Acknowledgment
The material for this course is based on clinical studies and reports published by
National Institute on Drug Abuse
National Institutes of Health
6001 Executive Blvd., Room 5213
Bethesda, MD 20892-9561
U.S.A.
Learning Objectives
Upon completing the course, you will able to:
Describe the beliefs and philosophy of 12-step approach to recovery.
Distinguish between addiction counseling and psychotherapy.
Discuss the logistics of the individual drug counseling model to treat cocaine addiction, such as frequency, duration, target population and setting of sessions.
Describe the application of Addiction Severity Index in the assessment of drug addiction.
Describe the patient-counselor relationship and list behaviors that the counselor should not indulge in.
List behaviors that a counselor should not indulge in.
List 12 objectives of individual drug counseling.
Describe 4 stages of addiction treatment: Treatment initiation, Early abstinence, Maintenance of abstinence, Advanced recovery.
List some of the erroneous beliefs that a patient experiencing denial may exhibit.
Outline 3 goals of the treatment plan and make detailed plans for introductory sessions.
List 5 goals of the second stage in the treatment of addiction, i.e., abstinence, and discuss 10 treatment issues with the patient.
Establish goals for maintaining abstinence and discuss various treatment issues with the patient as part of the ongoing recovery program.
Identify 11 steps that will carry a patient toward relapse.
Define codependency and enabling behavior and explain how they can contribute to a person's continued abuse of drugs.
Identify "character defects" that are obstacles to further recovery and outline the process for working on changing defects.
Discuss with the patient patient's thoughts and feelings about ending treatment in the final active treatment session.
Explain the purpose and goals of treatment booster sessions.
Identify 3 levels of severity of relapse and list appropriate interventions to be used in each case.
Discuss strategies for dealing with crises and relapses.
List ideal personal characteristics of an addiction counselor.
Explain the purpose and application of adherence scale in the IDC model.
Identify 6 important features of cognitive-behavioral therapy that make it particularly promising as a treatment for cocaine abuse and dependence.
Distinguish between cognitive-behavioral therapy (CBT) and 12-step or disease-model approach.
Compare CBT to other psychosocial treatments for substance abuse, such as cognitive therapy, community reinforcement approach, motivational enhancement therapy, 12-step facilitation and interpersonal psychotherapy.
Discuss two critical components of CBT: functional analysis and skills training.
Define various parameters of CBT such as format, length, setting, patients and compatibility with other adjunctive treatments.
List essential and unique interventions of CBT, interventions that are recommended but not unique, acceptable interventions and interventions that are not part of CBT.
Describe 7 strategies a counselor would use to help the patient master new skills.
Enunciate the basic principles of cognitive-behavioral therapy and describe how functional analysis and skills training are used to treat cocaine addiction.
Describe the CBT principle that holds forth the three ways individuals learn to use drugs: modeling, operant conditioning, and classical conditioning.
Describe the structure and format of a typical CBT session using the "20/20/20 Rule" and list tasks to be completed during each part of the session.
List 8 skill topics covered in CBT for cocaine dependence.
Outline the pharmacotherapy approach as used in cognitive-behavioral therapy.
Explain the treatment goal of cognitive-behavioral therapy.
List six strategies a counselor can use during a treatment session to enhance motivation and avoid resistance.
Outline the CBT model providing an explanation and rationale for the treatment.
Help the patient understand craving.
Elicit from the patient the experience of craving.
List 5 strategies to cope with cravings.
Provide key interventions to shore up motivation and commitment to stop.
List three basic principles in effective refusal of cocaine and other substances.
Identify examples of Seemingly Irrelevant Decisions and their relationship to high-risk situations.
Help the patient identify high-risk situations and develop a coping plan.
Help the patient practice problemsolving skills within the session by listing 5 basic steps.
Develop a concrete support plan for addressing psychosocial problems that present a barrier to treatment.
Assess the patient's risk for HIV infection and build motivation to change risk behaviors.
Set behavior change goals.
Formulate specific HIV risk-reduction guidelines
Involve significant others so that they can help patients become and remain abstinent.
Identify 6 strategies in which the significant other can offer support to the patient in his or her recovery.
Explore strategies through which significant others in the patient's life can help the patient become and remain abstinent.
List guidelines for effective supervision.
