Chapter 4Practical Application of Treatment Strategies

Theprecedingchapterdescribeswhatisknownabouttheeffectivenessoftreatmentsforstimulantusedisorders.Thischapterfocuseson
howtousethatinformationtoimprovetreatmenteffortswithstimulantusers.Wheneverpossible,treatmentrecommendationswill
employstrategieswithempiricalsupport.However,becausemanystimulantusetreatmentissueshavenotbeensystematicallyresearched,
therecommendationsoftheTIP'sConsensusPanelasaugmentedbyfieldreviewfeedbackarethebasisforotherrecommendations.

Individualsseekinghelpforstimulantdependencereceivethemajorityoftheirtreatmentinoutpatienttreatmentprograms.Accordingly,
thetreatmentstrategiesdescribedemphasizetechniquesemployedinoutpatienttreatmentprograms.However,manyifnotmostofthese
strategiesandtechniquescanbeintegratedintoprogramsotherthanstructuredoutpatienttreatmentprograms.

Thischapterdescribesthekeycomponentsofthestimulantusedisordersinchronologicalorderastheytypicallyunfoldtoprovide
cliniciansdeliveringtreatmentwithaclinicalroadmap.Treatmentrecommendationsareofferedtosystematicallyaddresstheseclinical
issuesastheyemerge.

Thischapteriswrittenwiththeassumptionthatabstinencefromallmoodalteringpsychoactivedrugsistheultimatetreatmentand
programgoal.Althoughthereisdebateabouttheuniversalappropriatenessofthisposition,thecurrenttreatmentsystemintheUnited
Statesisfoundedonthisphilosophy.Thischapteralsoassumesthatstructuredoutpatienttreatmentwillbeviewedasoneinterdependent
componentofalargersubstanceusedisordertreatmentprocessandsystem.Manystimulantdependentindividualsexperiencemedical
problemsoremergencies,psychiatricproblemsorcrises,orvarioussocial,legal,oremploymentproblems.Asaresult,althoughthis
chapterfocusesonoutpatienttreatmentofstimulantabuseanddependence,itacknowledgesthecriticalimportanceofinstitutionsand
processessuchashospitals,medical/psychiatricmanagement,andcasemanagement.

Thischapterassumesthattheclientorthepotentialclientismedicallyandemotionallyreadyforentryintooutpatientcare.Chapter5
describesthemedical/psychiatricfactorsthatshouldbeconsideredtoensurethesafeadmissionoftheclientintoanappropriatecare
setting.Inadditiontothesesafetyelements,thereareotherconsiderationsforsomestimulantusergroups(e.g.,pregnantwomen,women
withchildren,adolescents,thosewithcoexistingdisorders,theseverelyimpoverished,andhomelessindividuals)inwhichtheuseof
outpatientstrategiesmaynotbeappropriate.TreatmentconsiderationsforclientgroupswiththesespecialneedsarediscussedinChapter
6.ClientWorksheetsreferredtothroughoutthischapterarelocatedinAppendixB.

Treatment-Seeking Stimulant Users

Stimulantusedisordertreatmentisahealthcareservice,andstimulantusersarethecustomersforthatservice.Foratreatmentprogram
toeffectivelymeettheneedsofstimulantusers,itisessentialtounderstandtheperspectiveofthe"customer"assheapproaches,enters,
andparticipatesintreatment.Forexample,opiateaddictedindividualsfrequentlyinitiatecontactwiththetreatmentsystemwhenthey
haveexhaustedallresourcesandareinfearofthediscomfortofopiatewithdrawal.Theirinitialoverridingpriorityisfor"treatment"to
providemedicationtopreventoralleviatesymptomsofwithdrawal.Treatmentprogramsincapableofrespondingtothisclientpriorityare
unlikelytosuccessfullyengageopiateaddictsintreatment.

Stimulantusersapproachthetreatmentsystemwithadifferentsetofprioritiesthanopiateusers,becauseforthemavoidanceofthe
withdrawalsyndromeisnotamajormotivatingfactor.Theprioritiesofstimulantusersandtheassistancetheyareseekingvarymore
greatlythanthoseofopiateaddictedindividuals.However,therearesomecommonthemesinthepretreatmentperspectiveofmany
stimulantusers.

"Bad Things Are Happening"

Admissioninterviewswithstimulantusersprovidesubstantialevidencethatoneofthemajortreatmentseekingconsiderationsformost
individualsisthattheiruseofcocaineormethamphetamine(MA)hasresultedinnegativeconsequences.Theseconsequencesinclude
legal,jobrelated,medical,family/relationship,financial,andpsychiatricproblems.Frequently,thetreatmentseekingstimulantuseris
focusedmoreonreceivingassistancewiththeseproblemareasthanonachievingabstinencefromcocaineorMA.
"Life Is Out of Control"
Treatmentseekingstimulantusersfrequentlysay,"Mylifeisoutofcontrol."Theypointtotheirexcessivebehaviorsassociatedwith
obtaining,using,andrecoveringfromtheuseofcocaineorMA.Thesebehaviorsinclude,butarenotlimitedto

Extremefinancialirresponsibilityand/orinitiationofillegalactivities
Lackofroutineselfcarebehaviors(e.g.,eating,sleeping,bathing)
Excessiveorpersonallyaberrantsexualbehavior
Severelydeterioratedemployment/educationalperformance
Escalatingirresponsiblebehaviortofamilyandspouse(e.g.,spendingsubsistencemoneyondrugs,failuretocareforchildren,
maritalinfidelity)

Accompanyingthesebehaviorsisanarrayofemotionalturmoilincludingbutnotlimitedto

Extremecyclesofeuphoriaanddepression
Intenseanxiety,fear,guilt,andshameovermedical,fiscal,legal,andpersonalrelationships
Anergia(lackofenergy)andanhedonia(inabilitytofeelpleasure)duringperiodsofabstinence
Anger,paranoia,andirritabilityduringbothperiodsofuseandperiodsofabstinence

Cognitive Impairment/Clinically Significant Paranoia

AsdocumentedinChapter5,theuseofstimulantsproducessignificantcognitiveimpairment(vanGorpetal.,1998)andfrequentlyis
accompaniedbysevereparanoia.Usershavedifficultyconcentrating,impairedshorttermmemory,andarelativelyshortattentionspan.
Theirabilitytorecognizetheinterconnectednessoftheirstimulantuseandthechaosoccurringintheirlivesispoor,andthepervading
senseofparanoia(especiallyforMAusers)makesthedevelopmentofaplantoremediatetheirproblemsverydifficult.Inshort,itis
oftendifficultforstimulantuserstomakesenseofwhatishappeningtothem.

Ambivalence/Skepticism About Treatment

Manyuninitiatedcliniciansarefrequentlyfrustratedandangeredbywhattheyperceiveasa"lackofmotivation"orthepresenceof
"denial"intreatmentseekingstimulantusers.Fewstimulantusersentertreatmentwithunconditionalenthusiasmaboutthegoalsand
methodsoftreatment.Asignificantnumberpresentfortreatmentexhibitinghostility,skepticismabouttheneedfortreatment,and
oppositiontofundamentalelementsofmanytreatmentplans(e.g.,cessationofalcoholandsecondarysubstanceuse,participationinself
helpprograms).Althoughmanystimulantusersprofessastrongdesiretodiscontinuestimulantuse,theirresistancetoinitiating
recommendedtreatmentbehaviorsisoftenasourceofclinicianfrustration.Therecognitionofthisambivalenceasanintegralpartofthe
stimulantaddictionsyndrome,ratherthanasafrustratingimpedimenttoworkingon"therealtreatmentissues,"canhelpclinicians
recognizetheimportanceofeffectivetechniquestomotivatepositivebehavioralchange.

Craving
Theexperienceofcravingasubstanceisahallmarkofalmostallsubstanceusedisorders.However,forstimulantusers,theexperience
ofcravingplaysanimportantroleinthemaintenanceofdruguse.ThebasicresearchfindingsdescribedinChapter2havedocumented
theexistenceofneurophysiologicalcorrelatesofstimulantcraving.Virtuallyallstimulantusershaveexperiencedcravingbuthavelittle
understandingofthebiologicalunderpinningsofthissubjectiveexperience.Thepowerandvolatilityofthiscravingresponsecanbe
exceptionallydifficultforsomestimulantuserstoresist(especiallythosewhousetherapiddeliveryingestionmethodsofsmokingor
injection).Formany,itisvirtuallyimpossibletoimaginehow"counseling"orsomeotherformofnonresidentialtreatmentwillhelpwith
this"irresistibleforce."

Thiscombinationofbehaviors,attitudes,andemotionsisfrequentlypresenttovaryingdegreeswiththemajorityoftreatmentseeking
cocaineandMAusers.Otherissuesthatfrequentlyareprioritiestotreatmentseekingstimulantusersincludethedysphoriathatoccurs
upondiscontinuationofstimulants,oftenreferredtoas"thecrash"(GawinandKleber,1986)thecompulsivesexualbehaviorofmany
men(especiallyMAusers),whichisoftenreportedasequallyormoredifficulttocontrolthanthedruguse(Rawsonetal.,1998b)and
thediscouragementaboutpreviousattemptsinandoutsideoftreatmenttodiscontinuestimulantuse,onlytoexperiencerelapsetoeven
moreseverelevelsofdruguse.Thissetofattributesis,inmanyways,the"rawmaterial"thatprogramsneedtoaddressinthetreatment
ofstimulantusers.

Treatment Needs of Cocaine Users Versus Methamphetamine Users

InonesiteinSouthernCalifornia,agroupof500MAusersandagroupof224cocaineusersweretreatedusingthesameoutpatient
protocol(theMatrixmanual),inthesameoffice,withthesamestaffduringthesametimeperiod(Rawsonetal.,1996Huberetal.,
1997).Althoughthereweresomesubstantialdemographicanddrugusedifferencesbetweenthetwogroups,theirresponsetothe
outpatienttreatmentprotocolwasvirtuallyidentical.MAuserspresentedwithhigherratingsofdepression,hallucinations,andseveral
othersymptoms,andexhibitedamoreprolongedperiodofsymptomremission.Yetthedatacollectedduringtreatmentandatfollowup
suggestedcomparableresponsetothisoutpatientexperience.

Thereappearstobelittleempiricalrationalefordesignatinganyoneofthefollowingpsychosocialapproachesasbeingdifferentially
effectiveforthetwostimulantusergroups.Therefore,thefollowingtreatmentrecommendationsapplytousersofbothcocaineandMA.

Maximizing Treatment Engagement

Make Treatment Accessible

Programsshouldmaximizetreatmentaccessibility.Researchhasshownthatplacingtreatmentprogramsinareasconvenienttoclientsis
associatedwithlowerattritionrates(Stark,1992).Treatmentshouldbeprovidedduringthehoursandonthedaysthatareconvenientfor
clients.Ifthemajorityofclientsdonotworkandfindboredomandlackofdaytimeactivitiesasignificantcontributingfactortosubstance
use,daytimetreatmentprogrammingmaybehelpful.Forprogramswithasubstantialnumberofworkingclientsitisessentialtohave
eveninghours.Someprogramsmayneedmultiplesetsofhoursfordifferentclientgroups.Programsshouldbelocatedintheareasthat
areaccessibletoclients,suchasnearpublictransportationandinapartoftownviewedassafeforeveningvisits.Inruralareas,small
satellitesitesmaybeneededtobringtreatmentclosertoclients.Facilitiesshouldbeaccessibletoindividualswithdisabilities.

