for trying to help

vary. Anger and frustration usually build up, and feelings of hope

lessness and helplessness sometimes arise. Sometimes attempts to

help are met with resentment and anger from the partner with the

problem.”

“In this part of treatment, we focus on how cocaine use has affected

your relationship and how we can work to increase the positive as

pects of your relationship. We also discuss ways that your partner

Relationship Counseling

Session 1

Introduce

Relationship

Counseling
96

can assist you in achieving and maintaining abstinence. We hope to

be able to help you both deal more effectively with this cocaine prob

lem.”

“We have found that, where there are drug abuse problems, there are

usually communication problems. Usually, we see communication

that is filled with anger, silence, apathy, or resentment, and many

times partners try to get their needs met outside the relationship. By

the time patients come to see us, there is little, if any, enjoyment left

in their relationship.”

At this point, therapists should ask if any of this sounds relevant to their

situation and then discuss any issues that arise. After checking for questions

and comments, therapists can continue as follows.

“Another major reason we find it important to include partners is

that they can provide a source of support that is important for suc

cessful treatment. It is essential, as a person begins to stop using

cocaine and starts to engage in ‘good’ behaviors, that they be ac

knowledged for doing so. It is sometimes hard for others close to the

user to do that because most of what they have experienced during

the last months or years is negative emotion and disappointment as

far as their partner is concerned. Therefore, if we include the part

ners in treatment, they can perhaps empathize with and understand

more about what the patient is going through and the effort being

given toward treatment. This understanding may make it easier for

the partner to provide the support that will be helpful for increasing

the chances of recovery.”

“Our goals are to help you -

 • Achieve and maintain cocaine abstinence.

 • Change your current lifestyle.

 • Increase enjoyment in your relationship.

 • Learn better ways to solve problems.

 • Develop effective communication skills.”

“Achieving these goals will not be easy. However, if we all work hard

on making changes, the outcome will likely be positive, that is, you

will learn how to stop using cocaine and alcohol or other drugs. Our

role will be to help you make positive changes in your relationship so

that it becomes more meaningful and enjoyable. Like the other areas

of change, making changes in your relationship will require much

work. You will have to learn and practice new ways of communicat

ing and problemsolving. With such practice, we expect that you will

learn how to use your new skills to increase the satisfaction you get

from your relationship.”

“Before beginning relationship counseling, it is important to note that

blaming one another will not be helpful. Each of you is always
97

responsible for your own behavior. Cocaine use is your (the patient’s)

problem, and you are responsible for your choice to use or not. You

(the partner) are responsible for your behavior as well and whether

or not you do things that make it easier or harder for your partner to

stop.”

“There are many causes of cocaine abuse, so it does not help to blame

one thing or event. Genetics probably play a role, as do family and

societal stressors. Whether you consider your problem a disease or a

bad habit does not matter when you are trying to stop using. Once

your problem exists, the things that cause you to keep using in the

here and now must be dealt with to help you stop using. That will be

our focus in this program.”

After giving this introduction, therapists should ask both patients and partners how they feel about what has been said. Questions about the process,

rationale, causes, blame, responsibility, and so forth should be expected and

be answered in an empathic manner to reassure couples that counseling can

help them.

Next, to break the ice and create a more positive atmosphere, couples can be

asked to recount to each other what it was like when they first met and began

to spend time together. The rationale for this is to remind them why they

chose to be together and what they might like to regain in their relationship.

This exercise may provide good ideas for the types of goals to set in counseling to increase satisfaction in the relationship.

Therapists can then begin by asking patients what they liked about their partners, what sort of fun things they did together, and what attracted them in the

first place. Therapists should direct couples to speak directly to each other. If

either one tries to recount this to the therapist, redirect the person toward the

partner. Also, therapists should remind them that this is a positive exercise;

no negative or critical comments are allowed at this point. This exercise can

be embarrassing for some patients and partners, so it is important for therapists to make them feel as comfortable as possible. The exercise is meant to

be light and fun. If couples have difficulty participating and cannot think of

things to say, therapists should prompt, model, and gently coax them to continue.

After both have taken turns with this exercise, therapists should ask them to

do the same thing again, but this time to tell their partners what they like

about one another now. The same “rules” should be followed for this exercise, that is, only positive things should be shared, and each one should talk

directly to the partner. This exercise may highlight how the relationship has

changed and may indicate specific, positive aspects that have faded and need

to be recaptured.

After this exercise is completed, it is important for therapists to explain that,

because of the impact of drug use on their lives, they may not be

Introduction Exercise
98

communicating with each other the way they did in the past, and that many

of the things they liked about their partners may not be apparent now. However, this does not mean that those positives cannot be recaptured with hard

work.

At this point, therapists can introduce the Relationship Happiness Scale (exhibit 21). This scale is used to assess how happy couples are currently with

various areas of their lives. Each partner should complete the form independently. Therapists should emphasize that they are to evaluate the problems

in terms of current, not past, satisfaction. A list of examples (exhibit 22) is

given to couples to provide them with types of events relevant to each area.

Once completed, therapists should collect the forms and initiate a brief discussion of their responses. Therapists should explain that this happiness

scale will be completed at the start of each session to assess changes that

occur during treatment.

Therapists should next give patients and their partners each a copy of the

Daily Reminder To Be Nice Form (exhibit 23) and explain the rationale for

its use.

“Many times in relationships, partners begin to take each other for

granted. If you think about it, sometimes they treat strangers with

more courtesy, respect, or appreciation than they do their own part

ners. This situation can be even worse in relationships that are

stressed by drug use. Thus, we have created an exercise that can

help to reverse the negative behavior that may have become ha

bitual in your household. Even if your situation is not as bad as I

described, you both could probably still benefit from this exercise.

What I will be asking you to do is simply be nice to your partner.

This form lists seven ways to do that. The form is supposed to serve

as a reminder for you to do more of these nice things and to record

how well you are doing with actually engaging in these nice behav

iors.”

Therapists should then review the form with the couples, answer any questions they may have, and ask them to complete a sample form by reflecting

back on last week’s behavior. Once this is completed and discussed, therapists can ask how the patients would feel if their partners performed these

behaviors every day. Again, couples should be instructed to respond directly

to one another and to tell each other specifically what they would like the

other to do. The mood during this exercise should be light and fun.

Therapists should instruct patients to record on the sheet each day whether

they performed each of the positive behaviors. A discussion should be initiated concerning where the forms should be kept and how they will remember to fill them out. A good place to keep them is

Relationship

Happiness Scale

Daily Reminder

To Be Nice
99

This scale is intended to estimate your current happiness with your relationship in each of the 10

areas listed below. Ask yourself the following question as you rate each area:

How happy am I with my partner today in this area? Then circle the number that applies.

Numbers toward the left indicate some degree of unhappiness; numbers toward the right reflect

some degree of happiness. By using the proper number, you can show just how happy you are with

that relationship area.

Remember: You are indicating your current happiness, that is, how you feel today. Also, do not let

your feelings in one area influence your rating in another area.

 Completely Unhappy Completely Happy

Houshold Responsibilities 1 2 3 4 5 6 7 8 9 10

Rearing of children 1 2 3 4 5 6 7 8 9 10

Social activities 1 2 3 4 5 6 7 8 9 10

Money 1 2 3 4 5 6 7 8 9 10

Communication 1 2 3 4 5 6 7 8 9 10

Sex and affection 1 2 3 4 5 6 7 8 9 10

Academic (or occupational) progress 1 2 3 4 5 6 7 8 9 10

Personal independence 1 2 3 4 5 6 7 8 9 10

Partner’s independence 1 2 3 4 5 6 7 8 9 10

General Happiness 1 2 3 4 5 6 7 8 9 10

Name ____________________________________

Date _____________________________________

Source: Azrin et al. 1973, p. 370.

Exhibit 21: Relationship Happiness Scale
100

Source: Adapted from Azrin et al. 1973, p. 371.

Exhibit 22: Examples of Relationship-Related Activities

Sex/affection:

 • Frequency

 • Location

 • Type

 • Show of public affection

 • Extramarital relationships

 • Jealousy

Academic or occupational progress:

 • Spends too much or too little time on it

 • Meets status expectations

 • Too much procrastination

 • Constant complaining about the job

 • Poor job location

Personal independence:

 • Night out alone

 • Day off alone

 • Lets me drive the car by myself

 • Let me learn to drive

 • Feel free to ask partner’s advice

 • Have money easily available without

having to ask the partner

 • Make household decisions without

asking the partner

 • Able to go to social events without the

partner

Partner independence:

 • Partner relies on you for making house

hold decisions

 • Partner goes out without you, e.g., to

movies, sporting events, billiards

 • Partner will not go out without you

 • Partner makes most of the decisions

without consulting you

 • Partner is possessive

 • Partner is not possessive enough

 • Partner lacks friends

 • Partner has no personal interests, e.g.,

hobbies, friends

 • Partner does not know how to drive a

car

Household responsibilities:

 • Yard work

 • Cleaning the house, such as sweeping,

dusting, and cleaning the bathroom

 • Grocery shopping

 • Cooking the meals

 • Washing the dishes

 • Doing the laundry

 • Caring for the car

Rearing of children:

 • Preparing meals

 • Bathing the children

 • Disciplining the children

 • Watching the children

 • Playing with the children

 • Helping them when needed

Social activities:

 • Going together -

 • to the movies

 • out to dirmer

 • to parties, to night clubs, for walks

 • Participating in or watching sporting

activities together

Money:

 • Having an allowance

 • Buying or receiving presents

 • Budgeting money

 • Saving too little or too much

 • Buying clothes and other necessities

Communication:

 • Planned discussion periods

 • Frequent discussion periods

 • Frequent arguments

 • The use of tactful statements

 • Misinterpretation of things said

 • Solving problems through discussion
101
102

n the refrigerator or on top of the television set, any place where they can be

seen frequently to remind them to do the nice behaviors and to record them.