Identify some of the common problems encountered in supervision.
Review clinical research supporting CBT and compare its effectiveness against Interpersonal Therapy and Clinical Management.
Relate the efficacy of CRA+Vouchers approach over standard drug counseling and cite research studies to support this conclusion.
Adopt a counseling style and techniques consistent with the CRA+Vouchers treatment program.
List 3 categories of patients generally acceptable for the CRA+Vouchers program.
Outline the intake process listing various self-administered questionnaires.
Conduct the initial treatment session taking the patient through several steps.
List the tasks a therapist should complete in Sessions One and Two of the program.
Explain the concepts and procedures concerning functional analysis as the first step of CRA+Vouchers treatment plan.
Instruct the patient on the four components of the functional analysis.
Help the patient develop self-management plans for handling triggers to reduce the risk of cocaine use.
Instruct the patient in five components of effective refusal.
List at least 6 lifestyle change components for cocaine abusers in treatment.
Explain the importance of time management in achieving and maintaining abstinence from cocaine, and help the patient develop time-management skills.
Provide a rationale for working on lifestyle changes in social and recreational areas.
List 5 basic steps for problem-solving.
Help patients develop assertiveness skills, and distinguish between passive, aggressive and assertive behaviors.
Describe the purpose of relationship counseling and take the patient through various steps to improve the quality of his or her relationship.
Outline the general strategy for dealing with concurrent alcohol and cocaine use.
Introduce disulfiram protocol and develop compliance procedures.
Outline the general strategy for dealing with marijuana use concurrent with cocaine.
Describe the treatment protocol for dealing with depressive symptomatology and anxiety
following abstinence from cocaine.
Describe the function of clinical supervision of therapists in the CRA+Vouchers program.
Describe the behavioral treatment in drug abuse treatment as contingency management.
Evaluation of Individual Objectives
To assess the effectiveness of the course material, we ask that you evaluate your achievement of each learning objective on a scale of A to D (A=excellent, B=good, C=fair, D=unsatisfactory). Please indicate your responses next to each learning objective and return it to us with your completed exam.
Contents Outline
Introduction
Treatment Philosophy
Contributions of the 12-Step Approach
Role of Self-Help Groups
Role of Significant Others in Treatment
Comparison of Addiction Counseling and Psychotherapy
Similar and Dissimilar Approaches
Compatibility With Other Treatments
Chapter 3: Logistics of the Model
Frequency and Duration of Sessions
Duration of Treatment
Target Population
Setting
Assessment
Addiction Severity Index
Biological Assays
Patient-Counselor Relationship
Therapeutic Alliance
Behaviors That Should Not Be Done
Goals and Objectives of Individual Drug Counseling
Stages of Treatment
In Each Session
Goals
Treatment Issues
Denial
Introductory Sessions
Treatment Issues
Goals
Treatment Issues
Termination
Treatment Booster Sessions
Dealing With Lateness or Nonattendance
Denial, Resistance, or Poor Motivation
Strategies for Dealing With Crises
Dealing With Relapse
Levels of Severity of Relapse
Ideal Personal Characteristics of the Counselor
Educational Requirements
Credentials and Experience Required
Counselors in Recovery Themselves
Training and Supervision
Use of the Adherence Scale
Appendix -Adherence/Competence Scale for Individual Drug Counseling (IDC)
for Cocaine Dependence
Exhibit 10: Problem List Form
Why CBT?