Provide Support for Treatment Participation

Researchhasdemonstratedtheimportanceofaddressingclients'concreteneeds,includingtransportation,housing,andfinances(Chafetz
etal.,1970).Providersmayfinditnecessarytoestablishprotocolsforrapidlyaddressingtransportationbarriers,suchasbyprovidingbus
tokens,busandcabfare,andvans.Somelogisticalbarrierscanbeovercomebyonsiteservices,throughagreementswithsubcontractors,
orbyreferrals.Thesecanincludeprovidingonsitechildcareservices,referralstotemporaryshelters,vouchersforlunches,targeted
financialassistance,assistancewithpaperworkregardinginsurance,orfilingfordisability.

Referralsshouldnotbelimitedtoprovidingclientswiththename,address,andphonenumberofanagency.Rather,referralsshould
involveadvocacy:networkingwithagenciesandorganizations,callingthosecontacts,andsettinguptheappointmentsorvisits.

Respond Quickly and Positively to Initial Telephone Inquiries

Stimulantusersoftenmaketheirfirstcontactwiththetreatmentsystemonthetelephoneorasaresultofanexploratoryvisittoa
counselorortreatmentprogram.Themannerinwhichthereceptionist,intakeworker,counselor,orotherstaffpersonhandlestheinitial
contactwiththeprospectiveclientmaydecidewhetherornottheindividualdecidestoentertreatment.Timelinessisanimportantfactor
too.Havingacounselor,intakeworker,orotherstaffpersonavailabletoanswertelephoneinquiriesimmediatelyforasmanyhoursper
dayaspossiblewillincreaseadmissionrates.Telephoneinquiriesshouldbeansweredwithoutsubstantialdelay(stimulantusersareoften
impatientindividuals,whohangupwhenplacedonhold).Takingmessagesandcallingbacklaterwillfrequentlyresultinafailuretofind
theindividualsor,whencontacted,theymayhavechangedtheirminds.Having24hourhotlinescanbeusefulbecausesomestimulant
usersortheirfamilymembersmaketheirinitialtreatmentinquiriesduringlatenightandweekendhours.

Seekinghelpatanaddictiontreatmentprogramcanbeaprofoundlydifficultandpainfulact.Infact,inmanycases,afamilymemberor
friendoftenmakestheinitialcontactwiththetreatmentprogram.DatafromtelephoneinitialcontactstotheMatrixCenterclinicsin
SouthernCaliforniaindicatethatapproximately45percentofallinitialtreatmentinquiriesarenotmadebythepotentialclient,butrather
aremadebyafamilymemberorfriend.

Insometreatmentprograms,thereisabeliefthatunlessthepotentialclientmakesthecallfortheinitialappointment,itisinappropriate
toscheduleone.Thispolicyisapparentlybasedonthebeliefthatrequiringsubstanceusersthemselvestomaketheinitialcallhelpsto
reduceclient"denial"anddecreasesthe"noshow"rate.AnalysisofthedatafromtheMatrixcallsindicatednosignificantdifferencein
"noshows"dependingonwhomadetheinitialappointment.Becauseambivalenceabouttreatmentiscommonamongtreatmentseeking
stimulantusers,methodsto"screenout"thosewhoare"indenial"arecounterproductiveandimpedetreatmententry.

Schedule Initial Appointments With Minimal Delay

Theindividual'sdecisiontoseekhelpmaylastforonlyabriefperiodoftime.Asaresult,manyindividualsseekinghelpfailtoshowup
fortheirinitialappointmentifitisscheduledtoofarinthefuture.Forthesereasons,theinterviewshouldbescheduledassoonaspossible
andwithin24hoursafterclientsinitiallycontacttheprogram(HigginsandWong,1998).Figure41discussestheimportanceof
scheduling.

Box
Figure41:ScheduleAppointmentsQuickly.Makinganappointmentwithin24hoursofinitialphonecontact
significantlyincreasesthelikelihoodofshowingupforaninitialappointment(Festingeretal.,1995,1996Stark,
1992Starket(more...)

Programsmaynotalwayshavetheresourcestoconductthoroughintakeinterviewswhenevercontacted.However,programscanprovide
interimservicesorminimalcontact.Forexample,abriefintervieworapartialintakewithin24hourswouldbepreferabletomakingan
appointmentseveraldaysaftertheinitialcontact.Theinterviewmightidentifyanyacuteneedsthatrequireimmediateattention.Also,
treatmentprogramscanprovideorientationmeetingsinlieuofwaitinglists.Ifawaitinglistcannotbeavoided,staffmemberscan
telephonetheindividualtoexpressconcernfortheindividual'swellbeing,conductminiassessments,andprovidebasicrecommendations,
suchasattendinga12Stepmeeting.Sucheffortscanserveasatemporarybridgebetweentheinitialcontactandathoroughinterview
andassessment.Theseinterimservicescantakeadvantageoffleetingmotivationsforchange.

Assessment Procedures To Enhance Treatment Engagement

Keep Assessments Brief

Manyprogramsconductmultipleassessments,oftenbyseveralmembersofmultidisciplinaryteams.Thistechniquemaybeusefulfor
someclients,suchasthosewithcomplexcoexistingdisorders.However,stimulantdependentindividualsareoftenirritatedbylengthyand
repetitiveassessments.Forsuchclients,itisessentialthatclientassessmentsconductedearlyintreatmentnotbecomeonerousorbarriers
totreatment.Accordingly,initialassessmentsshouldbebrief,focused,andnonrepetitive.Thereareseveralclinicalassessment
questionnairesforstimulantusersavailableinWashtonandRawsonetal.(Washton,1991Rawsonetal.,1991b).

Identify Clients' Expectations

Itisimportanttoidentifyclients'expectations,aswellastheirfears,concerns,andanxieties.Forexample,clientswithprevious
treatmentexperiencesmayhaveanxietiesabouttreatmentfailure.Programsshouldspecificallymakeeffortstodiscoverclients'worries
andidentifythoseissuesthatcanbedispelledthroughinformationandeducationabouttheprogramandthetreatmentprocess.An
importanttaskhereistohelpeliminatetheirfearoftheunknown.

Provide Clear Orientations

Individualsneedathorough,clear,andrealisticorientationaboutstimulantaddictiontreatment.Clientsshouldacquireagood
understandingaboutthetreatmentprocess,therulesofthetreatmentprogram,expectationsabouttheirparticipation,andwhattheycan
expecttheprogramtodoforthem.Theyshouldunderstandthebasiccomponentsoftreatment,theamountoftimethatwillbeinvolved,
andwhatwillhappennext.Anorientationcanhelptodispelfearsandanxietiesandcanhelptocorrectmisunderstandings.Researchhas
shownthatprovidingeffectiveorientationshasapositiveeffectonprogramretention(Stark,1992).Partsoftheorientationmayneedto
berepeated,becausecognitivelyimpairedstimulantdependentclientsmayforgetwhattheyhavebeentold.

Offer Clients Options

Motivationresearchdemonstratesstronglyandconsistentlythatpeoplearemostlikelytoengageinanactionwhentheyperceivethatthey
havepersonallychosentodoso.Inordertoperceivethatonehasachoice,theremustbealternativesfromwhichonecanchoose(Miller,
1985).Researchsuggeststhatsubstanceusedisordertreatmentismoreeffectivewhenaclientchoosesitfromamongalternativesthan
whenitisassignedastheonlyoption(Kissinetal.,1971).Theabilitytochoosealsoseemstoreduceclientresistanceanddropout
(Costello,1975Parkeretal.,1979).Thus,itisimportanttoprovideclientswithoptionsandnegotiatewiththemregardingthetreatment
approachesandstrategiesthatarethemostacceptableandpromising.

Keep It Simple
Initialinformationandinstructionsshouldbesimpleandclear.Althoughclientswithstimulantusedisorderswillvary,manywillhave
cognitiveproblemsthatwilllimittheirabilitytofollowlongandcomplexinstructionsorexplanations.Asnotedabove,itisvaluableto
includeclientsinselectingtheirtreatmentplan.However,oncetheselectionismade,itisimportanttobeclearaboutthespecific
requirementsofthetreatmentrecommendationandthenextstepinthetreatmentprocess.

Involve Significant Others

Wheneverpossible,familyandsignificantotherswhosupportthetreatmentgoalsshouldbeinvolvedinthetreatmentprocess,including
theinitialassessmentandintakeprocesses.Significantotherscanprovidecollateralinformationregardingtheindividual'saddictionand
canbeevaluatedregardingtheirpotentialforhelpingtopromotethetreatmentgoalsorforhinderingprogress.

Significantothersshouldbeprovidedwithinformationabouttheaddictiveprocess,thetreatmentprogram,assessmentresults,andthenext
stepsforthemselvesaswellasfortheclient.Individualswhowalkawayfromasignificantother'sassessmentprocesswithoutinteracting
withprogramstaffmembersarelikelytofeelneglectedandignored.Also,significantotherscanbegiveninformationabouttheirrolein
theaddictionprocess.Theyalsoshouldbeprovidedwithinformationaboutcodependencyandselfhelpforsignificantothersofaddicted
persons,suchasthatprovidedbyAlAnon.

Staff Behaviors To Enhance Treatment Engagement

Treat Clients Respectfully

Researchhasshownthatwelcomingclientsandtreatingthemwithrespectareimportantfactorsinimprovingimmediateandlongterm
retention(Chafetzetal.,1970).Individualswhocontacttreatmentprogramsshouldbetreatedwithcourtesy,friendliness,respect,and
warmth.Theimportanceofprofessionaldemeanorandarespectfulattitudetowardclientsappliestoallstaffmemberswithwhomthey
havecontact,includingbothclinicalandnonclinicalstaffmembers.Potentialclientsshouldnot,forexample,beputonholdforlong
periodsoftime.

Althoughitistruethatsomestimulantdependentindividualscanbedifficultandprovocative,theseclientsareoftenfrightened,
disoriented,andcognitivelyimpaired.Allprogramstaffmembersshouldconsiderthecouragethatittakestoseekhelpfortreatmentand
theshameandanxietythatmostclientsexperienceenteringtreatment.Staffmembersshouldprovideindividualswithpositivefeedback
foraskingforhelpandseekingtreatment.

Convey Empathic Concern

Areviewoftreatmentresearchnotedthatevidenceofhighlevelsoftherapistempathyisassociatedwithpositivetreatmentoutcomes,
andempathywasthepredominanttherapistcharacteristicassociatedwithpositivetreatmentoutcomes(Landry,1995).Counselorsshould
bewarm,friendly,engaging,empathic,straightforward,andnonjudgmental.Althoughmanyclientswithstimulantusedisordersrespond
poorlytoconfrontationandpressure,counselorsshouldnothesitatetoprovideadvice,especiallybehavioralprescriptions.Adviceand
recommendationsshouldbeprovidedinacaringandhelpfulway,notinacontrollingorconfrontationalfashion.Counselorsshouldmake
deliberateattemptstoexertcalmingeffectsonclientsandremainmindfulofclients'potentialforextremeimpulsivenessandirritability.

Whenstimulantusersaretreatedinacalmandrespectfulmanner,violentreactionsareveryrare.However,authoritarianand
confrontationalbehaviorbythestaffcansubstantiallyincreasethepotentialforviolence.

Do Not Fight Resistance

Aggressiveconfrontationswithclientsmustbeavoided.Itiscounterproductivetofightresistancetochangeorresistancetotreatment.
Rather,takestepsthatpromotethetherapeuticalliance.(SeeMillerandRollnick,1991,foranexcellentdescriptionofthesemethods.)
Confrontationalstrategiesdesignedtobreakthroughthe"denialprocess"arecounterproductiveandmaybedangerouswithstimulant
users(Liebermanetal.,1973Milmoeetal.,1967).Clientreadinessfortreatmentandmotivationforchangearenotstaticconditions.
Rather,thesearedynamicprocessesthatcanbeincreased(ordecreased)throughcounselorefforts.Counselorsshouldcultivatethe
motivationandreadinessofclientsforchangeandgrowth(Miller,1995).