To make the partners even more aware of ongoing reciprocal behavior, therapists should have them list at least 10 satisfactions their partners are providing to them as well as 10 they provide to their partners. They should be

encouraged to refer to specific events rather than general attitudes. For example, “I do laundry each week,” “I clean the house,”I provide advice when

asked,”I provide moral support,”I went food shopping.” After the lists are

completed, they should be discussed so agreement is reached and the amount

of existing reciprocity is assessed.

After this session, the couple should be given Daily Reminder forms to

complete at home before the next session. In addition, they should be instructed to mention each day any novel, unusual, unanticipated, or unscheduled satisfaction they receive from their partners.

Each session thereafter, therapists should review the completed Daily Reminder forms and discuss how the expression of appreciation or satisfaction

is going.

When couples come in for their next session (and all subsequent sessions),

therapists should have them complete the Relationship Happiness Scale and

briefly discuss any changes from the last session.

Next, therapists should review and discuss the Daily Reminder forms completed during the days between sessions. Both partners should be encouraged to state specifically what behaviors they engaged in and how they were

affected by the other partner’s nice behaviors. In this way, the session begins on a positive note. The patients should then be given additional forms

and instructed to continue to complete them daily.

If patients and partners did not bring in their forms, or if they did not fully

comply with the procedures, a discussion and plan for how to increase compliance should be initiated. Therapists can emphasize the importance of following through with these assignments by reviewing the rationale.

Problemsolving techniques and appropriate behavioral procedures should

be used to address any compliance-related problems.

Next, therapists should give patients and partners the Perfect Relationship

form (exhibit 24) and provide the rationale for its use.

“We are going to use this form to target areas in which each of you

would like to see some changes from your partner. These changes

Session 2

Perfect Relationship

Form
103

Under each area, write down the kinds of activities that would occur in what would be an ideal

relationship for you. Be brief, be specific, and state in a positive way what you would like to

occur.

In Household Responsibilities, I would like my partner to:

1.

2.

3.

4.

In Childrearing, I would like my partner to:

1.

2.

3.

4.

In Social Activities, I would like my partner to:

1.

2.

3.

4.

In Independence, I would like my partner to:

1.

2.

3.

4.

In Personal Habits, I would like my partner to:

1.

2.

3.

4.

In Managing Money, I would like my partner to:

1.

2.

3.

4.

Other things, I would like my partner to:

1.

2.

3.

4.

Source: Sisson and Azrin 1989, pp. 254-255.

Exhibit 24: Perfect Relationship Form
104

should be things that you feel would increase the satisfaction or hap

piness you get from your relationship. The exercise is designed to

help you identify specific behaviors for change so it will be easier for

your partner to know and then respond to your needs. If you don’t

identify specific behaviors for change, it is difficult for your partner

to meet your needs or make you happier. Thus, this exercise will be

gin by identifying needs and then will move on to exploring ways to

ask for these changes that will increase the chance that your partner

actually will make those changes.”

Each partner then fills out the first section of the form, “Household Responsibilities.” They should list things in this category they would like their partner to do or to do more often. Therapists should repeat the instructions to be

specific and to word their requests in a positive manner. Encourage them to

be as selfish as possible in stating their wishes and give them an example.

“You would like your partner to help out more with the laundry and

vacuuming. Write down: On Saturday mornings after breakfast, I

would like it if you would vacuum the living room and our bedroom.

Also, on Saturday morning, I would appreciate it if you would gather

he laundry from all the rooms and place it in the laundry room.”

Next, therapists can work with couples to create specific lists of things each

would like the other to do. After completing one or two categories, couples

should take the form home, complete it, and bring it back to the next session.

After patients and partners have completed one or two sections of the Perfect

Relationship form, therapists should introduce the notion of positive requests.

This component is designed to teach couples how to request things from

each other in a way that will increase their chances of getting what they

want. The rationale for this component is provided as follows.

“Learning or relearning to communicate positively is important for

many couples who come to our clinic, because many times they have

stopped communicating as drug use has become prevalent in their

lives. Even when there is no drug abuse, it is common for couples to

stop using positive types of communication in ongoing relationships.

However, if you or your partner want the other to make changes, the

most effective way to do this is by using positive communication rather

than demanding, nagging, or ordering the other to change.”

“We would like to teach you how to use a particular method

for making requests that will increase the probability that your part

ner will make the effort to change. This type of communication is a

skill and, like any skill, requires practice to be able to do it effec

tively. Thus, it is important that you both agree to make an effort to

learn and practice

Positive Requests
105

these skills. Trying to use this type of communication may be diffi

cult at first and may seem forced or unnatural but, over time, you

will begin to feel more comfortable.”

Therapists then explain that some ways of making a request are more pleasant than others, which, in turn, make it more likely that a request will be

acted upon (exhibit 25).

 • Try to take the other person’s point of view and understand how it

feels. The other person may not recognize your needs or realize that

you are unhappy.

 • Try to take partial responsibility. For example, if you want your part

ner to take more initiative in helping the kids with their homework,

but have never told your partner how important that is to you and

why, then you could preface your request by saying, “I know I have

never told you how important it is to me for the kids to do well in

school, but because of how I failed and how it made me feel so stu

pid, I really don’t want them to have to feel that way their whole

lives. I know it’s partly my fault that we don’t spend a lot of time

with them on schoolwork, but I would like us to begin to do that as

much as possible.”

 • Offer assistance to make it easier for your partner to fulfill your re

quest. In the example I just gave, you could remind your partner, if it

is the partner’s turn to help with homework, that you could arrange

or schedule the times for this to happen. In making the request, you

could say something like, “ Would it be helpful if I...”Would it make

it easier for you to do this, if I...”

After reviewing these steps, another one or two examples of a positive request should be provided by therapists, and couples should be encouraged to

review these steps before they make a request.

Next, therapists can have each partner take out a Perfect Relationship form

and practice making positive requests. Each partner can pick one request to

practice. The components of an effective request are reviewed, and therapists help the partners choose words that are specific and positive. Each one

then practices making these requests to the other partner.

Couples should be encouraged to try to fulfill each other’s desires, at least in

part, and to adopt the attitude that any desire can be fulfilled and “If you

want it, you can get it.”

Techniques for working out compromises should be discussed next. Specifically, couples should be taught to turn a particular request into a continuum

rather than an all-or-none request. For example, if one partner wants the

other to initiate sexual activity and the other refuses to accept that responsibility, a discussion of exactly how often the
106

1.State What You Really Want

2.Take the Other Person’s Point of View

3.Take Partial Responsibility

4.Offer to Help

5.Always Try to Say Yes, If Possible

6.Look for Compromise, If Necessary

Exhibit 25: Positive Requests
107

partner wants the other to initiate sex can lead to an agreed-upon compromise.

Any time a request is made by one partner, the other should be asked whether

it will be done. If the answer is no, a compromise should be worked out. The

partners are encouraged not to refuse requests from one another. Rather than

saying no to a request, a partner might suggest an alternative. When proposing an alternative solution, the partners are instructed to follow the same

steps used for making a new request.

After compromises are practiced, therapists should ask each partner to pick

one request that will be the target for change in the next week. These requests are then directly stated to the partner in the session. The requests can

be practiced repeatedly, if necessary, with therapists providing feedback to

help shape effective, positive requests. Once the requests are agreed upon,

they should be written down in contract form on the request forms shown in

(exhibit 26).

In the next session, therapists should express interest in hearing from couples

about how things went. Couples should be informed that therapists will be

tracking progress with these requests each week. Lastly, patients are asked

to complete the rest of the Perfect Relationship form and bring it to the next

session. Therapists can again emphasize that these are to be thought of as

“perfect” relationship requests, not demands that they are forcing on their

partner. Thus, they can be encouraged to be selfish when writing down those

things they would like their partner to do.

At the beginning of the third session, therapists should review the Daily

Reminder forms and have the couple complete the Relationship Happiness

Scale. Next, the Perfect Relationship forms should be reviewed. If couples

did not complete these forms, they should take a few minutes during the

session to do so; at least a significant portion of the form should be completed. Progress on the reciprocal-request contract is then reviewed. If

progress was good, therapists should provide social reinforcement. If little

or no progress was made, a problemsolving discussion should follow, focused on developing a plan for the coming week that will increase the likelihood of compliance with the request.

Next, therapists and couples target another set of requests for change. The

Relationship Happiness Scale is used to prioritize areas for change. For example, areas that patients or partners rate as low in satisfaction are likely to

be areas in which therapists encourage them to make changes. Once an area

is agreed upon, each partner can pick one request from the Perfect Relationship form. Therapists then have couples practice making positive requests

using the steps reviewed in the

Session 3
108

Exhibit 26: Reciprocal Contract for Behavior Change

This contract is designed to assist you in achieving and maintaining positive changes in your relationship. During treatment, you will be asked to develop a number of these contracts that document

reciprocal changes requested by you and your partner. By making public commitment and putting it

in writing, you are actively taking steps toward achieving and maintaining positive changes in your

relationship.

I, __________________________, agree to make every effort possible to make the following

change(s) at my partner’s request. I understand that this change is very important to my partner and

therefore also very important to me.

Behaviorchange:

I, __________________________, agree to make every effort possible to make the following

change(s) at my partner’s request. I understand that this change is very important to my partner

and therefore also very important to me.

Behavior change:

This contract will continue throughout treatment unless a new contract is substituted or until one

or both parties decides to stop participating.

Patient: ________________________________________ Date_________________________

Partner: ________________________________________ Date_________________________

Therapist: ______________________________________ Date_________________________
109

ast session. Then another reciprocal contract for behavior change is completed and signed.

Usually only one new request for change is recommended each week and, if

no progress is made during the week, new requests are placed on hold until

couples successfully comply with the first request.