Components of CBT
Parameters of CBT
Active Ingredients of CBT
CBT Compared to Other Treatments
Learned Behavior
Functional Analysis
Skills Training
20/20/20 Rule
Exhibit 1: Session Flow in CBT, The 20/20/20 Rule
First Third of Session
Assess Patient Status
Urine Tests
Problemsolving
Listen for Current Concerns
Discuss the Practice Exercise
Second Third of Session
Final Third of Session
Assign a Practice Exercise
Anticipate High-Risk Situations
Topics
Integrating CBT and Medication
Session 1: Introduction to Treatment and CBT
Tasks for Session 1
Session Goals
Key Interventions
History and Relationship Building
Present the CBT Model
Establish Treatment Ground Rules
Introduce Functional Analysis
Practice Exercise
Exhibit 2: Functional Analysis
Tasks for Topic 1
Session Goals
Key Interventions
Practice Exercises
Exhibit 3: Coping With Cravings and Urges
Tasks for Topic 2
Session Goals
Key Interventions
Clarify Goals
Address Ambivalence About Abstinence
Identifying and Coping With Thoughts About Cocaine
Practice Exercises
Exhibit 4: Goals Worksheet
Exhibit 5: Coping With Thoughts About Cocaine
Topic 3: Refusal Skills/Assertiveness
Tasks for Topic 3
Session Goals
Key Interventions
Assess Cocaine Availability
Handling Suppliers
Cocaine Refusal Skills
Within-Session Role-Play
Passive, Aggressive, And Assertive Responding
Remind Patients of Termination
Practice Exercises
Exhibit 6: Managing Availability
Exhibit 7: Cocaine Refusal Skills
Topic 4: Seemingly Irrelevant Decisions
Tasks for Topic 4
Session Goals
Key Interventions
Understand Seemingly Irrelevant Decisions
Identify Personal Examples
Practice Safe Decisionmaking
Practice Exercise
Exhibit 8: Seemingly Irrelevant Decisions
Tasks for Topic 5
Session Goals
Key Interventions
Practice Exercise
Topic 6: Problems Solving
Tasks for Topic 6
Session Goals
Key Interventions
Practice Exercise
Exhibit 10: Reminder Sheet For Problemsolving
Tasks for Topic 7
Session Goals
Key Interventions
Problem Identification
Goal Setting
Resource Identification
Specifying a Plan
Monitoring Progress
Practice Exercise
Exhibit 11: Support Plan
Topic 8: HIV Risk Reduction
Tasks for Topic 8
Session Goals
Key Interventions
Build Motivation To Change
Set Goals
Problemsolve Barriers
Provide Specific Guidelines
Practice Exercise
Tasks for Significant Other Session
Session Goals
Key Interventions
Plan Ahead
Identify Strategies
Practice Exercise
Final Session: Termination
Tasks for the Termination Session
Session Goals
Therapist Training
Didactic Seminar
Supervised Training Cases
Rating of Therapists
Therapist Checklist
Certification of Therapists
Ongoing Supervision
Common Problems Encountered in Supervision
Speeding Through Material
Overwhelming The Patient
Unclear Strategies
No Specific Examples
Downplaying Practice Exercises
Abandoning The Manual With Difficult Patients
CBT and Interpersonal Therapy
CBT and Clinical Management
CBT and Depressive Symptoms
CBT and Alexithymia
One-Year Follow-up
CBT and Alcoholic Cocaine Abusers
References
Background
Psychosocial Interventions
Supporting Research
Use With Other Populations
Concurrent Alcohol Dependence
Program Overview
Lifestyle Changes
Vouchers
Other Drug Abuse
Treatment Parameters Schedule
Schedule
Components
Structure
Exhibit 1: Sample Schedule
Clinical Approach
Counseling Style
Flexibility
Empathy
Active Involvement
Directive But Collaborative
Social Reinforcement
Counseling Techniques
Behavioral Techniques
Additional Resources
Progress Graphs
Counseling Structure
Preparation
Session Protocol
Recent Problems or Crises
Special Issues
Absences
Tardiness
Extra Sessions
Drug and Alcohol Use
Concurrent Treatment
Premature Termination
Documentation of Patient Contact
Clinical Supervision
Exhibit 2: Therapy Session Checklist
Exhibit 3: Progress Note
Exhibit 4: Brief Contact Forms
The Voucher Program
Objective Monitoring
Exhibit 5: Recommended Reinforcement Schedule
Urinalysis Schedule
Specimen Collection
Laboratory Analysis
Presenting the Results
Intake
Initial Contact
Screen Applicants
Schedule Intake
Intake Procedures
Assessment
Self-Administered Questionnaires