The Treatment Plan

Fewdatasupportspecificrecommendationsontheappropriatedurationforoutpatienttreatmentepisodes.Similarly,thereislittle
empiricalevidencetoguidetheselectionofsessionfrequency,sessionduration,orsessionformat(groupvs.individual)ofoutpatient
servicesforcocaine/MAusers.However,itdoesappearaccuratetoviewtreatmentasasetofproceduresthataddressaseriesofclinical
issuesinafairlypredictablesequence.Toorganizetreatmentstrategies,itcanbehelpfultoviewthetreatmentprocessasconsistingof
(1)atreatmentinitiationperiod,(2)anabstinenceattainmentperiod,(3)anabstinencemaintenancephase,and(4)alongtermabstinence
supportplan.

The Treatment Framework

Oneimportantfunctionforanytreatmentplanistogiveclientsaclearstructureandframeworkfortheirtreatmentexperience.This
structuresetsupspecificexpectationsandprovidesclientswiththebenchmarkstheyneedtoplantheirtreatmentparticipationand
measuretheirtreatmentprogress.

Treatment Episode Duration

Therearenodatatoclearlyestablishtheproperdurationforatreatmentepisode.However,itisnecessarytoprovideclientswitha
frameworkfortheirtreatmentexperience.Manyoftheresearchstudiesandthosewithextensiveclinicalexperiencehaveused12weeks
(Carroll,1996)16to24weeks(Rawson,1986Washton,1989)or24weeks(Wellsetal.,1994).Ingeneral,itappearsthatadurationof
12to24weeks,followedbysometypeofsupportgroupparticipation,isacommonlyusedframework.

Session Frequency
Therearereportsintheliteraturethatdescribetreatmentplansscheduledfromonesessionperweek(Carrolletal.,1995b,1995c)upto
fivesessionsperweek(WashtonandStoneWashton,1993).Onestudythatreportedanegativetreatmentfinding(Kangetal.,1991)
reportedthatonceperweekpsychotherapywasnotaneffectivetreatmentforcocaineusers.Ingeneral,themajorityofreportshaveused
multiplesessionsperweek(2,3,4)foratleastthefirstseveralmonths,withareductiontofewer(1,2,3)throughmonth6.

Session Length
Thesessionlengthsreportedintheliteraturerangefrom30minutesto6hours.Ingeneral,sessionsof45to120minutesinlengtharemost
common.

Format
Thereistremendousvariabilityregardingtheoptimalsessionformat.Treatmentstrategiesdescribedintheliteratureincludeindividual
therapysessions(Higginsetal.,1993a)aspecifiedcombinationofindividualandconjointsessions(MeyersandSmith,1995)anda
collectionofindividual,groupcounseling,classroomdidacticsessions,andconjointsessionformats(Rawsonetal.,1995).Other
organizationsemployprimarilyagroupapproachwithindividualandconjointsessionsonanadhocbasis(Washton,inpress).Thereisno
researchtosupportthevalueofoneformatorcombinationofformatsoveranother.Themostcompellingfactorinchoosingaformatmay
bepracticalconsiderations.Individualsessionsaregenerallymoreflexibleforschedulinggroupsessionsaretypicallylessexpensiveto
deliver.Figure42presentsconsiderationsregardingtreatmentdurationandformat.

Box
Figure42:TreatmentDuration,Frequency,andFormat.Researchhasnotyetdemonstratedtheoptimalduration,
frequency,andformatoftreatmentforstimulantaddiction(HigginsandWong,1998).Someresearch(more...)

Theonlycertaintyaboutthetreatmentframeworkisthatitiscriticaltogivetheclientclear,specificexpectationsofhistreatment
involvement.Iftheexpectationistwoindividualsessionsfor4weeksfollowedbyoneindividualsessionfor8weeks,orthreegroup
sessionsperweekfor24weeks,thisshouldbeagreeduponinwritingbythecounselorandclient.Clientsshouldhaveawrittenschedule
ofexpectedattendancetheycankeepandgivetofamilymemberswhomaybeinvolvedintreatment.

Itdoesnotappearappropriatetodelivertheseservicesonanadhocorasneededbasis.Thestructureandexpectationofaprescribed
treatmentregimenhasclinicalvalue,independentofthecontentsofthetreatmentmaterials.Certainlytheremaybemodificationsinthe
treatmentplanastreatmentproceeds,basedonclinicalprogressorotherconsiderationshowever,theinitialcontractneedstobespecific
andclear.

Strategies for Initiating Treatment

Duringthefirstdaysandweeksoftreatment,itisimportanttorememberthatalthoughstimulantusersdonothavetocontendwiththe
uncomfortablewithdrawalsymptomsoftheopiateorthealcoholdependentclient,theyoftenareexperiencingasetofdysphoric
symptoms.Theinitialperiodofstimulantabstinenceischaracterizedbysymptomsofdepression,difficultyconcentrating,poormemory,
irritability,fatigue,cravingforcocaine/MA,andparanoia(especiallyforMAusers).Thedurationofthesesymptomsvarieshowever,in
general,theytypicallylastfor3to5daysforcocaineusersand10to15daysforMAusers.Theseverityofthesesymptomsandthe
dysfunctiontheyproducemaybesufficienttowarranthospital/residentialcareinordertoestablishaperiodofabstinence(seeChapter
5).

Initial Treatment Goals

Thefirstseveralweeksoftreatmenthavesomerelativelysimpleandstraightforwardpriorities.Theyareto

Establishtreatmentattendance
Discontinueuseofpsychoactivesubstances
Finishassessmentofclinicalneeds
Remediatestimulant"withdrawal"symptoms
Resolveanyimmediatecrises

Thefollowingrecommendationsforthisperiodcanbeintegratedintoavarietyoftreatmentframeworks.

Establish treatment attendance

Initiatingaroutineoftreatmentattendanceinvolvesgivingtheclientaclearexpectationofwhenandwherethisattendanceshouldoccur,
whatisgoingtohappenwhensheattends,positivereinforcementwhenattendanceoccursonschedule,andreminderswhentreatmentis
missed.Duringtheinitialweeks,clientswillbeearly,late,comeinundertheinfluence,andfrequentlybeincrisisandconfusion.This
initialperiodisanopportunityto"shape"appropriatebehaviorbyreinforcingproperattendance.Staffshouldrememberthatsimply
attendingthesessionsisamajorindicationoftreatmentengagementandshouldbeenthusiasticallyreinforced.Therewillbeampletime
togiveclientscorrectivefeedbackonbeinglateormissingsessions.

Schedule frequent contacts

Stimulantdependentclientsappeartobenefitfromfrequentclinicvisits,evenifthecontactsarebrief.Duringthefirst2to3weeks,such
clientsshouldbescheduledformultipleweeklyvisits,evenifthevisitsare30minutesorshorter(HigginsandWong,1998).

Use positive incentives to reinforce treatment participation

Oneofthemostpowerfulstrategiestoincreasetreatmentinvolvementandestablishtreatmentengagementistouseincentivesandother
tangiblepositivereinforcerstorewardprogressintreatment(HigginsandBudney,1997).Thespecificreinforcerswilldifferamong
clientpopulations.Someclientsprefervouchersforretailitemsorcouponsforfastfoodothersappreciateclothesforthemselvesortheir
childrenorrebatesforpayments.Someprogramsholdbriefceremoniesorpresentcertificates.RowanSzalandcolleaguesdemonstrated
theeffectivenessofincentivesforattendanceatcounselingsessionsandsubstancefreeurinalysesthroughtheuseof"stars"onanawards
board(RowanSzaletal.,1994).

Aprimarymessagethatshouldbeconveyedtoclientswithstimulantusedisordersisthattheyshouldreturntotheprogram,nomatter
what.Eveniftheyusestimulantsorothersubstances,theyshouldreturntotreatment.Clientsshouldbegivenappointmentremindercards,
flyers,andschedules,withthemessagethattheyareexpectedtoreturnandthattheywillalwaysbewelcomedback.

Call no-shows

Programsshouldroutinelytelephoneclientswhofailtoshowupforscheduledclinicvisits.Clinicstaffmembersshouldencourageclients
tocomeinfortheclinicvisitandinquireaboutanypossiblecrisesthatmayhavepreventedtheirparticipation.Personalletterscanalsobe
usedasreminders.

Create a positive environment

Researchhasdemonstratedthatprovidingtreatmentinsmallergroupsinfriendly,comfortableenvironmentsisassociatedwithlower
attritionrates(Stark,1992).Programsshouldbepreparedforclientfeedbackrelatedtonotbelongingandnotfeelingcomfortable.Clients
withstimulantusedisordersoftenfeelthattheydonotbelongintreatmentbecausetheyarenotaddicted,becausetheydonotlikethe
appearanceoftheprogram,orbecausetheydonotfeelthattheycanrelatetotheotherclients.

Ratherthansimplyassumingthatthesebeliefsrepresentdefensemechanisms,programsshouldtakestepstoimprovethecomfortlevelof
thetreatmentprogramandexperience.Forexample,wheneverpossible,programsshouldtakestepstohelpclientsmaximizetheirability
toidentifywithotherclientsandnotfeelalone.Thiscanincludeestablishinga"buddysystem"inwhichasomewhatseasonedclientor
alumnusisprovidedwithopportunitiestodispelfearsandconcernsabouttheprogramandtreatmentprocess.If"buddies"arematched
accordingtoassumedsimilaritiesinbackground,theprocesscanhelpclientstofeelthattheycanrelatetoothersintheprogram.

Discontinue use of psychoactive substances

Encourage abstinence immediately

Afteraninitialassessmentinterview,itcanbeusefultoaskclientstoagreetoa"temporary"trialperiodofabstinence.Counselorscan
endthefirstinterviewwithaspecificplanforabstinence,suchasabstainingfromsubstancesofabuseatleastuntilthenextclinicvisit.
Someformofstructuredpreparatorytreatmentthatcanactasabridgetotheregulartreatmentprogramcanbeusefulforclientswhoare
unwillingtomakesuchacommitment(Obertetal.,1997).Thesecanincludeapreparatorygrouptherapythatinvolvesmotivational
enhancementtechniques(MillerandRollnick,1991).Thesegroupscanbebriefbutfrequent,suchasthreetofivetimesperweek,and
canincludeurinetesting.
Itisimportanttorecognizethatanindividualmaybeatdifferentstagesofreadinessforchange(Prochaskaetal.,1992)regarding
differentsubstances.Forexample,anindividualmayhavemadethedecisiontostopusingstimulantsbutisstillcontemplatingthedecision
tostopdrinkingalcohol.Theindividual'shesitancytoentertreatmentmayreflectambivalenceaboutalcohol,notstimulants.A
motivationalgroupmayhelptomovehimfromthecontemplationphasetothedecisionandactionphaseswithregardtoalcohol.