Next, couples are given the Communications Skills Training #1 handout

(exhibit 27). The components of positive communication training are reviewed and discussed. These procedures for teaching positive communication skills are based on the approach of Gottman et al. (1976) and McCrady

(1986). The Perfect Relationship form is then used to identify areas of their

relationship the couple would like to improve. They then pick an area to

discuss in session. The rationale for this exercise could be explained as follows.

“Like any other skill, developing communication skills takes prac

tice. What I would like you to try to do now is to have a discussion

about [name subject area], and while doing so, try to keep in mind

the communication skills we just reviewed. During your discussion, I

will be interrupting you to point out particular strengths and weak

nesses of your interaction in terms of the communication skills. I

may show you some other ways to get across your points. I may ask

you to try again and practice another way of phrasing something, or

practice omitting parts of your comments that are not effective. You

may find this exercise a little strange or embarrassing; it may also

be quite frustrating. However, I would like you to try to stick with it

and even try to enjoy yourself. Learning new ways to communicate is

not easy, but the only way to improve and to change old habits is to

practice.”

The rest of the session should be used to practice these communication skills.

Before leaving, the couple should pick two problem areas they will discuss

during the next week, using the communication skills learned. Therapists

should encourage them to select a specific day and time to have the discussions and to write down their impressions of these encounters and how they

felt they did. Finally, therapists should remind them to continue to complete

the Daily Reminder sheets.

At the beginning of this session, therapists should -

 • Review the Daily Reminder To Be Nice completed in the past week.

 • Have the couple fill out the Relationship Happiness Scale.

 • Review progress on the reciprocal contract requests.

 • Review how the couple fared in the scheduled discussion of the two

problem areas.

Communications

Training

Session 4
110

If there were problems, these should be dealt with. It is important to spend

as much time as needed to review, problemsolve, and discuss any relevant

issues. If the couple complied well with the reciprocal requests, an additional request should be considered. If it is decided that the couple is going

to add another request, the same procedures as in Session 2 should be followed to target and practice this request.

Next, therapists should give the couple Communications Skills Training #2

(exhibit 28). The communications skills are reviewed with the couple and

the procedures used in Session 3 are used to teach and practice these skills.

Again, therapists should provide as much positive feedback as possible as

they try to shape effective, positive communication between the couple.

With some couples this will be painstakingly slow, so it is important to be

flexible and to use a reflective and empathic counseling style and behavioral skills to help the couple comply and progress in this area of change.

At the end of the session, the couple should be asked to repeat the same

assignments given in the last session (i.e., discuss two problem areas and

practice using the communications skills and complete the Daily Reminder

sheet).

Throughout the remainder of the relationship counseling sessions, the couple

should continue to complete the Relationship Happiness Scale, the Daily

Reminder sheets, make reciprocal contract requests, and practice communication skills. Many times, the first few weeks or so of this counseling go

very smoothly. Because patients are making an effort that can readily be

seen by their partners, many positive changes usually occur. It is important

to recognize that this may not last. The old, habitual patterns of communication will most likely surface as stressors occur or if the patient uses cocaine.

Therapists should persist in teaching the communication and relationship

skills. These are the skills that will help couples get through the difficult

times.

The last few sessions should be scheduled further apart (biweekly, then

monthly) prior to ending relationship counseling. Therapists should ensure

the patients’ partners that they are still involved, even if not attending regularly, and that they can contact the therapist any time they feel the need.

Communications

Training

Sessions 5 - 8
111

Be polite to your partner. When talking with your

partner, use the same courteous words and tone

you would use with a stranger or a coworker.

Express positive feelings. Try to let your partner

know what you like about things they have done

or how they have been acting. Spend at least as

much time on the things that are going well as on

those that are not.

Do something nice for your partner. Without

being asked or without a special reason like a birthday, do something that your partner would like or

find special. Do this without asking for or expecting something in return.

Determine the importance of an issue before

you complain. Ask yourself whether something

is worth complaining about. Don’t get into the

habit of always complaining about something.

Express complaints only about things that matter.

Choose a “good” time to bring up a complaint.

Try to pick a time to discuss a problem that will

provide a good setting for a positive discussion.

For example, make sure you will have some uninterrupted time to discuss it. Don’t bring it up when

you are really angry. Don’t bring it up when your

partner is angry.

Have a goal in mind when you bring up a complaint. Give some thought to the problem before

you bring it up with your partner. Ask yourself

what you would like to get out of it. What changes

are you hoping for? Why do you want those

changes? Are those changes reasonable or achievable?

Be specific about your complaint. Focus on only

one thing at a time. Try to have a very specific

example of what you are upset about so you can

help your partner understand the issue exactly. You

should be able to describe specifically what you

would like the partner to do differently. Don’t bring

up other problems; stay focused.

Improving Communication

Request changes in a positive manner. Tell your

partner, in the most positive way possible, what is

bothering you and what you would like changed.

Use the steps outlined in Positive Requests training. Avoid criticisms, put-downs, name calling, and

assumptions about your partner’s motives.

Prepare to compromise. Prepare yourself to discuss the issue and come up with a solution that

works for both of you. Don’t use ultimatums or dismiss your partner’s ideas.

Disagreements

Below is a brief outline of some important issues

and behaviors that may help you through disagreements that arise in your relationship.

Expect to have disagreements. Even in the best

of relationships, partners do not always agree. Disagreements are normal parts of a relationship.

Some disagreements are not real disagreements

- they are miscommunications.

Miscommunication happens when the message

you are trying to send your partner provokes a

response that you did not expect or intend the

partner to have.

Miscommunications typically result from not

expressing yourself clearly, specifically, or completely. Do not make assumptions about what your

partner knows or doesn’t know. Provide reasons

for why you are complaining or making a negative

statement. Use the communication skills discussed

in Positive Requests training and those listed above.

Intent should equal response. If your message gets

a response that you did not intend, assume that

something went wrong with the communication

process.

The problem may be in the message. You - the

message sender - could have said something that

you did not intend to by-

 • Not saying what you really meant.

Exhibit 27: Communications Skills Training #1

Below is a list of communication behaviors you may find helpful for improving communication with

your partner.
112

 • Leaving out information or assuming your

partner already knew.

 • Giving a nonverbal message that was not

consistent with the verbal message (e.g.,

using a sharp tone of voice because you

were in a bad mood).

 • Hidden agendas. Unresolved issues may

enter into problems any time you get upset;

that is, you may have made statements that

are not directly related to the problem you

were raising.

The problem may also occur with the person

who receives the message. Persons receiving the

message may also react differently than they intend

because of the same types of things that affect the

delivery of the message.

Conflicts

Arguing and fighting. Arguing and fighting often

occur because the communication skills described

above are not being used. For example, if you do

not stay on a specific topic, call someone a bad

name, bring up every little thing that bothers you,

or raise issues at inappropriate times, a fight or

argument is likely to arise.

The first step in gaining control of fighting behavior is to recognize your pattern of fighting. Fights

are defined as bringing up issues without discussing or resolving them. It doesn’t matter if people

are yelling at each

other or not. If there is no resolution and a

problem is left hanging, it is a fight. It is important that you learn to identify fights and make a

list of what situations typically result in fights

with your partner.

Avoidance. Some couples rarely argue. They

simply avoid conflict by never talking about

issues. In this situation, either one partner

usually gives in all the time or both partners

become good at ignoring issues. This avoidant

style of communication usually results in one or

both partners feeling resentful, unloved, not

cared for, or unimportant. The communication

skills that need to be used are to recognize what

issues are important and to communicate these

issues to your partner at an appropriate time.

Sometimes it is hard to recognize whether

you and your partner are having problems

with avoidance. Some clues or signals that

avoidance may be a problem are-

 • You think there is no conflict at all in

your relationship.

 • Conversations tend to be dull and

routine and you don’t feel connected.

 • You feel that certain topics cannot be

talked about because they will start a

fight or result in awful consequences.

 • You feel resentful toward your partner

much of the time and don’t want to do

special favors.

Exhibit 27: Communications Skills Training #1 (continued)
113

Good listening can help couples communicate

more effectively. Although you may feel that listening is easy or natural, it isn’t. Active listening

that involves trying to understand your partner is

very difficult. It usually takes some training and

practice in listening skills.

Before responding, a good listener will try to -

 • Completely understand what the part ner

was trying to communicate - what the part

ner wants and how the partner is feeling.

 • Request the feedback and information

needed to accurately summarize what the

partner intended to say.

Questions you can use to get such feedback are -

 • Are you saying ... ?

 • I’m not sure what you mean; can you ex

plain that to me?

 • How are you feeling now?

 • Are you mad or upset with me?

 • I don’t think I understand your point; can

you explain it a little differently?

 • Can you give me an example? I’m not sure

I understand why you are so upset.

Validation. It is important that you try to validate

partners’feelings, that is, let them feel that you think

you can understand how and why they feel the way

they are feeling. Communicate to them that their

feelings make sense. This does not necessarily mean

that you agree with them, but that you can understand their point of view. Validating feelings is probably the most important way you can let them know

you care about them and the way they feel. It lets

partners know that they are important. There are

very few other effective ways to convey that message to your partner.

Examples of validating statements are -

 • I can understand how you would feel that

way, given that ...

 • No wonder you feel so angry.

 • If that’s how you see it, no wonder you are

so upset.

Examples of statements that are not validating

are -

 • That’s silly.

Exhibit 28: Communications Skills Training #2

 • You shouldn’t feel that way.

 • That’s ridiculous.

 • I don’t think that should upset you so much

.

If you can’t validate your partner’s feelings because you are too upset, take some time to regroup.

Suggest a short break in the conversation. Come back

when you feel you can validate your partner’s feelings.