Program Description
Structured Interviews
Initial Treatment Session
Get to Know the Patient
Provide Overview and Rationale
Introduce the Voucher Program
Describe Abstinence Contract
Explain Urinalysis Monitoring
Explain Voucher Program
Review Abstinence Contract
Priming
Problem List
Practical Needs Assessment
Appointment Book
Significant Others
Disulfiram Procedures (if applicable)
Collect Urine
Schedule the Next Session
Exhibit 7: Intake Worker Summary
Exhibit 9: Sample Abstinence Contract
Exhibit 10: Problem List Form
Exhibit 11: Sample Problem List
Outline a Treatment Plan
Sessions One and Two
Complete Intake and Treatment Orientation
Introduce Functional Analysis and Stimulus Control
Assist With Practical Needs
Use the Appointment Book
Start To Develop the Treatment Plan
Discuss Areas for Change
Prioritize Problems
Set Specific Target Goals
Drug Avoidance Skills
Functional Analysis
Components of Functional Analysis
Triggers
Behavior
Positive Consequences
Negative Consequences
Conduct a Functional Analysis
Self-Management Planning
Rationale
Initiate Training
Make the Plan
Drug Refusal Training
Rationale
Refusing Cocaine and Other Drugs
Components of Effective Refusal
Practice Refusal Skills
Homework
Exhibit 13: Discovering Triggers of Your Cocaine Use
Exhibit 14: Functional Analysis - Cocaine Behavior Form
Exhibit 15: Functional Analysis - Cocaine Behavior Form (example)
Exhibit 16: Components of Effective Refusal
Time Management
Develop Time-Management Skills
Apply Time Management
Social/Recreational Counseling
Rationale
List Activities and People
Set Goals and Assess Progress
Facilitate Change
Problem-solving
Rationale
Steps for Problem-solving
Recognize the Problem
Identify the Problem
Brainstorm
Select Approach
Evaluate Effectiveness
Practice
Vocational Counseling
Rationale
Set Goals
Treatment Components
Social-Skills Training
Assertiveness Training
Rationale
Assertiveness Skills
Practice
Set Goals and Assess Progress
HIV/AIDS Prevention
Rationale
AIDS Knowledge Pretest
Video and Discussion
Pamphlets and Condoms
AIDS Knowledge Posttest
HIV Antibody and Hepatitis B Testing
Provide Information
Discuss Results
Exhibit 17: Problem-solving Worksheet
Procedure
Practice Exercise
Exhibit 18: Being Assertive
Exhibit 19: AIDS Risk Knowledge Test
Exhibit 19a: AIDS Risk Knowledge Test (Answers)
Exhibit 20: Recommendations to Prevent HIV Transmission Through Shared Drug Injection Equipment
Relationship Counseling
Session 1
Introduce Relationship Counseling
Introduction Exercise
Relationship Happiness Scale
Daily Reminder To Be Nice
Session 2
Perfect Relationship Form
Positive Requests
Session 3
Communications Training
Session 4
Communications Training
Sessions 5-8
Exhibit 21: Relationship Happiness Scale
Exhibit 22: Examples of Relationship-Related Activities
Exhibit 23: Daily Reminder to be Nice
Exhibit 24: Perfect Relationship Form
Exhibit 25: Positive Requests
Exhibit 26: Reciprocal Contract for Behavior Change
Disagreements
Conflicts
Other Substance Abuse
General Approach
Treatment Goals
Abstinence
Reduced Use
No Intervention
Concurrent Alcohol Use
Abstinence
What Is Disulfiram?
Medical Oversight
Disulfiram Protocol
Exhibit 29: Disulfiram Consent Form
Exhibit 30: Disulfiram Contract
Exhibit 31: Therapist's Disulfiram Checklist
Exhibit 32: Backup Disulfiram Contract
Introduce Disulfiram
Limited Alcohol Use/Safe Drinking
Patients Who Hesitate or Refuse
Backup Agreement
Marijuana Use
Depressive Symptomatology
Evaluate Suicide Risk
Monitor Symptoms
Treatment
Anxiety
Relaxation Protocol
Relaxation Exercise and Practice
Applications
Insomnia Protocol
Rationale
Sleep Diary
Sleep-Hygiene Rules
Sleep Restriction and Stimulus Control
Practice
Exhibit 34: Sleep Hygiene Rules
Exhibit 35: Sleep-Restriction and Stimulus-Control Instructions
Clinical Supervision
Weekly Clinical Staff Supervision
New Cases
Active Cases
Counselor Treatment Team Meetings
Exhibit 36: Supervisor Checklist by Case
"Excellent course! Highly recommended!" - O.I., RN, CA
"I enjoyed this class!" - B.B., LPC, SC
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