Establish daily schedule

Timeplanningandschedulingshouldbepromotedasanimportantwaytodeterspendingalotoftimealoneorhavingbigblocksoftime
withoutplannedactivities.Typically,thedailyroutineofstimulantdependentindividualsrevolvesaroundseeking,using,andrecovering
fromtheeffectsofstimulants.Tobreakthispattern,clientscanbetaughttousebasicdailyschedulesthroughwhichtheycanprovide
structureandaccountabilitytotheirlives.CounselorscanprovideclientswithsimpledailyschedulessuchasthoseillustratedinClient
Worksheet1,DailyScheduleandPlanner(seeAppendixBforclientworksheets).Clientsshouldbevigorouslyencouragedtoschedule
andplaneachday,especiallyduringthisearlyphaseoftreatment.Clientsshouldbeencouragedtoplantimeforclinicvisits,12Step
meetings,meals,healthysocialactivities,exercise,recreation,andleisuretime.

Initiate urinalysis schedule

Immediatelyuponenteringthetreatmentprogram,clientsshouldbeplacedonamandatory,vigilant,andfrequenturinetestingschedule.
Thisscheduleshouldcontinuethroughoutthetreatmentprocess,althoughthefrequencyoftestingcanbetaperedastreatmentprogresses.
Urinesamplesshouldbetakenevery3or4dayssoasnottoexceedthesensitivitylimitsofstandardlaboratorytestingmethods(seethe
StrategiesforInitiatingAbstinenceSectionbelowformoreonurinetesting).

Encourage 12-Step participation

Clientsshouldbeencouragedtoattenda12Stepprogrammeetingassoonaspossible.Theyshouldbeprovidedwithascheduleof
meetingsthatareeasilyaccessibletothem.Participationinselfhelpgroupsshouldbestronglyencouragedbutnotrequired.Some
individualswhorefuseselfhelpparticipationneverthelesssucceedintreatment.Thus,althoughselfhelpparticipationhasbeenshownto
beassociatedwithpositivetreatmentoutcomes(Landry,1995)andwillbeagreatresourceformanyclients,itisnotanecessary
conditionforallclientstosucceed.

Finish assessment of clinical needs

Assess psychiatric comorbidity

Manystimulantusers,especiallythosewhouseMA,willentertreatmentexhibitingsymptomsofdepressionandpsychosis.Clearlynotall
stimulantusershavecooccurringdepressiveillnessorapsychoticdisorder.Withmoststimulantusersthesesymptomssubsideover
severaldays(forcocaineusers)orseveralweeks(forMAusers).However,somestimulantusersdohaveacooccurringdepressionor
thoughtdisorder.Duringtheinitial2weeksitisimportanttoassessthepossibleexistenceoftheseotherpsychiatricconditionsand,if
present,initiateappropriatetreatment,includingmedication.Individualswhoexpresssuicidalideationorplanningshouldbetakenvery
seriouslyandshouldbetreatedasanyotherpotentiallysuicidalperson.

Assess stimulant-associated compulsive sexual behaviors

Researchdemonstratesanassociationbetweenstimulantusedisordersandavarietyofcompulsivesexualbehaviors(Rawsonetal.,
1998b).Thesebehaviorsincludepromiscuoussex,AIDSriskybehaviors,compulsivemasturbation,compulsivepornographicviewing,and
homosexualbehaviorforotherwiseheterosexualindividuals.

Stimulantdependentclientscanhavetremendousconcernsandanxietiesaboutthecompulsivesexualbehaviorsthattheyengageinwhile
usingstimulants.Suchclientsoftenassumethattheyaretheonlyoneswhohaveexperiencedsuchfeelingsandengagedinsuchbehaviors.
Asaresult,theymaybelievethattheyarepervertedsexuallyorhavesexualidentityissues.Thesefeelingscanbebarrierstotreatment
engagementandretention.Thus,programscanprovideeducationtostimulantdependentclientsabouttheassociationsbetweenstimulant
abuseandcompulsivesexualbehavior.

Remediation of stimulant "withdrawal" symptoms

Duringtheinitialseveralweeksoftreatmentitisimportanttoremindclientsthatpropersleepandnutritionarenecessarytoallowthe
neurobiologyofthebrainto"recover."Givingclients"permission"tosleep,eat,andgraduallybeginaprogramofexercisecanhelpto
establishsomebehaviorsthatwillhavelongtermutility.Thesebehaviorswillalsohelpclientsbegintothinkmoreclearlyandbeginto
feelsomebenefitfromtheinitialeffortsintreatment.

Provide crisis resolution

Clientsshouldleaveearlytreatmentsessionswithanassurancethattheprogramcanprovideorsecureimmediateattentiontocritical
medicalandpsychiatricproblems.Clientsshouldunderstandthattheprogramwillhelpthemtoobtainrapidaccesstomedicaland
psychiatricevaluationandtreatmentiftheyneedit.Writtenlistsofcommunityandselfhelpresourcesarehelpfulresources.Programs
shoulddevelopandalwayshaveaccessiblefordistributionavarietyofselfhelpandcommunityresourcematerialstoprovidetotheir
clients.Thesematerialsshouldincludethename,address,telephonenumber,anddescriptionsof12Stepmeetings,otherselfhelp
resources,medicalclinics,socialserviceagencies,temporaryhousingandshelters,batteredwomen'sshelters,andchildren'sresources.

Strategies for Initiating Abstinence

Duringthefirstseveralweeksoftreatment,mostindividualsstoporatleastreducetheiruseofstimulants.However,evenifpeoplehave
difficultyachievingtotalabstinence,thefirstseveralweekscanbeconsideredsuccessfuliftreatmentengagementisestablishedandsome
initialstepstowardabstinencearemade.Aftertheinitialtreatmentengagementof1to2weeks,aclearfocusisontheachievementof
abstinence.Althoughthereisnocleardelineationbetweenclientswhoareinitiatingabstinenceandthosemaintainingabstinence,the
initiatingperiodoccursroughlyfrom2to6weeksintotreatment.

Theprimarygoalsofstrategiesusedinthisphaseoftreatmentareto(1)breakthecycleofcompulsive,repetitivestimulantuse,(2)
initiateaperiodofabstinencefromallsubstancesofabuse,(3)encouragetheestablishmentofbehaviorsthatsupportabstinence,and(4)
initiatechangesinattitude,behavior,andlifestylethathelpmaintainabstinence.Thefollowingsectiondescribestechniquesfor
accomplishingthesegoals.

Establish Structure and Support

Initiatingabstinencefromstimulantaddictionisnotamentalexercisebutaspecificplanofbehavioralaction.Toinitiatethisplan,abasic
structureanddailyroutinemustreplacethelifestyledominatedbydrugseeking,using,andrecuperating.Structure,stability,and
predictabilityareprovidedbyasimpleplanthatclientscanfollowonadailybasis.Thedailystructureshouldincorporateandbuild
aroundtheclient'sparticipationinthetreatmentprogram.Thiswillincludeestablishingshorttermgoals,frequentcounselingsessions,
frequenturinetesting,developingasupportsystem,andtimeplanning(Washton,1989).

Shorttermgoalsshouldbesetimmediatelyandshouldbereasonablyachievable.Onesuchgoaliscompleteabstinencefromall
substancesfor1week.Becausemanystimulantdependentclientsengageinbingeuse,acomparablegoalistoachieveaperiodof
abstinenceapproximatelytwiceaslongastheusualtimeperiodbetweenbinges.Brief,frequentcounselingsessionscanreinforcethe
shorttermgoalofimmediateabstinenceandestablishatherapeuticalliancebetweentheclientandcounselor.Eventsofthepast24hours
arereviewedineachsession,andrecommendationsareprovidedfornavigatingthenext24hours.Establishingasocialsupportsystemand
conductingfrequentandregularurinetestingarealsocriticaltoprovidingstructure,support,andaccountability.

Daily schedule

Thedailyschedulingexercisedescribedintheprevioussectioncontinuestobeanextremelyimportantorganizingstrategythroughthis
phaseoftreatment.Proactivelyplanningtimeisadirectcounterpointtotheimpulsive,freeformlifestyleofthesubstanceuser.Clients
shouldwritedowntheirschedulesduringsessiontime,andsessiontimeshouldbeusedtoreviewcompliancewiththescheduleprepared
intheprevioussession.Manyclientswillfindthistaskdifficultandmayresistthis"regimentation"oftheirtime.However,ifcounselors
reinforcesuccessiveeffortstofollowsuchschedules,compliancewillimprove.

Conduct urine testing

Stimulantdependentclientsinoutpatientprogramsneedstructurethatprovidessupportforengaginginhealthybehaviors.Urinetestingis
partofthatstructure.Itshouldnotbepresentedorusedprimarilyasaninvestigativetoolorasamethodtotestthehonestyofclients.
Rather,itshouldbeusedandpresentedasameansofsupportforinitiatingandmaintainingsobriety.

Urinetestingshouldbeconductedfortheprimarystimulantandforsecondarysubstances.Testingshouldbeconductedinconcertwiththe
clinicvisits.Duringthisphaseoftreatment,urinetestingshouldbeconductednolessthanonceaweek.Testsshouldbespacedsothatthe
resultsareobtainedfromaprevioustestbeforeconductingthenexttest,whichgenerallymeansspacingtestsnomorefrequentlythan
every3days.Testingshouldberandomlyconducted,althoughitisadvisabletotestondaysthatcloselyfollowperiodsofhighrisk,such
asholidays,paydays,andweekends.Toensurethattheurineisavalidsamplefromtheclient,testingshouldbeeitherobservedor
monitoredthroughtheuseoftemperaturestrips.

Address Secondary Substance Use

Moststimulantdependentclientsalsousesomeothersubstance,suchasalcoholormarijuana.Theyoftendonotperceivetheiruseofa
secondarysubstanceasproblematic.Indeed,formanyclients,theirsecondarysubstanceusemaynothavebeenassociatedwithadverse
consequencesorcompulsiveuse.Asaresult,suchclientsneedhelptoidentifytheconnectionsbetweentheuseofothersubstancesand
theirstimulantaddiction.Clientsshouldlearnthatusinganothersubstanceincreasesthelikelihoodofrelapsetostimulants(Rawsonetal.,
1986Carrolletal.,1993a,1993b).

Clientsshouldlearnthatsomesecondarysubstancesofchoice,suchasalcohol,canhaveadisinhibitingeffectandleadrapidlyto
stimulantuse(Higginsetal.,1996).AsimilarfindinghasanecdotallybeenreportedbyMAuserswithregardtotheiruseofmarijuana
(Rawsonetal.,1996).Clientsshouldlearnthatthedoseorthefrequencyofuseofthesecondarysubstanceisnotimportant,butthat
disinhibitingeffectsandpotentconditionedresponsesandcuescanoccuratlowdoses.Achievingabstinencehelpsclientslearntodevelop
substancefreecopingmechanisms.

Clientscanbehelpedtoexaminesomeofthereasonsforwhytheyusesecondarysubstances.Forexample,somestimulantdependent
womenusealcoholasawaytotolerateanabusivesituation.Also,clientscanbetaughtavoidancestrategiesforthesecondarysubstance,
suchaseschewinghighrisksituationswherealcoholwillbeserved.

Clientsaresometimesreadyfortreatmentfortheprimarysubstanceofchoicebutnottheirsecondarysubstance.Thus,secondary
substanceuseiscommonduringthisphaseoftreatment.Althoughprogramsshouldpromoteabstinencefromallpsychoactivedrugs,
clientswhousetheirsecondarysubstanceshouldnotbediscontinuedfromtreatmentsolelybecauseofthisuse.Rather,theyshould
receivetreatmentstrategiestohelpthemdecreasethelikelihoodofdoingsointhefuture.

Establish Contingencies
Contingencymanagement(describedinChapter3)reinforcesdesiredbehaviorbyprovidingimmediateconsequences.Itcanbeusedto
improvecompliancewithtreatmentcomponentsandtopromoteabstinence.Itsetsconcretegoalsandemphasizespositivebehavior
changes.