Poor Listening

A major cause of poor communication is not listening to your partner. Each partner must seek to

understand the other. If you don’t understand a problem, it is very hard to fix it. If you can’t hear and

understand your partner’s point of view, the problem will never be resolved effectively.

Poor listening usually sends the following messages:

 • I am not interested in your opinions or feel

ings.

 • Your feelings are ridiculous or silly.

 • You are foolish to have those feelings.

 • Your feelings don’t deserve my attention or

concern.

 • My opinions and feelings are more impor

tant that yours.

 • My opinions and feelings are more reason

able than yours.

Obviously, these messages will not resolve a problem. Most likely, they will cause more resentment,

bad feelings, and difficulties.

Identifying poor listening behavior is not always easy.

A few things to look for are -

 • Self-summarizing: You or your partner con

tinually restate your position over and over

during a discussion or argument.

 • Cross-complaining: The complaint of one

partner is met with a complaint by the other

instead of problemsolving the original com

plaint. Thus, many old complaints and issues

are brought up each time an issue is raised.

 • Mind-reading: issues are avoided (at least

at first) by partners feeling and acting as if

they know the other partner’s feelings and

desires. This results in one partner feeling left

out of decisionmaking, unimportant, and re

sentful.

Good Listening Skills
114

Stop Action or Timeout: Dealing With Poor

Communication

The time to act to prevent or effectively deal with

conflict is when you recognize that you are getting a response from your partner that you did not

intend to get.

If you or your partner realize that miscommunication has occurred, one of you should call a timeout

or stop action. You should simply say hold it,

timeout, or whatever vou find comfortable. This

should signal that it is time to stop the discussion

and try to analyze what went wrong.

Once one of you calls a timeout, you should both

do the following:

 • Find out why your partner is upset or has

responded in a particular way.

 • Express the message you intended to com

municate and specify the response you ex

pected.

 • See if you can identify anything like voice

tone or bad mood that affected the com

munication.

 • Ask yourselves the following:

 • Are there any hidden agendas?

 • What was I trying to say? Did I say it in an

appropriate manner?

 • Was I trying hard to understand my part

ner?

 • Was I being impolite or just plain stub

born?

 • Did I demonstrate that I cared what my

partner was feeling?

Restart the conversation with the intention of listening to your partner. Use good communication

skills to express your feelings. Do not blame each

other, and try to identify what went wrong the first

time in terms of good communication skills. These

steps can be used to guide the timeout:

 • Call timeout or stop action.

 • Listen for feedback from your partner.

 • Try to summarize your partner’s viewpoint.

 • Try to validate your partner’s feelings.

Patterns of Communication Problems

Once you start identifying the communication

problems that exist in your relationship, you will

probably

notice that you and your partner have developed

certain patterns or styles that occur time and time

again. just like any other behavior, the way you

communicate - good or bad - has become a wellIearned habit. The first step in changing these

problematic communication patterns is to label

them so you know what you need to deal with.

Four common communication patterns that result

in conflict are listed below.

Mind-reading. The ineffective communication

behaviors that occur when mind-reading is the

problem are -

 • You think your partner should know what

you want or need without asking.

 • If you have to tell your partner what you

want, you feel it “doesn’t count.”

 • You feel you know what your partner

wants or is thinking without being told.

It is unrealistic for you to feel that your partner

should know what you want or need. It would be

nice if they did, but expecting it is a romantic fantasy. Directly communicating your needs, wants,

and feelings is necessary for your partner to learn

better to provide you with what you need. Similarly, don’t assume you know what your partner

wants; ask your partner so you can more effectively meet your partner’s needs.

Yes, but-ing. If you or your partner have this common communication problem, you will notice that

during most arguments or disagreements one or

both of you responds to the other’s suggestion or

opinion by saying, “Yes, but that won’t work because...... or ‘Yes, but you don’t really understand

why I didn’t do it,’ or ‘Yes, but we can’t do that

because...” This type of communication sends the

message that you don’t want to change or meet

your partner’s needs or understand the partner’s

point of view. Instead of yes, but-ing, learn to respond by-

 • Requesting more information.

 • Suggesting a compromise.

 • Saying positive things and being more un

derstanding.

Character assassination. Another common communication problem is making change requests or

comments that attack your partner’s whole self,

rather than specific problem behaviors

Exhibit 28: Communications Skills Training #2 (continued)
115

 or areas for change. For example, if you find yourselves making statements like, “Can’t you be more

like Jim,” or “Can’t you stop always thinking of yourself,” or “Why do you always have to be so stupid,”

then you are engaging in character assassination. This

means you are making impossible demands on your

partner or inaccurate critical statements. All this usually does is provoke defensive, aggressive, or hurt

behavior from your partner. It also does not let your

partner know the specific things you would like the

partner to do differently. It is important to learn to

make specific change requests rather than global,

vague assassinations. Also, it is important for the receiver of the assassination to ask the assassin to be

more specific and say exactly what is wanted.

The complaining rut. This problematic pattern of

communication describes couples who complain all

the time without including any suggestions for

change or alternatives. If you hear you or your partner saying things like: “Why do you always have to

be so mean” or “Can’t you stop coming home late

all the time” or “I wish you would stop hanging

around with

hose folks” or “I wish you would spend more

time with the kids,” that is a complaining rut.

If you make statements like that without including some alternatives or specific requests

for change or improvement, then you are in a

complaining rut. The problem with this approach is that, when you don’t identify alternatives, all you can do is take note when your

partner is engaging in the bad behavior again.

If you suggest constructive alternatives, you

can then take note of when the partner is making that change and feel good about it.

It is important to learn to only make complaints

that include specific statements about what you

would like your partner to do instead of the

problem behavior. For example, instead of just

saying, “I wish you would stop hanging around

with those guys,” you could include, “It would

be nice if you spent some time each night with

the kids helping them with their homework

and maybe on Friday nights we could go out

to the movies.” Your goal should be to give

your partner something specific to try to do so

your partner can demonstrate an effort to

change.

Exhibit 28: Communications Skills Training #2 (continued)
116

Blank Page
117

The majority of cocaine-dependent individuals abuse other substances as

well; approximately 60 percent are also alcohol dependent, and about 30

percent are marijuana dependent. Many others use such substances but do

not meet dependence criteria. Since concurrent drug use may influence outcome, any effective treatment for cocaine dependence must address other

forms of substance abuse. This chapter provides a general approach to concurrent use of substances other than cocaine and a more detailed approach to

handling alcohol and marijuana problems.

CRA + Vouchers recommends but does not require simultaneous cessation

of all abused substances as a condition of treatment. The philosophy of this

approach is to, first and foremost, provide patients with treatment for the

specific problem for which they are seeking help - cocaine dependence. Many

patients do not consider alcohol or other drug use a problem, or may acknowledge it as a problem but express no desire to change. In general, therapists work toward sustaining and strengthening the patients’ efforts to resolve their cocaine problem while, at the same time, trying to motivate them

to abstain from use of other substances.

Therapists should be clear in their recommendations regarding the benefits

of abstinence but should adopt a flexible approach toward patients’ use of

alcohol and drugs other than cocaine. Dwelling on abstinence issues that

patients are not interested in may lead to early dropout. Similarly, overemphasis on other drug use can lead to an adversarial or confrontational relationship between patients and therapists that can interfere with effective treatment for cocaine problems.

Other Substance Abuse

General Approach

(This chapter does not address concurrent abuse of cocaine and opioids, although vouchers are effective with this population (Silverman et al.1996) as is an adaptation of CRA + Vouchers (Bickel et al. 1997). Cigarette smoking cessation is

currently not a treatment goal despite the high usage (over 70 percent) in the cocaine-dependent population. However, that

policy may change if it turns out that quitting smoking does not interfere with, or perhaps enhances, cocaine abstinence.)

Treatment Goals
118

Also, patients who express no interest in abstaining from other substances

during the early stages of treatment may change their minds later.

 • They may find that they cannot achieve their goal of cocaine absti

nence while continuing to use other drugs.

 • Their success with cocaine abstinence may be reinforcing and, in

turn, may lead them to try abstaining from other substances.

 • They may find that the negative consequences they hoped to avoid

by giving up cocaine continue because of their drinking or other drug

use, leading them to increase attempts to abstain in order to avoid

these consequences. Similarly, other drug use may interfere with pa

tients’ ability to meet their lifestyle change goals because of hang

overs, low energy levels, or too little time for positive social activi

ties.

 • The use of other substances may result in new negative consequences,

such as an arrest for driving while intoxicated or possession of mari

juana, which change the patients’ interest in eliminating other drug

use.

A small minority of patients can make progress in discontinuing cocaine use

despite using other substances. Therapists can continue to advise total abstinence while accepting the fact that therapeutic goals cannot be dictated to

patients. Instead, therapists can engage them in treatment around the issues

where there is therapist-patient agreement and attempt to work from there to

facilitate more wide-ranging therapeutic changes in the future.

While maintaining a flexible stance toward other drug use, therapists should

continue to strive for patient abstinence from alcohol and other drugs. Laboratory research has shown that alcohol, even at relatively low doses, can

increase preference for cocaine use over nondrug activities (Higgins et al.

1996). Other drugs may do the same by increasing the reinforcing effects of

cocaine, placing patients in closer proximity to cocaine, or directly interfering with the skills needed to successfully avoid cocaine use.

 • Patients who stop cocaine use but continue regular use of other sub

stances are likely to remain in a cocaine-using environment within

the same social network. This would make it difficult for them to

engage in new social activities.

 • If patients are abusing other substances, the consequences of that use

may prevent them from developing the stable lifestyle that is impor

tant to maintaining cocaine abstinence. For example, if patients are

getting drunk frequently, it is unlikely that their family relationships

will improve, that they will maintain stable

Abstinence
119

employment, or that they will have the time or energy to engage in

regular activities unrelated to alcohol abuse.

Many cocaine-abusing patients are not interested in stopping their use of

other drugs or alcohol, even after being given good reasons for doing so. For

those patients, the next alternative is to try to set reduction and safe-use

goals for the other substances. If patients are willing to work on these reduced use goals, therapists can help them set appropriate goals and teach

them self-control skills to increase their ability to achieve those goals. Abstinence from all illicit drug and alcohol use is recommended; however, with

patients who refuse that goal, therapists should seek to facilitate at least some

movement in a therapeutic direction.

For patients who also refuse reduction goals, therapists should proceed by

targeting cocaine only, while monitoring use of other substances. Continue

to counsel these patients toward abstinence and reduction goals but, if they

refuse, do not provoke a confrontation or discontinue treating their cocaine

dependence.

Alcohol is the substance most commonly used or abused in combination

with cocaine. Many patients report that they almost always drink alcohol

either before, during, or after cocaine use (Higgins et al. 1994c).

 • Alcohol is their primary drug of choice.

 • They like the high associated with the combination.

 • Alcohol helps them counteract cocaine-induced anxiety.

 • Alcohol helps relax them.

 • Alcohol makes them more sociable.

Some patients report that they do not drink very often and that alcohol is not

a problem. Others say they only drink when they use cocaine, whereas some

report that they only use cocaine when they drink. Because of this high incidence of alcohol use associated with cocaine dependence, disulfiram therapy

is included as a component of CRA + Vouchers.

The general strategy for dealing with alcohol use is as follows.

 • If patients meet criteria for alcohol abuse or dependence, strongly

recommend abstinence and encourage them to agree to monitored

disulfiram therapy. Also focus on behavioral strategies targeted to

abstinence.

Reduced Use

No Intervention

Concurrent Alcohol Use
120

 • If patients do not meet criteria for alcohol abuse or dependence but a

positive relationship exists between their alcohol and cocaine use,

recommend abstinence with monitored disulfiram therapy and be

havioral strategies.

 • If patients will not agree to abstinence as a goal, encourage them to

reduce drinking and restrict it to safe circumstances. Ask them to

agree to a backup contract which states that they will initiate disul

firam therapy if they cannot meet their limited drinking goals.

 • Patients should not be discharged or terminated because they refuse

to cease or reduce alcohol use or are unable to meet alcohol-related

goals.

A combination of behavioral interventions and monitored disulfiram therapy

should be provided to patients who agree to set abstinence goals. The behavioral interventions used for cocaine abstinence have been successfully applied to alcohol abstinence; the voucher program is generally not used. The

disulfiram procedures should be used with all patients who agree to take this

medication.

Disulfiram, often sold as Antabuse, is an alcohol-deterrent medication that

inhibits the liver enzyme aldehyde dehydrogenase, which assists in the breakdown of acetaldehyde, the major alcohol metabolite (Fuller 1995). Consuming alcohol while disulfiram is in the body causes an accumulation of acetaldehyde, which produces an unpleasant physical reaction. Symptoms can include flushing, rapid or irregular heartbeat, dizziness, nausea, vomiting, difficulty breathing, and headache. This reaction can be medically dangerous,

especially in individuals with certain preexisting health conditions. Thus,

the medication is available only by prescription, and disulfiram therapy can

only be used in collaboration with a physician.

The disulfiram protocol must be administered under medical supervision. If

a clinic physician is unavailable, disulfiram therapy must be handled by a

referral to the patient’s family physician or, preferably, by a community physician who is informed about substance abuse and the utility of disulfiram

therapy.

It is prudent to work out, in advance, with one or more community physicians, a protocol that facilitates referral, workup, and initiation of disulfiram

therapy. Before the first dose of disulfiram is given, it is essential that medical personnel determine the patient’s baseline meas-ures. Patients are then

monitored regularly for any serious deviations from their normal state.

Abstinence

What Is

Disulfiram?

Medical

Oversight
121

The following disulfiram protocol has two elements. First, therapists must

educate appropriate patients about disulfiram therapy. If patients are interested in trying disulfiram therapy, then plans to support medication compliance are developed.* Therapists should discuss disulfiram with appropriate

patients early in the treatment process.

Introduce Disulfiram

The topic of disulfiram therapy can be raised with appropriate patients in the

manner described below.

 • Bring up the topic of alcohol use. Review the patients’ history of

alcohol-related problems, using information obtained in the intake

assessment. During this interaction, elicit patient feedback and con

firmation.

 • Recommend that patients consider disulfiram therapy and give the

rationale for doing so. Find out what the patients know about disul

firam. If they have sufficient knowledge about disulfiram, acknowl

edge that and offer a brief review. If they are unfamiliar with disul

firam, then request a few minutes to explain.

Disulfiram

Protocol

“Disulfiram comes in a pill that looks like an aspirin. If you take it

daily, it usually has no effect on you, unless if you drink alcohol. If

you drink alcohol for up to 14 days after taking disulfiram, you will

get sick. Disulfiram can help you refuse to drink because you know

alcohol will make you sick. It works by preventing the alcohol you

drink from being properly processed in your body. Usually, the alcohol is digested or processed by different enzymes which break it down

into a form your body can tolerate. Disulfiram prevents this from

happening, which results in your feeling sick.”

“If you drink when you are taking disulfiram regularly, you will start

to feel sick in about 5 minutes. You will flush, become nauseous and

sweaty, and your heart rate will speed up. This reaction depends on

how much you drink. The more you drink, the worse the reaction

gets. If you continue to drink, or drink a large amount at once, such

as four or five beers or shots, you will probably vomit and feel like

you might faint.”

“Because disulfiram’s effects can last up to 2 weeks after taking the

last pill, it can really help individuals who have mixed feelings about

drinking or who tend to drink impulsively. If you were to feel like

drinking one day just out of the blue, or for some specific reason,

disulfiram can give you a reason not to drink. It also can buy you

some time to change your mind again before you do decide to drink.”

“Disulfiram therapy also gives you a way to seek help or advice before you decide to drink again. In disulfiram therapy, we can involve

*The procedures discussed here were adapted from Sisson and Azrin 1989.
122

another person in your life to assist you in taking disulfiram at home.

You can take your disulfiram at our clinic on the days you come for

urinalysis testing. If you feel like drinking, you will want to stop tak

ing your disulfiram, and you will have to discuss this with someone.

You can talk about what you are feeling and perhaps find another

way to deal with whatever causes you to want to drink.”

 • Explain the importance of alcohol abstinence. Do not use the term

alcoholic. Explain that while alcohol may not be a major problem, it

may interfere with their efforts to stop cocaine use. Describe what

has been learned about the adverse effects of drinking on cocaine

use, that is, that even modest amounts of alcohol can increase co

caine use. Discuss the benefits of disulfiram.

 • Taking disulfiram assures those around you that you’re not drinking

and that you have made a strong commitment to abstain from alco

hol and cocaine use.

 • Disulfiram may help your family or friends trust and work with you.

Compliance Procedures

Those patients who are interested in trying disulfiram therapy should review

and sign the consent form (exhibit 29) and meet with the supervising physician to obtain medical clearance. When everything is approved, patients

should be given written information to take home

By accepting disulfiram therapy, I acknowledge the need for assistance in solving a drinking

problem. I also understand that, with my full cooperation in this therapy, I am most likely to

achieve successful recovery. It has been explained to me and I understand the effects which

disulfiram can trigger if I should consume even a small amount of alcohol in any form. These

symptoms include flushing, nausea, vomiting, thirst, low blood pressure, and possible convulsions. I understand the this reaction may occur up to 2 weeks after I discontinue disulfiram. It has also been explained to me that the safe use of this drug in pregnancy has not been

established. I understand that sexually active women taking disulfiram should be practicing a

medically effective, reliable method of birth control. I understand that if I were to become

pregnant, it is recommended that I terminate disulfiram therapy.

Signature: ________________________________

Witness: ________________________________

Date: ________

Exhibit 29: Disulfiram Consent Form
123

about the disulfiram protocol. A booklet, “Disulfiram Guidelines,” is available free from Wyeth-Ayerst Laboratories. If this is used, therapists could

then have patients take the disulfiram quiz and complete the medical ID card

that comes with the booklet.

The following disulfiram assurance procedures are recommended when an

appropriate spouse or significant other is available.

Show the patients (and their partners, if present) what disulfiram looks

like. Demonstrate how you would like them to take the disulfiram.

Crush it in a ceramic cup and mix it with some warm water. Add a

few ounces of juice, stir it, and have the patients drink it.

Provide encouragement and support if patients have difficulty decid

ing to drink the disulfiram. Once patients have ingested the medica

tion, offer praise (and instruct the partner, if one is participating, to

do so as well). Therapists can make positive statements like: “That

was a big step”

You should feel proud of making such a commitment” or just “Con

gratulations on making a new start.”

After drinking the disulfiram, it is important for therapists, patients,

and partners to take some time to work out the logistics of the com

pliance procedures.

• Instruct patients and partners that disulfiram will be taken at the

 clinic on urinalysis-test days and clinic staff will be their compli

 ance partner. Also, let patients know that the disulfiram prescrip

 tion will be kept at the clinic, and each time they come to treat

 ment, they will take disulfiram and receive the appropriate num

 ber of doses to be taken at home.

• Decide on a time and place to take disulfiram daily when it is

 taken at home. Suggest times such as before going to bed, before

 dinner, before breakfast, or at lunch. Try to find a regularly occur

 ring event that can be paired with disulfiram ingestion.

• Discuss the importance of reinforcing disulfiram ingestion. Dis

 cuss a reciprocal contract in which patients agree to take the disul

 firam and partners agree to do something to reinforce compliance,

 such as verbal praise, which is the simplest form of reinforcement.

 Emphasize to partners that reminding patients of the importance of

 disulfiram can help with compliance.