Incontingencymanagement,aspecifictargetbehavior,suchasprovidingstimulantfreeurinesamples,isselected.Thetargetbehavior
shouldbeeasilymeasured.Next,aspecificanddesirablecontingencyisidentifiedandselectedasarewardforeachtimethatthetarget
behaviorisaccomplished.Therewardshouldnotbeexchangeableforcash,butcanhaveacashequivalent,suchasacashequivalent
vouchersystemornonrefundablemoviepasses.Thelinkbetweenthetargetedbehaviorandtherewardshouldbespecified.Finally,the
agreementshouldbedocumentedinawrittencontractandshouldspecifythedurationandanychangesovertimeincontingencies.
Contingencymanagementinterventionshavebeenshownincontrolledresearchstudiestobeeffectiveforhelpingcocaineuserstoachieve
andsustainabstinence(Higginsetal.,1994bSilvermanetal.,1996).
Initiate Avoidance Strategies
Theprocessofidentifyingcuesandtriggersisdynamicandongoingandwillchangeovertime.Forexample,asclientslearnmoreabout
theassociationsbetweenspecificemotionalstatesandstimulantcues,theycanbecomeincreasinglysophisticatedaboutidentifyingand
avoidingordefusingpotentialtriggers.However,thereareseveralstrategiesthatshouldbeusedveryearlyinthetreatmentprocessto
helpclientstoavoidcertainexternalorenvironmentalcuesthatarelikelytobepotenttriggersforstimulantcravingsandurges(Washton,
1989).Theseincludediscardingdrugs,drugparaphernalia,andmaterialsrelatedtosubstanceusebreakingcontactwithdealersand
usersavoidinghighriskplacesanddevelopingbasicrefusalskills.

First,iftheclienthasnotalreadydoneso,aspecificactionplanmustbedevelopedtofindandgetridofallsubstances(includingalcohol)
anddrugrelatedparaphernalia.Clientsshouldbeencouragedtoaccomplishthistaskwiththehelpofafamilymember,soberfriend,or
12Stepsponsortoensurethatalldrugrelateditemsarefoundandpermanentlydiscarded.Inadditiontoobjectsusedtoprepareorinject
stimulants,materialsassociatedwithdrugusethatshouldbediscardedincludephonenumbersofdealersandprostitutes,pornographic
videotapes,containersusedtoholddrugsupplies,mirrorsorspecialtablesusedtocutstimulants,andweighingscales.

Second,itisessentialforclientstodevelopspecificactionplanstobreakcontactswithdealersandotherstimulantusers.Whenspouses
andsignificantothersarethemselvesstimulantusers,itisimportanttodevelopaplantoassertivelyencouragethesignificantothertoalso
seekhelp.

Third,anactionplanshouldbedevelopedtohelptheclientavoidhighriskplaces.Thisinvolvesidentifyingplacesstronglyassociated
withstimulantuseandmakingspecificplanstoavoidthem.Thismayincludetakingdifferentrouteshomefromwork,goingtocertain
locationsattimesdifferentthannormal,orusinga"buddysystem"whengoingtoahighriskarea.Finally,aplanofactionshouldbe
developedtodealwithconfrontationswithacquaintanceswhoarestillusingstimulants.Clientsshouldpreparespecificdrugrefusal
statementsthatcanbeusedwhentheyencounterdrugusingfriendsandpracticewiththeircounselorandfellowgroupmembers.This
actionplanmustincludeimmediatelyleavingthesituationaftertheencounter.ClientWorksheet5,ActionPlanforAvoidanceStrategies
(seeAppendixB),canbeusedtoassistclientsdevelopstrategiestoavoidpotenthighriskcuesandtriggers.

Provide Client Education

Clientswithstimulantusedisordersoftendonotunderstandmanyofthethingsthattheyhaveexperiencedasaresultoftheirstimulant
use,suchasimpulsivebehaviors,angerandhostility,andcognitivedeficits.Theyrequireeducationtohelpthemunderstandthelearning
andconditioningfactorsassociatedwithstimulantuse.Similarly,theyneedinformationabouttheimpactofstimulantsandother
substancesonthebrainandbehavior,suchascognitiveimpairmentandforgetfulness.Informationaboutstimulantinducedbehaviorcan
helpthemunderstandtheepisodesofanger,hostility,andsexualcompulsivity.

Clients,especiallythosewithMAusedisorders,shouldbeeducatedabouttheearlyabstinencesyndromeandprotractedabstinence.Also,
theyshouldlearnhowtheirsecondarysubstanceofchoicehasanimportantroleinrelationtorelapsetostimulantuse.Theyrequire
educationaboutthebiopsychosocialprocessesofaddiction,treatment,andrecovery.Theyshouldalsolearnaboutthestagesoftreatment
andrecovery,aswellasthespecifictasks,goals,andpitfallsofeach.

Teach Basic Conditioning

Althoughmanyclientswithstimulantusedisordersinearlytreatmentphaseshavepoorretentionofinformationandtemporarycognitive
deficits,theycanunderstandbasicinformationaboutcuesandtriggers.Theycanbetaughthowconditioningfactorscanelicitdrug
cravingsandurges,thatthesecravingsandurgesareanaturalpartofearlyabstinence,andthattherearemethodstodealwiththem.
Clientswithstimulantusedisordersshouldbeprovidedwithbasiceducationabouttheconditioningprocessandhowthisprocessisapplied
totheirdisorder.

TheseeducationaleffortsshoulddescribebasicconditioningfactorsrelatedtostimulantuseasdescribedinFigure43.

Box
Figure43:BasicConditioningFactorsinStimulantUse.Stimulantcravingsarethepredictableresultsofchronic
stimulantuseandtypicallycontinuelongafterthestimulantuseisstopped.Stimulantcravings(more...)
Identify Cues and Triggers
Stimulant(andsecondarysubstance)usebecomesstronglyassociatedwithcertainpeople,places,objects,activities,behaviors,and
feelings.Becauseclientswithstimulantusedisordersmayhaveengagedinstimulantusehundredsorthousandsoftimes,theirdailylifeis
filledwithnumerousremindersorcuesthatcantriggerstimulantcravingsandstimulantuse.Althoughitiscommonformanyclientsto
havesomeofthesamecuesandreminders,suchasseeingthedrugorthedealer,therearewidedifferencesamongclientsregardingthe
specifictype,strength,andnumberofcues.Accordingly,itisimportantforcounselorstohelpclientstoacknowledgeandidentifythe
clusterofcuesuniquetotheirlives.

Theprimarytasksherearetoteachclientshowcuesaredevelopedandhowthesecuescantriggerdrugcravinganduse,andto
encouragethemtoactivelyidentifytheircuesandtriggers.Thiscanbeaccomplishedthroughexercisesandworksheets.ClientWorksheet
2,IdentifyingExternalCuesandTriggers,andClientWorksheet3,IdentifyingInternalTriggers,canbethebasisofexercisestohelp
clientsaccomplishthesetasks.

Develop Action Plan For Cues and Triggers

Externalandinternalcuesoftenpervadeeveryaspectofstimulantusers'lives.Asaresult,clientsshoulddevelopactionplanswith
specificbehavioralandmentalstepstopreventcuesfrombecomingtriggers.Theyshouldbetaughttoavoid,whereverpossible,external
cuesthatstronglyremindthemofstimulantuse.Theyshouldbetaughttoleavesituationsthataremakingthemthinkaboutstimulantsor
experiencecravings.Theyshouldbetaughtspecifictechniquestostopdrugthoughtsfrombecomingdrugcravings.Finally,theyshouldbe
taughtimmediatelyachievabletechniquesthatcandefusestimulantcravingsfromleadingtodruguse.ClientWorksheet4,ActionPlan
forCuesandTriggers,canbeavaluablepartofsucheducationalefforts.

Enlist Family Participation

Familiesandsignificantothersshouldbeencouragedtoparticipateintreatment.Thefamilyshouldreceiveeducationabouttheaddictive
process,itsroleintheprocess,anditsroleinthetreatmentandrecoveryprocesses.Familymembersalsoneedinformationaboutthe
effectsofstimulantsonthebrainandbehaviorinordertounderstandthestimulantinducedbehavior.Theyshouldreceiveaprimeronthe
classicalconditioningaspectsofstimulantusedisorders,andlookatcravingsasaconditionedresponse.

Theinformationshouldbeclearandsimple,andnottooconceptualorabstract.Theidealformatisagrouppsychoeducationalsession,
consistingofabriefdidacticsession,followedbyavideoandagroupdiscussion.Theprocessshouldhelptoelicitdiscussionsand
examplesabouthowwhattheyheardandsawappliestothem.Also,familyparticipationcanbeanopportunitytodoaninformal
evaluationofthesubstanceusedisordersofotherfamilymembers.Throughthisprocess,programstaffmembersmaybeabletoidentify
certaintreatmentneeds,whichmayrequiretreatmentorreferral.

Forclientswhoareactivelyworkingonachievingabstinenceandwhohaveastablemarriageorrelationshipwithsomeonewhoisnot
usingstimulants,involvingthespouseandclientincouplesorrelationshipcounselingcanbevaluable.Thisstrategycanhelptoimprove
communicationskillsandtherelationship.Researchhasshownthatmaritalandrelationshipcounselingcanhavepositiveeffectson
substancetreatment(Landry,1995StantonandShadish,1997).Ifrelationshipcounselingisconsidered,thesignificantothermustnot
haveproblemswithsubstanceuse(exceptingnicotine),andthesignificantothermustagreewiththebasictreatmentgoalsofabstinence
andbewillingtoengageinbehaviorsthatsupportsobriety.Someresearchresultsrelatedtobehavioralrelationshiptherapyarepresented
inFigure44.

Box
 Figure44:RelatedResearch:BehavioralRelationshipTherapy.Areviewofresearchevidenceregardingbehavioral
relationshiptherapyandsubstanceusedisordertreatmentoutcomes(Landry,1995)notedthatBehavioralrelationship
therapy(more...)

Establish Social Support Systems

Clientswithstimulantusedisorders,especiallyduringtheearlyphasesofabstinence,seemtohavelowfrustrationtoleranceandappearto
berestlessingroupsessions.Butassoonasclientsareabletodoso(generallywithinafewdays),theyshouldbeintroducedtoa
structuredandtherapeuticgroupprocess,suchasabeginner'srecoverygroup.Thesegroupscanprovideapreexistingsupportnetworkand
aforumforopenlytalkingaboutearlyabstinenceproblems.Atthesametime,participationin12Stepmeetings,suchasAlcoholics
Anonymous(AA),NarcoticsAnonymous(NA),orCocaineAnonymous(CA),shouldbestronglyencouraged.Clientscanbegiventhe
shorttermgoalofattendingninety12Stepmeetingsin90days.

Also,clientscanbeencouragedtoestablishorreestablishrelationshipswithnonsubstanceusingfriendsandfamilyand,perhaps,to
establisha"buddysystem"withahealthyfamilymember,friend,or12Stepsponsortocallduringcrises.

Address Stimulant Use-Associated Compulsive Sexual Behaviors

Someclientswithstimulantusedisordersdevelopsignificantstimulantinducedcompulsivesexualbehaviors.Thesecaninclude
compulsivemasturbation,compulsiveorimpulsivesexwithprostitutes,andcompulsivepornographicviewing.Fortheseclients,
interventionscanbeconducted,theresultofwhichistodecreasethelikelihoodofboththecompulsivesexualbehaviorsandstimulant
relapse.