• Complete the Disulfiram Contract (exhibit 30); indicate the time

 of administration, number of days it is in force, place of adminis

 tration, and nature of reinforcement provided in response to tak

 ing the disulfiram.
124

 • Therapists should then discuss potential problems, that is, under what

circumstances might patients feel like drinking and not taking their

disulfiram. Preface this with an acknowledgment that this is some

times hard to talk about but is normal and to be expected. Discuss

ways that significant others can help support disulfiram therapy. Also

ask patients how they would like clinic staff and significant others to

respond if they want to discontinue disulfiram. Remind them again

that disulfiram will stay in the system for up to 2 weeks and that they

cannot drink during that period.

 • Next, engage patients and partners in role-playing on how to handle

common problems. If no partner is involved, therapists and patients

should role-play the patients’ refusal to take the disulfiram. If a part

ner is involved, training and instruction in positive communication

techniques should be used to help with appropriate responses to a

decision to discontinue disulfiram.

I, _________________________________, agree to take disulfiram at

the regularly scheduled time outlined below. I agree to do this for ______

days. After this time, I agree to talk to my therapist and to discuss whether

or not to continue taking disulfiram. I also agree to have the person

designated below witness the administration of the disulfiram each time

it is scheduled.

I, _________________________________, agree to be present and witness each take-home administration of disulfiram.

Time: __________________

Days: __________________

Where: __________________

In response to _________________________________ taking disulfiram as scheduled, I agree to_________________________________

as a means of reinforcing the taking of disulfiram.

________________________ ____________________________

Patient’s Signature Partner’s Signature

________________________ ___________________

Therapist’s Signature Date

Exhibit 30: Disulfiram Contract
125

During role-play, therapists should model effective responses for the

partner.

“I know this is difficult for you and that you are under a lot of stress,

but since you have been taking disulfiram and not drinking or using

cocaine, we have gotten along so much better. I really like being

around you when you’re not high or drunk. Is there something I can

do to help you, so we can keep things the way they are since you

stopped drinking? Perhaps we could go to the movies, or you could

go out and exercise? It would make me feel so much better if you

took your disulfiram.”

Therapists should have patients and partners practice until each one

feels comfortable in making effective responses.

 • Therapists should also facilitate a behavioral rehearsal on what to do

when partners do not want to be part of this procedure any longer.

Using modeling and constructive feedback, therapists and partners

should role-play possible scenarios in which the partners refuse to

participate in the disulfiram plan. This may occur because patients

have used cocaine or couples have had an argument. Therapists should

instruct patients to still take the disulfiram in front of their partners,

even if the partners refuse to participate.

 • Therapists should instruct patients and partners to call the clinic

promptly any time either of them does not wish to participate in the

disulfiram therapy.

 • Congratulate patients on taking a big step toward successful resolu

tion of their alcohol and cocaine problem.

 • Complete the therapist’s disulfiram checklist (exhibit 31).

Goals for reducing alcohol use and restricting use to safe environments can

be set with patients who refuse an abstinence goal. Therapists can help patients develop reasonable goals and teach patients self-control strategies to

achieve them. Miller and Munoz’s (1982) text, “How to Control Your Drinking,” contains a detailed description of the protocol.

Examples of typical goals and the clinical strategies that can be used are -

 • Limit the amount of alcohol consumed on any given day.

 • Limit the number of days in which alcohol is consumed.

 • Limit drinking to safe environments (e.g., only in the home, with

spouse present, only at restaurants when accompanied by partner).

Limited Alcohol

Use/Safe Drinking

____Arranged the patient’s

baseline disulfiram checklist

with clinic staff before the

patient received the initial dose

of disulfiram.

____Reviewed disulfiram

instructions with the patient and

gave the patient a copy of an

information sheet to take home;

informed the patient that side

effects will be monitored on a

regular basis by clinic staff.

____Reviewed the consent form

with the patient, obtained

patient’s signature, and gave a

copy of signed form to patient.

____Gave the patient written

information for disulfiram users

and had the patient complete an

identification form and place in

wallet; instructed the patient to

read booklet at home.

____Negotiated a timeframe

of___ days for disulfiram

therapy with patient; completed

the disulfiram contract with

patient (and partner, if applicable) and gave patient a copy

of signed form.

Exhibit 31: Therapist’s

Disulfiram Checklist
126

Strategies to help achieve these goals include -

 • Stimulus-control training.

 • Drink substitution.

 • Drink-refusal skills.

 • Self-monitoring and significant-other monitoring.

 • Contingency contracting.

Patients who are unable to meet their reduction goals can be encouraged to

set abstinence goals and initiate disulfiram therapy. Obtaining a backup contract can facilitate the transition to an abstinence goal. If patients continue to

refuse to set an abstinence goal after failing with their limited drinking goals,

continue to work with and counsel them toward abstinence.

The goal with patients who at first refuse disulfiram is to motivate them to at

least sample it for some specified time, perhaps only for a week or a few

days. Begin by requesting that they take disulfiram for the entire treatment

period but negotiate from there as necessary.

“How about 30 days? Give us 30 days of no drinking by taking dis

ulfiram so we have at least a month to work with you without alcohol

being a problem. This way you will be able to focus more on making

the lifestyle changes that are important to stopping cocaine use. This

doesn’t mean that you can never drink again. It just means that you

with your goal of staying off cocaine.”

Patients may refuse or hesitate because they want to succeed on their own or

by willpower. If this is the case, let patients know that by taking disulfiram

they are doing it on their own.

“You are the one who has to take the pill. You are the one actively

doing something to stop cocaine use and drinking. I think you are

doing it the smart way - you are taking steps to control the problem

before any more difficulties occur. You are not just talking about it,

you’re taking action.”

Another approach is to ask partners how disulfiram therapy would make

them feel. Have them tell the patients directly and in a positive manner why

they feel that way and the potential benefits they see in disulfiram therapy. If

patients still refuse, suggest that it is going to be more difficult to achieve a

successful outcome without disulfiram. However, do not push. Use clinical

judgment to ensure that patients do not drop out of treatment. Remember,

patients are seeking help for cocaine dependence,

Patients Who

Hesitate or Refuse
127

ot alcohol. If patients are adamant, relax and move on to another topic.

For patients who do not agree to take disulfiram, try to obtain a Backup

Disulfiram Agreement (exhibit 32). This agreement should clearly state that

patients will take disulfiram if drinking remains a problem or cocaine use

occurs in a drinking context. Here you must work closely with any partner

who is involved, so that all parties understand the agreement. If patients

agree to this, have them sign the written agreement.

If patients do not agree to sign a Backup Disulfiram Agreement, therapists

should move on and not dwell on this issue. If alcohol use continues to be a

problem, the suggestion of disulfiram therapy should be raised and discussed

with patients in a supportive and caring manner on a regular basis.

Marijuana use, like alcohol use, is common among persons presenting for

treatment of cocaine dependence. Common reasons given for the use of

marijuana by cocaine abusers are similar to those given for

Marijuana Use

Backup Agreement

It has been shown that alcohol abstinence aids in remaining cocaine

abstinent. Disulfiram is an effective aid in achieving alcohol abstinence. By choosing to take disulfiram, I make a choice not to drink.

With that in mind, I,______________________________, agree that

if I provide a positive urine sample for cocaine, fail to provide a

scheduled sample, or drink to intoxication, I will start disulfiram

therapy.

If any of the above occur, I agree to take disulfiram for _______ days.

I will follow the procedures for taking disulfiram observed at the

clinic and on my own on nonclinic days, and I will comply with blood

work as required.

In order to be cleared by a physician to take disulfiram, I will make an

appointment with the designated staff for a medical update, and I will

complete the laboratory work, if needed, as soon as possible.

Patient Signature: __________________________ Date: ________

Therapist’s Signature: _______________________ Date: ________

Exhibit 32.– Backup Disulfiram Contract
128

nalcohol use: enjoy the high, counteract cocaine-induced anxiety, relieve

cocaine-induced depression, and as a substitute when cocaine is scarce. There

are large individual differences in the frequency and pattern of marijuana

use among patients. As with alcohol, staff should assess and make recommendations based on whether marijuana use seems to be related to cocaine

use, not on whether patients meet criteria for abuse or dependence. Consideration should also be given to how marijuana use might interfere with other

lifestyle change goals. Marijuana use has rarely been observed to be a direct

antecedent of cocaine use.

Some individuals can use marijuana regularly without adversely affecting

cocaine abstinence (Budney et al. 1991, 1996). Not surprisingly, many patients are not interested in discounting marijuana use. Nevertheless, abstinence from marijuana is recommended for all patients.

The general strategy for dealing with marijuana use is as follows.

 • Recommend abstinence and offer to assist patients in applying the

strategies targeting cocaine use for marijuana abstinence as well.

 • If patients refuse abstinence as a goal, encourage them to reduce their

use through the various treatment strategies used for cocaine and al

cohol use.

 • Never discharge or terminate patients because they refuse to cease or

reduce marijuana use or are unable to meet marijuana-related goals.
129

The clinical focus of CRA + Vouchers is on resolving cocaine abuse. Other

psychiatric problems are only addressed when they appear to keep patients

from achieving or maintaining cocaine abstinence. The symptoms that most

commonly interfere with treatment are related to affective and anxiety disorders. These are addressed with behavioral interventions and, when appropriate, referrals for additional care.

When patients exhibit psychiatric problems that have no apparent relationship to cocaine abstinence but are of concern to them or the staff, they should

be referred elsewhere for treatment of those problems. Patients with psychosis and dementia have so far been excluded from CRA + Vouchers treatment, so no data are available about treating them for cocaine problems.

The majority of cocaine-dependent patients enter treatment reporting clinical levels of depressive symptomatology. In most cases, these symptoms

appear to be a consequence of cocaine and other substance abuse and dissipate precipitously with several weeks of treatment. For approximately 10

percent of patients, depressive symptoms continue to be a significant problem despite abstinence. The following protocol was developed for treating

that subset of patients. This protocol should be used in conjunction with,

rather than as a substitute for, an appropriate referral for evaluation for pharmacotherapy or other medical interventions.