Afirststepinvolvesaskingclientstoagreetoatemporarysexabstinenceplanfor2to4weeks.Next,clientsshouldbemadeawarethat
sexualfeelings,thoughts,andfantasiesareconceptualizedasveryhighrisktriggersthatwillbeactedoutiftheyarenottalkedout.For
peoplewhohavethisproblem,evennormal,routinesexualthoughtsandcontactscanquicklybecomemajortriggers.

Programsshouldprovideasafeenvironmentforsuchclientstotalkabouttheseissues,eitherwithinthecontextofagroupsessionor
individualcounseling.Discussionsshouldbeheldaboutsafeandunsafesexualbehaviorsinregardtorelapseprevention.Specificand
clearrecommendationsshouldincludenothavingsexwithanyonewithwhomtheclienthasgottenhigh,andnotpursuingsexwith
anonymousorunknownpartners.Clientfearsshouldbeaddressed,suchasthefearthatsexwithoutdrugswillbeboringorimpossible.

Manyoftheavoidancestrategiesusedwithpsychoactivesubstancescanbeemployedfortheseclientsinrelationtosexualcues.Forsome
clients,thesexualbehaviorhasahigherreinforcingeffectthanthestimulant.

Clientswillneedreminderstostayawayfrompeople,places,andthingsrelatedtosexualbehaviors.Thesecanincludepornoshops,
certainstreetswithprostitutes,andvideoshops.Also,clientsshouldbeeducatedaboutreciprocalrelapse,inwhichonecompulsive
behaviorisinextricablyinvolvedwithanother,andtherefore,engaginginthebehaviorsassociatedwithoneconditioncancauseonetoact
outbehaviorsassociatedwiththeothercondition.

Respond to Early Slips

Itisrareforclientstogofromactive,fullblownstimulantaddictiontocompleteabstinence.Rather,mostclientsgothroughaphase
duringwhichtherearedayswithoutsubstanceuseandoccasionaldayswithsubstanceuse.Infact,substanceuseduringthisearly
transitionfromabusiveordependentusetoabstinenceshouldnotbeconsideredrelapsebecausetherewasnotagenuineperiodof
abstinencefromwhichtorelapse.

Thus,substanceuseduringthisperiodoftransitionshouldnotbecharacterizedasrelapsebutratherasdifficultyinbreakingthepatternof
stimulantuse.Also,clientsshouldunderstandthatsubstanceuseisnormalduringthisdifficultphase,despitetheirhardeffortstothe
contrary.Programstaffmembersshouldunderstandthatsubstanceuseduringthisphaseisnotasignofpoormotivationbutreflects
multipleprocesses,includingcuesandtriggersandanotyetstablebrain.Slipscanalsobethoughtofasabehavioralindicatorofconflict
andambivalenceaboutstopping.Atthesametime,counselorsshouldclearlycommunicatethattheyarenotgivingclientspermissionto
use.Rather,theyaremakingeffortstokeeptheclientengagedintreatment.

Earlyslipsshouldbeconsideredopportunitiesforadjustingthetreatmentplanandtryingotherstrategies.Theycanbeopportunitiesfor
gaininganappreciationofthestrengthofcravingsandtriggers,andlearningnewmethodstohandlethem.Theycanbeanopportunityto
examineifthetreatmentplanisadequateandappropriateortoincreasethefrequencyofcontactwithtreatmentand/orthesupport
system,suchasselfhelpmeetingsandcontactswiththesponsor.Somerecommendationsforguidinggroupdiscussionsofslipsarelisted
inFigure45.

Box
Figure45:RespondingtoSlipsinGroupSessions.Askthepersontoprovideadetailedaccountofthesequenceof
feelings,events,andcircumstancesthatledtotheslip.Encouragegroupmemberstoasktheperson(more...)

Earlyslipsshouldnotbeconsideredastragicfailuresbutratherasmistakes.Whenslipsoccur,counselorscanmakeaverbalor
behavioralcontractwithclientsregardingshorttermachievablegoals.Thiscanincludesuchsimpletasksasagreeingnottouse
psychoactivesubstancesforthenext24hours,toattendaspecificnumberofclinicsessionsoverthenextcoupleofdays,andtobringa
significantothertotreatmentthenextday.Thisprocesscaninvolvehavingtheclientidentifyareasthatneedtobeaddressedorenhanced.
Itmaybeimportanttotakeacloserlookatcuesandtriggersanddetermineifanythinghaschanged.

Strategies To Maintain Abstinence

ManystimulantuserscandiscontinuetheuseofcocaineorMAforperiodsoftimewithouttheassistanceoftreatmentinvolvement.As
previouslymentioned,"withdrawal"isalessimportantconsiderationforstimulantusersthanitisforusersofsubstancesthatproducea
physicallyuncomfortablewithdrawal,suchasopiates,alcohol,andbenzodiazepines.Forstimulantusers,thetrickisnotinstopping,butin
stayingoff,oravoidingrelapse.Inthetreatmentofstimulantusers,achievingabstinenceisthe"warmupact"sustainingabstinenceis
"themainevent."

Thedichotomybetweenstrategiestoachieveabstinenceandstrategiestomaintainabstinenceissomewhatartificialandarbitrarybecause
manyofthesameprinciplesapplyandmanyofthesametechniquesareusedoverthecourseoftreatment.However,therearesome
issuesthatappeartoincreaseinimportanceoverthe1to4monthperiodtypicallyneededforlearninghowtomaintainabstinence.These
arediscussedbelow.

Protracted Withdrawal Symptoms

Oncestimulantuseisdiscontinuedandaclient'ssleepingandeatinghabitsarenormalized,themajorityofsymptomsdescribedasthe
"crash"typicallylessens.However,theresolutionofthecrashsymptomsdoesnotsignalthatthebrainisbacktonormal.Clinical
observationsshowthattherearesignificantbiologicalandpsychologicalsymptomsthatcontinuetohamperthefunctioningofstimulant
users90to120daysafterdiscontinuationofsubstanceuse.Thesymptomsdescribedincludeamilddysphoria,difficultyconcentrating,
anhedonia,lackofenergy,shorttermmemorydisturbance,andirritability.

Theexistenceofthese"protractedwithdrawal"symptomshasbeenthesubjectofsomedebate.Recently,evidencefrompositronemission
tomography(PET)scanresearchhasprovidedtangibleevidenceinmonkeysthatMAuseproducesverysignificantchangesinbrain
functioningthatlastformorethan6months(Melega,1997a).Thebrainareasinvolvedandtheneurochemicaldeficitsobservedinthese
PETscansareconsistentwiththeclinicalsymptomatologyofthis"protractedwithdrawalsyndrome."Althoughthereisstillreasontobe
cautiousaboutspecifyingtheprecisecauseortimecourseofthissyndrome,theredoesappeartobeneurophysiologicalevidenceto
supportthefactualbasisofthisphenomenon.

Predictable Relapse Scenarios

Thereareanumberofcommonpatternstotherelapseepisodesofstimulantuserswhoareattemptingtomaintainabstinence(Havassyet
al.,1993).Theseinclude

Alcohol/secondarysubstanceuseleadingtostimulantrelapse.Severalstudieshavereportedontherelationshipbetween
alcoholuseandcocainerelapse,andotherreportshavesupportedthissamepatternwithalcoholandmarijuanaforMArelapse
(Rawson,1986Carrolletal.,1993a,1993b).
Returntosubstanceusingfriends.ThePanel'sclinicalexperiencesuggeststhatreturningtosubstanceusingfriendsisa
primaryreasonforastimulantuser'srelapse.
Sexualbehaviorassociatedwithsubstanceuse.Particularlyformen,sexualbehaviorsespeciallyassociatedwithstimulantuse
(e.g.,prostitutes,pornography)areanimportantelementcontributingtostimulantrelapse(Rawsonetal,1998b).
Cravingelicitedbyexternalandinternalstimuli.ThepowerfulinfluenceofPavlovianconditionedcuesontheproductionof
cravinghasbeenreportedbymanystimulantusersasacontributortostimulantrelapse(O'Brienetal.,1993).
Negativeaffectivestates.Emotionalstatescanbeimportantantecedentstorelapse(Havassyetal.,1993).Stimulantusersfind
anger,depression,loneliness,frustration,andboredomquitedifficulttomanage,andthesefeelingscaninitiateabehavioral
sequencethatendsinstimulantuse.

Need for New Activities

Manystimulantusershavespentagoodportionoftheyearsleadinguptotreatmententrywiththeirlivesrevolvingaroundsubstanceuse.
Frequently,duringtheinitial6to12monthsofabstinencetheyhavelittleideawhattodowiththeirlives.Inparticular,theyoftenhave
verypoorsocialandrecreationalbehaviorrepertoires.Thecreationofnew,positivelyreinforcingactivitiesandinterestsisanimportant
partofthisperiodoftreatment.

Abstinence Maintenance Techniques

Thestrategiesrecommendedformaintainingabstinencedrawprimarilyfromthebehavioralandcognitivebehavioralmodelsdescribedin
Chapter3.Oneoverallthemeinthefollowingmaterialsisthatnewlyabstinentstimulantuserscanbetaughtasetofinformationand
skillsthatcanhelpthemavoidrelapse.Thefollowingstrategieshavebeenfoundtohelpstimulantusersmaintaintheirabstinence.

Teach Functional Analysis Of Stimulant Use

Thepurposeoffunctionalanalysisistoteachclientshowtounderstandtheirstimulantusesothattheycanengageinproblemsolving
solutionsthatwillreducetheprobabilityoffuturestimulantuse.Thecorecomponentsofafunctionalanalysisare(1)teachingclientsto
examinethetypesofcircumstances,situations,thoughts,andfeelingsthatincreasethelikelihoodthattheywillusestimulants(2)
counselingclientstoexaminethepositive,immediate,butshorttermconsequencesoftheirstimulantuseand(3)encouragingclientsto
reviewthenegativeandoftendelayedconsequencesoftheirstimulantuse.ClientWorksheet29,ComponentsofaFunctionalAnalysis,
givesclientsanoverviewofthesecomponents.

Maintain Positive Reinforcement

Employingcontingencymanagementagreementscanhelpsustaininitialtreatmentgains.Whencontingencymanagementisused,the
behavioralcontractmustbebasedonobjectivecriteriasuchasurinalysisresultsandattendanceatgrouptherapysessions.Allspecifics
mustbeclearlydetailedinthewrittencontract.Systematicandconsistentimplementationoftheagreementiscrucial:Reinforcement
mustbedeliveredpromptlywhenthecontractissatisfiedandwithheldwhenitisnot.Frequent,positivereinforcementofsuccessis
critical.

ClientWorksheet28,SampleBehavioralContractforStimulantAbstinence,canbemodifiedandusedtohelpmeetthetreatmentneedsof
specificclients.Asthissamplecontractillustrates,contingencymanagementcaninvolvereceiving"points,"credits,money,orother
benefitsorincentives.

Relapse Prevention Techniques

Relapsepreventiontechniquesteachclientstorecognizehighrisksituationsforsubstanceuse,toimplementcopingstrategieswhen
confrontedwithhighriskevents,andtoapplystrategiestopreventafullblownrelapseshouldanepisodeofsubstanceuseoccur(Marlatt
andGordon,1985).Thetechniquesinvolveseveralcognitivebehavioralinterventionsthatfocusonskillstraining,cognitivereframing,
andlifestylemodification.