If there is any indication of suicidality, a supervisor or clinician trained in

assessing suicide risk should be informed and meet with the patient. If suicide risk is high, patients should be referred immediately for further evaluation.

If patients are not an imminent threat for suicide, therapists should proceed

with treatment as usual, but evaluate suicide risk at each patient contact.

This evaluation should include standard clinical questions used to assess

suicide risk. If possible, therapists should obtain

Other Psychiatric Problems

Depressive Symptomatology

Evaluate Suicide Risk
130

written agreements from patients to engage in “safe” behavior, which includes agreeing to call the therapist or designated agency (e.g., crisis clinic)

if feeling suicidal. Therapists should keep the supervisor informed of any

changes related to suicidal status. Any time therapists feel uncomfortable

about a patient’s level of risk, the patient should be referred to an appropriate service.

The intake assessment should identify patients with depressive symptoms.

Those who score high on tests such as the BDI or have a history of depression should be monitored throughout treatment. The BDI can be administered every 2 weeks until the score falls into the normal range, after which it

can be administered monthly. Most patients who comply with their treatment plan for cocaine dependence show significant drops in their depression scores.

A decision to intervene with depression is typically not made until patients

have achieved a relatively stable period of abstinence from cocaine as well

as any other drugs or alcohol (usually 2 to 4 weeks). However, in some

cases, when patients continue to use cocaine and depression appears pervasive, treatment directly targeting depression may be initiated before abstinence is achieved.

Depression can be targeted in two ways.

 • Patients can be given a copy of the book “Control Your Depression”

by Lewinsohn et al. (1986). Therapists and patients then systemati

cally work through the chapters in the book in the manner suggested

by the authors. The theoretical basis for this treatment is that depres

sion is associated with a low density of positive reinforcement and a

high density of aversive events. The primary therapeutic goal is to

help patients alter their environment to increase the density of rein

forcement and decrease aversive events. This treatment is readily

integrated into the CRA + Vouchers approach because it involves

similar components and behavioral targets.

 • Patients can be offered a referral for evaluation for pharmacotherapy

for depression.

As patients try to implement needed lifestyle changes, they may exhibit

various levels of social anxiety about meeting new people, dating, and so

forth. If the social anxiety interferes with treatment goals, therapists should

provide a combination of social-skills and relaxation training. In addition, a

number of patients complain about persistent insomnia, which can also be

treated by behavioral methods.

Monitor Symptoms

Treatment

Anxiety
131

Relaxation training can be used in the context of CRA + Vouchers to reduce

anxiety that interferes with patients’ ability to develop a new social network,

to cope with restlessness that may contribute to insomnia, and for general

stress reduction.(This relaxation training protocol was adapted from McCrady

1986 and Goldfried and Davison 1994.)

Therapists should begin by discussing with patients how learning to relax is

an effective way to cope with their anxiety. The rationale should be tailored

to the patients’ situations.

“If you find that anxiety is preventing you from meeting new people

or going to new, drug-free social settings, relaxation skills may help

you overcome these barriers to change. Relaxation skills can be used

in the same way you have used alcohol, cocaine, or other drugs to

deal with these social situations. You can learn to feel more relaxed

and confident and to be more effective in social situations.”

After discussing the rationale, therapists should emphasize that relaxation is

a skill that patients develop through practice. Learning to relax, like any

other skill, takes time to learn, and it will take awhile for them to become

“good” at it. With practice, however, they will be able to use their new skill

effectively in many situations that are relevant to their cocaine problem.

Therapists should use guidelines and instructions, such as those developed

by Goldfried and Davison (1994), to teach patients progressive muscle relaxation skills. During the session, therapists should guide patients through

a relaxation exercise. Audiotapes of the exercise can be made so patients can

take them home and practice this new skill. Patients should be instructed to

practice twice a day, if possible. Therapists should provide patients with

self-monitoring forms for recording how relaxed they feel after each practice.

At the next session, therapists should take patients through the relaxation

exercise again, providing feedback if necessary and soliciting comments and

suggestions from them. Relaxation can be induced in many ways, and patients may have important input on what works best for them (e.g., music,

meditation). Therapists need to be flexible about procedures and practice,

while emphasizing regular, frequent practice.

After 2 to 3 weeks of practice, patients should feel fairly comfortable with

the relaxation procedures. It is important to reemphasize the need for practice. Only by continued practice can these skills be applied effectively in

daily life.

Once patients report feeling confident in their ability to relax during the

practice exercise, therapists should discuss learning to relax more quickly.

Discuss the notion that now that they and their bodies have learned what it

feels like to relax, it will be much easier to relax on

Relaxation Protocol

Relaxation

Exercise and

Practice
132

command without going through a 10 - 15 minute relaxation induction procedure.

Have patients try to relax in the office without using the tense-relax techniques they have learned. Instruct them to simply command their body to

relax and then briefly scan each muscle group to check and facilitate relaxation. Add that this brief kind of relaxation can be very useful in many situations. Have them try this once more in session and discuss how it feels.

Again, therapists should emphasize the need for practice and how with practice they will become very good at this.

Therapists and patients should set a goal to practice this brief type of relaxation during the upcoming week. Patients should be encouraged to try it as

many times each day as possible. Reminder prompts should be also discussed, such as the use of a wristwatch that beeps on the hour. Each beep can

cue patients to engage in the brief relaxation exercise.

After patients become fairly proficient with this new skill, therapists can

begin to discuss specific applications of relaxation training. Therapists should

review the patients’ functional analysis of cocaine use to identify situations

in which relaxation might serve as an alternative to cocaine use, as a means

of avoiding or preventing a trigger from occurring, or in some other way

help to reduce cocaine use. Therapists should also look for areas in the patients’ lives, such as the job site, while parenting, or in social situations,

where relaxation might improve functioning and lead to less stressful and

more pleasurable nondrug experiences.

Specific goals for using relaxation that are tailored to the patients’ situations

should be set for the upcoming week. Patients should choose one or two

situations (triggers or stresses) in which to try the relaxation skills. These

goals should then become part of the active treatment plan and modified as

needed throughout treatment.

A common symptom that occurs following discontinuation of cocaine use is

insomnia. It is important to deal with insomnia if it persists, because a regular sleep pattern is essential to good physical and mental health. For patients,

persistent insomnia is likely to interfere with making the lifestyle changes

deemed important to abstaining from cocaine use.

Therapists should consider using a behavioral intervention for any patient

who reports significant sleep difficulties that do not subside after 2 - 4 weeks

of treatment. The one described here is based largely on the effective protocols of Lacks (1987) and Morin (1993). Therapists who implement this protocol should consult one or both of these exellent resources.

Applications

Insomnia Protocol
133

Therapists should give patients an explanation and rationale for the sleep

protocol.

“To help with your sleep difficulties, we can provide a treatment that

is consistent with the other parts of your treatment program. This

treatment has been widely tested and shown to be effective. We will

try to teach you to sleep better by having you -

• Learn more about sleep.

• Keep a record of your sleep patterns.

• Learn to use what we call ‘stimulus control’ procedures to teach

 yourself to sleep on a regular schedule.

“Like other aspects of your treatment, this sleep program will in

volve learning and practice. You will learn to -

• Go to sleep rapidly once you go to bed by practicing not doing

 anything else in bed except sleep.

• Use the feeling of sleepiness as the cue to go to bed.

• Stop doing things that are associated with staying awake.

• Keep a regular sleep schedule.”

“These procedures should result in good sleep habits which will lead

to better sleep. Developing these habits will take much planning and

practice on your part. However, if you can follow through with what

you learn, you will sleep better and will have a skill you can use for

the rest of your life.”

“Most likely, it will take 4 weeks for you to see any benefits from the

sleep program. You may experience continued difficulties for the first

few weeks. You may even have additional problems and feel worse.

So, it is important not to be in too much of a hurry to sleep better, for

like any other skill, it takes time and practice to improve.”

“These new habits may seem difficult to develop at first, but you will

become more comfortable with the procedure with repeated prac

tice. Expect to be up numerous times in the beginning. You will prob

ably even feel worse after the first week of following these steps.

However, teaching your body that the bed is for sleeping, not for

worrying, tossing and turning, reading, or other activities, is prob

ably the most important part of this treatment.”

Next, explain in detail the importance of keeping a weekly sleep diary (exhibit 33) and provide patients with a copy. Explain to patients that an important part of building new and better sleep habits is closely monitoring sleeprelated behaviors to identify and strengthen cues that are associated with

falling asleep quickly, and to identify and weaken those cues associated with

staying awake. The sleep diary provides an

Rationale

Sleep Diary
134
135

inexpensive, nonintrusive, and efficient method of measuring the experiential component of insomnia.

Therapists should then show patients how to use the sleep diary.

“You are to record, soon after waking up, your estimates of how long

it took to fall asleep, how many hours you slept, how difficult it was

to fall asleep, and the quality of your sleep. It is important to find a

place to keep this form so that you remember to complete it each

morning for the next week.”

Throughout treatment, patients should closely monitor and chart their sleeprelated behaviors.

Therapists should next introduce the notion of sleep hygiene and give a

copy of the six rules (exhibit 34) to patients. These rules should be presented as important suggestions that, if followed, can help improve the

sleep pattern. Therapists should be familiar with the rationales for

Sleep-Hygiene

Rules

Rule 1 Do not drink alcohol later than 2 hours prior to bedtime.

Rule 2 Do not consume caffeine after about 4 p.m. or within 6 hours

 prior to bedtime. Learn all the foods, beverages, and medica

 tions that contain caffeine.

Rule 3 Do not smoke within several hours prior to your bedtime.

Rule 4 Exercise regularly. The best time to exercise is in the late

 afternoon. Avoid strenuous exertion after 6 p.m.

Rule 5 Use common sense to make your sleep environment most

 conducive to sleep. Arrange for a comfortable temperature and

 minimum levels of sound, light, and noise.

Rule 6 If you are accustomed to it, have a light carbohydrate snack

 before bedtime (e.g., crackers, graham crackers, milk, or

 cheese). Do not eat chocolate or large amounts of sugar. Avoid

 excessive fluids. If you awaken in the middle of the night, do

 not have a snack then or you may find that you begin to wake

 up habitually at that time feeling hungry.

Exhibit 34: Sleep Hygiene Rules
136

these rules, as discussed by Lacks (1987) and Morin (1993). It is important

for them to take the time necessary to explain the rationale for each rule and

be able to respond to patients’ questions and concerns.

After the sleep-hygiene rules are reviewed and plans are made to practice

them, therapists should discuss sleep-restriction and stimulus-control strategies (exhibit 35) and give patients a copy. Again, it is important that therapists be familiar with the rationales behind these recommendations and be

able to explain them for each instruction and respond to all concerns expressed by patients.

Sleep

Restriction

and Stimulus

Control

 • Do not go to bed until you are sleepy,

 • Get up at approximately the same time each morning, including

weekends. If you feel you must get up later on weekends, allow

yourself to arise a maximum of I hour later.

 • Do not take naps.

 • Do not use your bed or bedroom for any activity other than

sleep or sexual activity. You should not read, watch television,

talk on the telephone, worry, argue with your spouse, or eat in

bed.

 • Establish a set of regular presleep routines that signal that

bedtime approaches. Lock the door, plug in the coffee machine,

brush your teeth, set the alarm, and perform any other behav

iors that make sense for this time of night. Use your preferred

sleep posture and favorite pillows and blankets.

 • When you get into bed, turn out the lights with the intention of

going right to sleep. If you find you cannot fall asleep within a

short time (about 10 minutes), get up and go into another room.

Engage in some quiet activity until you begin to feel drowsy

and then return to the bedroom for sleep.

 • If you still do not fall asleep within a brief time, repeat the

previous step. Repeat this process as often as necessary

throughout the night. Use this same procedure if you awaken in

the middle of the night and are unable to return to sleep within

about 10 minutes.

Exhibit 35: Sleep-Restriction and Stimulus-Control Instructions
137

A common concern of many patients is that these procedures (not going to

bed until they feel drowsy, getting up at the same time every day, and no

naps) will result in their not getting enough sleep and being unable to

function at work or school. It is important for therapists to reassure them

that this is the best method for determining how much sleep a person

needs to function well. Although it may result in less sleep in the beginning, eventually the body will adjust and get on a regular schedule. Patients may not function at their optimal level during this adjustment period, but they will be able to cope. They have probably been coping with

fairly little sleep in the recent past, and this can be used as an example of

how they will be able to get through this difficult time.

Goals for practice and recordkeeping should be arranged for each relevant

behavior change. The timeframe for implementing these strategies should

be determined by patients and therapists together.

After reviewing the two handouts, therapists should reiterate the importance of following the sleep-hygiene and sleep-restriction and stimuluscontrol instructions every day.

Practice
138

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139

CRA + Vouchers should be supervised by a trained professional experienced

in substance abuse treatment and behavior analysis. Supervisors provide significant input into treatment plans and all targets for behavior change. One

of their primary functions is to keep the treatment focused on cocaine dependence and those problems that directly affect it, because this population

presents with many additional problems that may have no direct relationship

to cocaine use and can distract the therapist from the task at hand.

Supervisors’ style should include a balance of support, feedback,

problemsolving, and instruction. They should promote team problemsolving

while also making clear that therapists have primary clinical responsibility

for their patients’ care. Considering that CRA + Vouchers requires an active

therapeutic approach that can be effortful, the supervisor must serve as a

stable source of support, encouragement, and direction in implementing the

treatment plan.

Clinical Supervision

In a recent case, one patient’s goal was to arrange for direct deposit of

his paycheck so he would not have cash on hand to purchase cocaine.

The paycheck clearly functioned as a cue for cocaine use. The patient

agreed to the goal, and it became a top priority. The next week the supervisor asked if direct deposit had been arranged, and the therapist reported

that it had not. The therapist also reported that the patient had received a

paycheck and engaged in a cocaine binge. When the situation was discussed the goal with the patient who “agreed” to follow through; he did

not and instead used cocaine. Records clearly showed that the patient

had a poor history of following through on therapeutic goals and tasks.

The supervisor acknowledged that he should have made it clear that they

could not rely on the patient to make all the arrangements for direct deposit. Because it was important to maintaining abstinence , the therapist

should have assumed partial responsibility for directly assisting the patient and closely monitoring whether the task was completed prior to any

opportunity for cocaine use. In hindsight, the supervisor recognized his

mistake in not clarifying the need to the therapist of ensuring that the

task was completed. During the next session, the therapist accompanied

the patient to the bank and helped make the necessary arrangements for

direct deposit of the patient’s pay check.

Example of Supervision: Maintaining Focus
140

Weekly group supervision sessions are an efficient way to review cases. These

meetings generally last about 2 - 3 hours and cover all new and active cases.

During the meeting, therapists update the team on each patient’s progress.

Specific behavioral targets and goals are set. Supervisors assist therapists in

evaluating progress and in revising plans that are not progressing adequately.

The supervisor completes the Supervisor’s Checklist (exhibit 36) for each

patient each week to ensure that progress on all specific treatment goals is

reviewed.

New cases are presented according to the following guidelines.

 • Cases should be staffed in the weekly supervision meetings within 1

week of case assignment.

 • It is the therapist’s responsibility to see that the following materials

are available for the staffing:

 • An overview of the intake notes, including a detailed lifetime history

of cocaine and other drug use and the reasons the person is now seek

ing treatment

 • Other relevant historic or current situation information, such as prior

treatment, probation status, other ongoing treatment, and suicidal ide

ation

 • Scores from the self-tests and assessment instruments used

 • A completed problem list

 • A tentative treatment plan

Treatment plans should be finalized after the therapist presents the new case

and the supervisor and other staff have provided input. If more information

is needed, the treatment plan can be finalized during the next supervision

meeting.

 •Goals and priorities should be set by the supervisor and therapist in col

laboration. Both primary and secondary areas for change should be

identified and prioritized. How and whether to use a voucher system

should be decided.

 • Goals should be operationalized. The supervisor should assist the

therapist in defining goals in concrete, measurable terms so that

progress on specific behaviors can be tracked.

 • The supervisor should assist the therapist in determining how to mea

sure and depict progress graphically in each goal area.

Weekly Clinical Staff Supervision

New Cases
141

Exhibit 36: Supervisor Checklist by Case

Name________________ Dates

Primary drug (graph)

Secondary drug (graph)

Attendance (graph)

Primary behavior (graph)

Secondary behavior (graph)

Crisis?

Name________________ Dates

Primary drug (graph)

Secondary drug (graph)

Attendance (graph)

Primary behavior (graph)

Secondary behavior (graph)

Crisis?

Name________________ Dates

Primary drug (graph)

Secondary drug (graph)

Attendance (graph)

Primary behavior (graph)

Secondary behavior (graph)

Crisis?

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____
142

Therapists should present each active case, following the format outlined on

the supervisor’s checklist.

 • The therapist should begin by presenting the patient’s cocaine uri

nalysis graph; this underscores the primary focus of treatment. Any

recent cocaine positives should be discussed. Procedures to decrease

the likelihood of further cocaine use should be suggested and spe

cific behavioral interventions defined.

 • Any alcohol or other drug use that is being actively targeted or moni

tored should be reviewed. Graphs should be shown with urinalysis,

breath alcohol levels, or self-report data, and interventions in that

area should be reviewed or suggested.

 • Any attendance problems should be discussed.

 • The primary behavior change targeted, other than drug abstinence,

should be reviewed and progress evaluated in graphic form. Any

change in goals or new behavioral strategies should be suggested and

implemented at this time.

 • Up to four other secondary behavior change goals should be reviewed

in a similar manner. Any change in goals or new behavioral strate

gies should be suggested and implemented at this time.

 • Once treatment targets are reviewed, any recent crises or relevant

clinical issues, such as suicidal ideation or newly identified problem

behaviors, should be discussed.

At any point in treatment, treatment goals and behavioral targets can be

changed. Changes in goals may be precipitated by -

 • Achievement of prior goals.

 • Failure to make any progress toward a specific goal.

 • Clear indication that the goal is not functionally related to cocaine

use. Proposed changes should be discussed and specific revi-sions

documented. This process should continue throughout treatment.

Therapists and other staff members should meet daily to briefly (e.g., 10

minutes) inform each other about issues that may require team assistance.

CRA + Vouchers requires a team effort, and CTT meetings are used to facilitate and coordinate that approach. Therapists and other clinic staff can enlist

one another’s help to facilitate patients’ behavior change by using their joint

resources.

Active Cases

Counselor Treatment Team Meetings
143

These meetings help keep therapists focused on patients’ specific behavior

changes and provide a means for group support, problemsolving, and accessing help from colleagues. Additionally, they serve as a prompt for therapists to be proactive in facilitating progress on their patients’ goals. CTTs

are particularly useful in facilitating continuity of care when therapists are

out ill, on vacation, or otherwise unavailable. For example, if a goal of one

patient is to complete an application for employment at a particular worksite

but his therapist is not available to assist him, another therapist or staff member can volunteer to cover the case and assist in completing the application.

Most importantly, CTTs enhance the clinic’s ability to provide comprehensive and timely treatment interventions, which are the mainstay of the CRA

+ Vouchers approach to treating cocaine dependence.
144

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145

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