Relapsepreventiontechniquesfallintoseveralcategories:

Psychoeducationabouttherelapseprocessandhowtointerruptit
Identificationofhighrisksituationsandrelapsewarningsigns
Developingcopingandstressmanagementskills
Enhancingselfefficacyindealingwithpotentialrelapsesituations
Counteractingeuphoricrecallandthedesiretotestcontroloveruse
Developingabalancedlifestylethatincludeshealthyleisureandrecreationactivities
Respondingsafelytoslipstoavoidescalationintofullblownrelapse
Establishingbehavioralaccountabilityforslipsandrelapseviaurinemonitoringand/orBreathalyzertesting

Asreviewedinthepreviouschapter,thereisasubstantialbodyofliteratureontheuseofrelapsepreventiontechniqueswithstimulant
users.ThemanualdevelopedbyKathleenCarrollprovidesanexcellentsetofrelapsepreventionexercises,whichcanbedirectlyapplied
intreatmentsettings(Carroll,1996).TheMatrixmanual(Rawsonetal.,1991b)previouslydescribedhasasectiononconductingrelapse
preventiontraininginagroupsettingandsupplieshandoutsandinstructionsfortheiruse.Washtonhaspublishedasetofrelapse
preventionmaterialsthatcanbeeasilyincorporatedintotreatmentprogramming(Washton,1990a,1990b).Also,Figure46setsoutbasic
preceptstobeusedinaddressingrelapse.Thefollowingtreatmentthemesarecriticaltotherelapsepreventionbasedtreatment
strategies.

Box
Figure46:AddressingRelapse.Anintegralaspectofrelapsepreventioninvolveseliminatingandcorrectingdangerous
mythsandmisconceptionsregardingtheprocessofrelapseandtheappropriatetreatmentresponsetoit.TheConsensus
Panel(more...)

Provide Psychoeducation About Relapse Prevention

Onemajorelementofarelapsepreventionapproachisthedeliveryofinformationtostimulantusersaboutavarietyofuserelatedtopics.
Onefrequentlyusedformatfordeliveringthisinformationisinpsychoeducationgroups.Thesegroupsconsistofamixtureofeducation,
peersupport,andrecoveryorientedtherapy.Thegroupleaderprovidesabriefdiscussionorshowsashortvideotapeonaspecifictopic
thatisrelevanttothegroupparticipants.Thegroupmembersareencouragedtodiscussthetopicasitispersonallyrelevanttothem.Also,
thegroupleaderencouragesgroupmemberstodiscusstheproblems,challenges,andsuccessesthattheyarecurrentlyexperiencing.

Thetopicstypicallydiscussedinapsychoeducationgroupforclientswithstimulantusedisordersinclude

Cravingsandconditioning
Protractedabstinence
Stimulantsandthebrain
Identificationofhighrisksituations
Developingcopingandstressmanagementskills
Enhancingselfefficacyindealingwithrelapseriskysituations
Counteractingeuphoriaandthedesiretotestcontroloveruse
Developingabalancedlifestyle
Respondingsafelytoslipstoavoidescalation
Establishingbehavioralaccountability
Manyoftheseareaddressedinthesectionsbelow.SomerecommendationsforrunningarelapsepreventiongrouparepresentedinFigure
47.

Box
Figure47:RecommendationsforRunningaRelapsePreventionGroup.Arelapsepreventiongroupisaforumfor
clientstocreateaprogramofrecoveryandrelapseprevention.Thegroupprovidesasettingforsharing(more...)

Address High-Risk Situations

Duringthepreviousphaseofestablishingabstinence,clientsshouldhavelearnedskillsfornegotiatinghighrisksituations.Inparticular,
clientsshouldbeabletoidentifycuesandtriggers,developactionplansforcuesandtriggers,anddealwithearlyabstinencesymptoms.

Enhance Self-Efficacy Regarding High-Risk Situations

Onceclientslearntoidentify,manage,andavoidhighrisksituations,thecounselorandclientshouldtrytodetermineiftheclientis
confidentinherabilitytousethoseskillsintherealworld.Itisimportanttoevaluateandhaveclientsengageinselfevaluationto
determineiftheyareoverconfidentregardingtheiravoidanceandrefusalskills,andtodetermineiftheyactuallyhavemoreskillsthan
theyimagine.ClientWorksheet11,EvaluatingYourSelfEfficacyRegardingRelapse,canhelpclientstoevaluatehowtheythinkthey
wouldhandlecertainhighrisksituationsthattheycannotavoid.Similarly,ClientWorksheet12,IncreasingYourSelfEfficacy,involves
roleplayingexercisesdesignedtosimulaterealworldhighrisksituationsandtoincreasetheclient'sselfefficacy.

Counteract Euphoric Recall And the Desire To Test Control

Twoimportantriskfactorsforstimulantrelapseareeuphoricrecallandthedesiretotestcontroloverstimulantuse.Euphoricrecallis
theactofrememberingonlythepleasuresassociatedwithstimulantuseandnottheadverseconsequences.Euphoricrecallisapotent
relapseriskfactorbecauseitminimizesclients'perceptionsofstimulants'danger,promotinganambivalenceaboutquitting.Forthese
reasons,socalled"warstories"thatincludeeuphoricrecallandselectivememoryarepowerfulrelapsetriggersandshouldbestrongly
discouragedinrecoverygroups.ClientWorksheet18,SelectiveMemoryAboutStimulantUse,canhelpclientstoexplorethisissue.

Afterbeginningtofeelhealthier,moreincontroloftheirlives,andfreeofsomeoftheirstimulantrelatedproblems,someclientsfeel
thattheyarereadytotryanewapproachtostimulantuse.Forexample,somemayfeelthatiftheyare"careful,"theycanusestimulants
withoutlosingcontrolovertheiruse.Othersmayfeelthatthisisagoodtimetotryusingstimulants"onelasttime,"justtoseeiftheycan
doitwithoutescalatingintocompulsiveuseandlossofcontrol.Clientsshouldbetaughtthaturgestotesttheircontroloverstimulantuse
areapowerfulrelapsewarningsign.ClientWorksheet19,FantasiesAboutControlledUse,canbepartofpsychoeducationefforts
designedtorecognizethesefantasiesaswarningsignsthatneedtobeaddressed.Also,ClientWorksheet20,ThoseUglyReminders,can
helpclientsmakelistsofnegativeconsequencesofstimulantuse,whichcanbereviewedwhentheyexperiencecravings,fantasizeabout
controlleduse,orromanticizetheirexperienceswithstimulants.

Respond to Slips To Avoid Escalation

Stimulantslipsandrelapsesaremistakes,notfailures,andindicateaneedtoadjustthetreatmentplan.Afteraslip,arelapsespecific
sessionshouldbescheduledasrapidlyaspossible.Thecounselorshouldreassureclientsthathehasnotgivenuponthem.Counselorsand
clientstogetherreviewandanalyzetheeventsleadinguptotheslipandidentifywhichwarningsignswerepresent.Clientsshouldbe
encouragedtoconsidertheeventsofthepreviousfewweeks,suchaschangesatwork,atschool,insocialnetworks,orinfamily
situations.Similarly,theyshouldcloselyexamineeventsandissuesthatoccurredintreatment,suchasgettingnewcounselors,moving
fromonephaseoftreatmenttoanother,oreventshappeningtoanotherclient.

Clientsshouldbehelpedtoidentifyspecificstepsthatcanbetakentoavoidfuturerelapsesintheeventthatasimilarsetofcircumstances
recurs.Mostimportantly,slipsandrelapsesshouldpromptrevisionsinthetreatmentplan.Suchrevisionsmayincludeincreasingthe
numberofselfhelpmeetings,participatinginindividualcounselingforabriefperiodoftime,orobtaininga12Stepsponsor.Also,
clientsshouldreceiverecommendationsandguidancetohandlethenegativethoughtsandfeelingscausedbyslips.ClientWorksheet7,
PermissiontoRelapse,isausefulclienthandoutforthispurpose.

Teach Drug Refusal and Coping Skills Training

Stimulantusersinrecoveryareoftensurroundedbyindividualswhocontinuetouse:dealers,neighbors,friends,orfamilymembers.The
abilitytorefusestimulantswhenofferedrequiresaspecialtypeofassertiveness,hencetheneedforaspecialtypeofassertiveness
training.Drugrefusaltrainingremindsclientsthatindividualsofferingthemstimulantsdonothavetheclient'sbestinterestsinmind.
Rather,clientsaretaughttothinkofsuchindividuals(eveniffriendsorfamilymembers)as"drugpushers"whomustbediscouraged.
Clientsaretaughtthattheirprimarygoalistorefuseoffersofstimulants.Theyaretaughtthattheirsecondarygoalsaretoreinforcetheir
commitmentstonotuseandtofeelgoodaboutthemselvesfordoingit.

Thisapproachemphasizesthefollowingelementsthatshouldbeincorporatedintoencounterswithindividualsofferingstimulantsor
invitingtheclientintohighrisksituations.

Thefirstthingthatshouldbesaidtothepersonmakinganofferofstimulantsis"No."
Thepersonmakingtheoffershouldbeclearlytoldnottomakesuchoffersnoworinthefuture.
Theclientshouldmakegoodeyecontactandadoptanexpressionandtonethatclearlyindicatestheseriousnessoftherequest.
Offeranalternativeandhealthyactivityiftheclientwantstobewiththeindividual(suchastakingthechildrenforawalkor
goingtoaworkout).
Changethesubjecttoanewtopicofconversation.

Inthisapproach,thecounselorguidestheclientthroughthreescenariosinvolvingspecificindividuals,specifictimesoftheday,and
specificsituations.Basedonthesescenarios,theclientandcounselorengageinroleplayingexercisessothattheclientcanpracticethese
behaviors.Furthermore,clientsareencouragedtoengageinadditionalroleplayingexerciseswithsignificantothersorotherappropriate
people.

Other Strategies Useful in Maintaining Abstinence

Provide Relationship Counseling

Theoverallgoalofrelationshipcounselingistodevelopeffectivecommunicationskillstohelpcouplesachieveandmaintainabstinence,
changetheirlifestyle,increaseenjoymentintheirrelationship,andlearnbetterwaystoproblemsolve.Specificexercisesforconducting
thesesessionscanbefoundintheCommunityReinforcementApproachManual(BudneyandHiggins,1998).

Provide Social and Recreational Counseling

Thesetreatmentexercisesaredesignedtoincreaseparticipationinprosocialactivitiesthatmayserveasalternativestostimulantuse.
Thisincludeshelpingclientstodevelopinterestsandparticipateinrecreationalandsocialactivitiesthatdonotinvolvestimulantorother
substanceuse.Potentialactivitiescanbeevaluatedbythecounselorandclientaccordingtohowinterestingtheyaretotheclient,how
costly,towhatdegreetheyinvolveothers,howmuchtimetheyrequire,howlikelytheclientistoengageinthem,andhowmuchphysical
exertiontheyrequire.Potentialcoparticipantsareidentified.Thenextstepinvolvesthedevelopmentofanactionplantoidentifythe
specificstepsnecessarytoengageintheactivities.Theseshouldbeincorporatedintothetreatmentplan.Examplesoftheseexercisesare
includedinseveraloftheaforementionedmanuals.

Provide Social Skills Training

Thesocialskillstrainingeffortsareusedtohelpclientslearnandpracticeskillsthatwillfacilitatenonsubstancealternativesfor
socializing,recreating,andcopingwithstressfulinterpersonalsituations.Thegoalistohelpclientsexperiencemorepositivereinforcing
effectsandfewernegative,adversiveeffectsfromsocialinteractions.Thetrainingcanbeespeciallyhelpfulforclientswhohave
problemsmeetingnonsubstanceusingpeersorinteractingwithcoworkers,andwhofeeluncomfortableinsocialsettings.Socialskills
trainingtechniqueshavebeendevelopedforangermanagement,anxietyinsocialsituations,initiatingpleasantconversations,and
assertivenesstraining(AlbertiandEmmons,1982Chaney,1989Montietal.,1995).

Provide Vocational Counseling

Thiscounselingisfocusedonhelpingunemployedclientslocateajob,andhelpingimprovetheemploymentsituationsofclientswith
unsatisfactoryjobsorjobsthatarehighriskforrelapse.

Promote a Balanced Lifestyle

Treatment,recovery,andrelapsepreventioneffortsshouldaddressbiological,psychological,social,andspiritualareasoflife.Clients
shouldbetaughtthevalueofrecreationalandleisureactivitiesandhowtoincorporatethemintotheirrecoveryprogram.Many
recreationalactivitiescanofferopportunitiesforclientstolearnorpracticesocialskills,suchascooperation,teamwork,healthy
competition,andleadership.

Vigorousphysicalexercisehelpsclientsfeelgoodaboutthemselves,decreasesanxietyanddepression,increasesappetite,andoftenhelps
clientssleepbetter.Clientsshouldbetaughtthevalueofregularaerobicexerciseandhowtoincorporateitintotheirdailyorweekly
schedule.Clientsshouldbeprovidedwithavarietyofoptionsforexercise,suchasdancing,walking,biking,jogging,tennis,swimming,
skating,aerobics,andweightlifting.ClientWorksheet23,ExerciseandRecovery,andClientWorksheet24,ExamplesofExercise
Activities,canhelpclientsunderstandthevalueofexerciseintheirrecovery,reviewpotentialtypesofexercises,andlearntoincorporate
exerciseintotheirrecoveryprogram.

Manyclientsintreatmentforsubstanceusedisordershaveproblemsrelatedtonutritionanddiet.Stimulantsdecreaseappetite,leadingto
decreasesintheintakeofcaloriesandnutrition.Clientswithstimulantusedisorderseatinsufficiently,andwhentheydoeat,ofteneat
impulsivelyandeatfoodswithnegligiblenutritionalvalue.Asaresult,theseclientsshouldreceiveaformalnutritionalassessment
conductedbyanutritionistaswellasguidanceregardingeatinganutritionallybalanceddiet,discardingpatternsofinfrequentand
impulsiveeating,andlearningtoplanandschedulenutritionallyappropriatemeals.ClientWorksheet25,NutritionalSelfAssessment,can
helpclientsevaluatetheirownunhealthypatternsofeatingandneedforstructureregardingnutrition.

Monitoring Disulfiram For Alcohol/Cocaine

IntheCommunityReinforcementApproach,allclientswhomeetthediagnosticcriteriaforalcoholdependenceorwhoreportthatalcohol
usecausesproblemsintheirattemptstoachieveabstinencefromstimulantuseareoffereddisulfiramtherapy.Atypicaldisulfiramdoseis
250mg/dailyunlesstheclientreportsbeingabletoconsumealcoholatthatdosewithoutareaction.Insuchsituations,thedoseis
increasedto500mg.Disulfiramingestionisobservedbyclinicalstaffmemberswhenclientscomeforurinalysismonitoring.Takehome
dosesareprovidedfortheotherdays.(SeeFigure48forrelatedresearchondisulfiramtherapy.)

Box
Figure48:RelatedResearch:DisulfiramTherapy.AnuncontrolledstudybyHigginsetal.(1993a)notedthat
superviseddisulfiramtherapywasassociatedwithsignificantdecreasesinalcoholandcocaineuseamongoutpatients
withcocainerelated(more...)

The Role of Self-Help Strategies

Selfhelpstrategiescanbevaluablecomponentsofallphasesoftreatment.Selfhelpstrategies,especiallythosethatfocusonsubstance
use,areespeciallyvaluableasancillaryactivitiesthatsupportthetreatmentgoalsofmaintainingabstinence.Ingeneral,selfhelp
programshelpclientstodevelopappropriatesocialskills,createhealthysocialnetworks,establishhealthyintimaterelationships,and
engageinsubstancefreehealthyactivities.Theyalsoprovideopportunitiestolearnsociallyappropriatemoresandnorms,howtoreceive
andgiveadvice,andhowtomentorothers.
Themostfrequentlyusedandavailableselfhelpstrategyisthe12Stepapproach.ItistherarecitythatdoesnothavemanyAAgroup
meetingseveryday,andmostlargercitieshavenumerousCAandNAmeetings.Clientsshouldbeprovidedwithinformationregarding
the12Stepprocess,suchasmeetingformat,thespiritualcomponent,thebasiccontentandmeaningofthe12Steps,theroleofthe12
Stepsponsor,andtheroleofanonymity.

AlthoughtheConsensusPanelrecommendsparticipationina12Stepgroup,providersshouldnotrequireclients'participation.Rather,it
isbettertoencourageandrecommend12Stepparticipation,especiallybecause12Stepprogramsareselfdescribedasvoluntaryself
helpprogramsofrecovery.Similarly,familymembersofclientsshouldbeencouragedtoparticipatein12Stepprogramsdesignedfor
familymembers,suchasAlAnon.Suchencouragementcanbeprovidedbyhavingmeetingsonsite.Bothclientsandfamilymembers
shouldreceivelistswiththeaddressesandtimesofmeetings,andprovidetransportationwhennecessary.

Also,selfhelpstrategiesotherthanthe12Stepprogramscanbevaluablecomponentsoftreatment.Somearespecificallyrelatedto
substanceuse,suchasRationalRecovery,SaveOurSelves,andWomeninSobriety.Thesemaybeparticularlyhelpfulforindividuals
whoarereluctanttoparticipateinthe12Stepprograms.Theseincludesuchactivitiesaschurchrelatedgroups,cancersurvivorgroups,
anddomesticviolencegroups.SomeresearchfindingsonAAareshowninFigure49.

Box
Figure49:RelatedResearch:AlcoholicsAnonymous(AA).AcomprehensivereviewoftheresearchonAAreveals
severalimportantfindings:ResearchdemonstratesastrongassociationbetweenAAparticipationthatoccursduringor
following(more...)

The Role of Psychodynamic Therapy

Substanceusecounselinggenerallyconsistsoftherapeuticeffortsthatfocusprimarilyonsolvingpresentdayproblemsthatinterferewith
abstinenceandrecovery.Althoughthereisvariation,counselinggenerallyfocusesoncurrentissuesandinvolvesadvice,guidance,and
encouragement.Itistypicallyconductedingroupformats.

Incontrast,psychodynamictherapy,typicallyconductedinindividualsessionformats,focusesonintrapsychicprocessesthatimpair
effectivecopinganddamagerelations.Psychodynamictherapiesdiffergreatly,butwhenusedinsubstanceusedisordertreatment,they
oftenassumethatsubstanceuseisatleastinpartastrategytoselfmedicateproblemsoracopingmechanismtodealwithsuchproblems
astrauma,victimization,andlowselfesteem.

Viewsdifferregardingtheappropriatenessofindividualpsychodynamictherapyforclientswithstimulantusedisorders.Asaresult,the
ConsensusPanelmakesthefollowingrecommendations.First,clientsshouldbethoroughlyevaluatedtodeterminetheirneedforthistype
oftreatment.Aretheclient'sindividualtreatmentneedselicitedthroughthetreatmentplanningprocessbestmetbyindividual
psychodynamictherapyorbyprovidingbasicskillstomaintainabstinence?Second,clientsshouldbethoroughlyevaluatedwithregardto
theirreadinessforpsychodynamictherapy.Becausepsychotherapycanstimulatefeelingsandthoughtsthatmayprovokerelapsetriggers,
clientsshouldbeevaluatedregardingtheirreadinesstohandlesuchtriggers.Doclientshavetheemotionalstability,relapseprevention
skills,andsocialsupportstohandlethistherapy?Third,ifindividualpsychotherapyisintroduced,itshouldbeconsistentandcoordinated
withothertreatmentstrategies,especiallygroupcounselingandselfhelpinvolvement.Forexample,psychotherapyorientedtothestages
ofrecoverycanbeespeciallyuseful(Wallace,1992).

Overall,theConsensusPanelsuggeststhatnotallclientswithstimulantusedisordersareappropriatefor,need,orwantindividual
psychotherapytoestablishormaintainabstinence.Whenprovided,thereshouldbeanexplicittreatmentneed,theclientshouldhavethe
requisiteskills,andthetherapyshouldsupportabstinence.

Next Steps
Becausetreatmentshouldbebasedontheindividualclient'suniqueneeds,thelengthoftreatmentshouldnotbedictatedbythenumberof
weeksintheprogram.Inparticular,terminationoftheabstinencemaintenancephaseoftreatmentshouldbebasedspecificallyon
achievingthetreatmentgoalsdocumentedinclients'treatmentplans.

Theendoftheabstinencemaintenancephaseisagoodopportunitytohelpclientsreviewtheirtreatmentexperiences.Counselorsshould
engageinactivitiesandexercisesthathelpclientstocriticallyexaminetheirtreatmentsuccesses,theareaswheretheyexperienced
problems,andthewaysinwhichtheyaddressedtheseproblems.Similarly,counselorsshouldhelpclientstoevaluatethestrengthoftheir
currentrecoveryprogramandidentifyareaswheretheyneedstrengthening.Throughthisprocess,thecounselorandclientshoulddevelop
acontinuingcaretreatmentplanthatidentifiesremainingtreatmentneedsandstrategiesthatwillbeusedtomeetthoseneeds.

Terminationoftheabstinencemaintenancephaseoftreatmentshouldbeatransitiontoalowerlevelofcare,notaterminationperse.
Abruptterminationshouldbeavoided.Rather,programsshouldhaveordevelopstrategiesthatallowandencourageclientstoremain
connectedwiththeprogram.Furthermore,programsshoulddevelopstrategiesthatspecificallyeducateclientsaboutthecontinuingcare
treatmentservicesavailabletothemandthatactivelyencourageclientstoutilizetheseservices.Waysinwhichprogramscanhelpclients
toremainincontactwiththeprograminclude

Continuingcareoraftercaregroupmeetingswhichclientscanattendweeklyormoreoftenasneeded
Individualcounselingorpsychotherapywhichcanbemadeavailabletoclientsonanasneededbasis
Familytherapymadeavailabletoclientsandtheirfamilies,andtofamilieswithouttheclient,suchasduringrelapseepisodes
Cleanandsoberalternativeactivitiesfocusingonrecreation,leisure,education,andsocialactivities(e.g.,dances,fieldtrips,
summerbarbecues,picnics,holidayevents,lecturesontopicsnotnecessarilyrelatedtotreatmentorrecovery)
Treatmentprogramalumnimeetingssuchasquarterlymeetingsduringwhichallprogramgraduatesareinvited
Treatmentprogramalumniclubsinwhichprogramssponsorandencourageregionalgroupsofalumnitohaveregularmeetings
andevents(programscanprovidespeakersonmotivationalandeducationalissues)
Peermentoringprogramsinwhichprogramalumnihelpnewlyarrivingclientsbysharingexperiences,advice,andprogram
expectations
Surveysandnewslettersmailedtoprogramalumniasawaytocollectposttreatmentdata,toencourageparticipationinalumni
activities,andtoencouragecontactwithprogram,especiallyduringtimesofneed

Publication Details

Copyright
Copyright Notice

Publisher
Substance Abuse and Mental Health Services Administration (US), Rockville (MD)

NLM Citation
Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US);
1999. (Treatment Improvement Protocol (TIP) Series, No. 33.) Chapter 4Practical Application of Treatment Strategies.