As can be seen from this list of situations, the Relapse Prediction Scale allows the therapist to target certain vulnerable circumstances very quickly. This information allows the therapist to suggest prompt coping interventions early in treatment to reduce the likelihood of a lapse or relapse.

Orienting the Drug-Abusing Patient to the Cognitive Therapy Model

Most drug abusers have an external view of their problem. They may believe, for example, that, “Under my current circumstance, I have no control whatsoever,” or, “I just need to submit myself to the doctors and they will cure me.”

Thus, it is important that patients be oriented to the cognitive therapy model in the initial stages of therapy. Orienting the patients involves modifying their beliefs about control from an externalized orientation (e.g., “Control is beyond me”) to a more internalized control orientation such as, “I can expect some control over myself and my drug use.”

As part of the process of orienting the patient, key terms are defined, including drug-related beliefs, adaptive beliefs, automatic thoughts, external/internal circumstances, lapse, and relapse. The interrelationship between these phenomena is explained with emphasis on the role of beliefs in drug use.

The actual process of orienting the patient to the cognitive therapy model varies from person to person depending on each individual’s aptitude for self-examination.

For example, a psychologically minded individual might easily accept the idea that thoughts and feelings are important and worthy of examination. With such an individual, it might be relatively easy to explain the cognitive therapy model using diagrams, drawings, and analogies.

On the other hand, some patients will be more concrete in their cognitive style, requiring repeated use of simple examples. Regardless of the process used, the primary goal of orienting the patient to the cognitive therapy model is to begin modifying  dysfunctional beliefs, with particular importance being placed on dysfunctional drug-related beliefs. An essential part of this orientation involves helping the patient to understand how beliefs can develop and change over time.

The development of various types of beliefs is illustrated in the following case.

Mr. C. had the initial belief that he could not become addicted to cocaine. He felt that he had complete control and that he could be a recreational user. Initially, he used cocaine only in social situations.

Later, he developed a belief that he could work better using cocaine and that the drug gave him more energy and made him more creative. This, in turn, led to the use of cocaine prior to going to work and especially when he was under pressure to meet deadlines. It is interesting to note that Mr. C. had the illusion that he was more productive at work when using cocaine, when, in fact, the objective data indicated that he became less productive because of missed days from work following weekend binges.

Later, when he tried to stop using and he began to experience stronger urges and cravings, Mr. C.'s beliefs became focused on the cravings themselves. Some of these beliefs were: “I cannot stand the cravings.” “The feelings will not go away.” “The cravings make me use.”

Later, when his life appeared to be falling apart, he was in debt, and his wife was considering leaving him, he developed the belief that his problems would still be just as awful even if he stopped using cocaine. As shown in the above illustration, Mr. C. had a series of beliefs that developed over time that lead to his feeling hopeless about his situation and facilitated his increased use of cocaine.

Examining and Testing Beliefs

Generally, beliefs develop over an extended period of time. As a result, they become overlearned and extremely resistant to change (Beck et al. 1990b; Young 1990).

The drug abuser collects data supporting beliefs such as “Drugs are fun and very exciting,” “Cocaine greatly enhances sex and many other activities,” “Nothing is quite like using cocaine,” and so forth.

Many substance abusers have spent years rejecting more functional beliefs such as “Drugs are harmful.” Though many patients have tried to quit using drugs, their  difficulty in doing so provides them with apparent validation for beliefs such as “I am not in control of my problem” or “I am helpless.”

Given the resistant nature of drug-related beliefs, the process of modifying them requires much diligent therapeutic work. After the therapist has assessed the patient’s beliefs and oriented the patient to the cognitive therapy model, an examination and testing of beliefs should begin.

Examining drug-related beliefs involves asking patients probing questions that lead to closer scrutiny of these beliefs. This process is known as the Socratic method, or guided discovery. The following are some examples of questions appropriate for this process: “What is your evidence for that belief?” “How do you know the belief is true?” “Where did you learn that?” “How strongly do you believe that?” “How likely is it that your belief is true?”

The primary goal of Socratic questioning is to heighten the patient’s awareness of his or her functioning. As the patient considers the therapist’s questions, drug-related beliefs should begin to “loosen;” that is, he or she should begin to understand that these beliefs are biased and there is a possibility that they are incorrect and self-defeating.

Mr. C. had developed the belief that urges and cravings made him use. However, through questioning, the therapist was able to help him examine this belief. One of the key questions in helping Mr. C. to modify this belief was, “What is the evidence against the idea that cravings make you use?”

Upon reflection, Mr. C. realized that he did not always use when he had urges and cravings. Nevertheless, he had the illusion that every time he had an urge he gave into it.

The therapist instructed the patient to list recollections of times when he had had strong urges and cravings to use cocaine but in fact did not use. Reviewing this evidence helped to undermine Mr. C.'s very strong belief that the urges and cravings made him use.

Development of Adaptive Beliefs

The therapist’s use of the Socratic method stimulates patients to examine their drug-related beliefs, to modify them, and ultimately to  replace them with more adaptive beliefs. For example, Mr. C. had the belief that “There is only one way for me to have fun–to use drugs.”

First, the therapist asked him to list those activities that he enjoyed before getting hooked on drugs. Mr. C. listed playing tennis, biking, and going out to dinner with his wife, among others.

The therapist then asked Mr. C., “On a scale of 1 to 10, how much pleasure would you get out of playing tennis now?” He replied, “Probably a 2.” The therapist then asked Mr. C., “For homework, would you go play a game of tennis and then rate on a 1-to-10 scale how much you enjoyed it?”

He agreed to do it. At the next therapy session, Mr. C. reported that he did the homework and, to his surprise, he actually scored a 9, which would indicate that he had had a good time. This experiment helped to chip away at Mr. C.'s belief that “There is only one way for me to have fun–to use drugs.”

Mr. C. experimented with other pleasurable activities, and eventually the aforementioned dysfunctional belief became very weak. A new belief began to emerge: “Besides doing drugs, there are many different things that I enjoy.”

Another strategy for examining and testing drug-related beliefs and developing adaptive beliefs is the use of the daily thought record (DTR). The DTR is a structured form for listing and modifying distorted thoughts.

Specifically, the DTR has four columns containing the following categories: situation, emotion(s), automatic thought(s), and rational response. An example of a completed DTR appears in figure 5. For example, when patients experience urges or cravings, they write in the situation column the triggering event. In the next column, they list the feeling they are having.

The automatic thoughts section is where they write spontaneous negative thoughts and images associated with how they are feeling. Alternative adaptive responses are written in the rational response section. This is illustrated by Mr. C.'s DTR (see figure 5).

Under the column entitled “situation,” Mr. C. described how he was sitting at home, he recently had had an accident, his hand was broken, and he had plenty of money in his pocket. Under “emotions” he wrote, “Bored.” Under the “automatic thoughts” column, he had listed the following: “There is nothing to do,” “I cannot stand the boredom,” “Therapy is not doing me any good.” and “I need a hit to cool down.”

The therapist taught Mr. C. to examine these automatic thoughts by asking himself the following questions: “What is the evidence for and against my automatic thoughts?” “What are some other ways to look at this situation?” “What are the realistic consequences?” “What are the disadvantages of my continuing to say this to myself?” “What constructive action can I take?”

Mr. C. began by examining the thought “There is nothing to do” by asking himself, “What is the evidence that there is nothing to do?”

He responded by saying, “There is no evidence that there is nothing to do. Actually, there are plenty of things I can do; for example, I can go to an Alcoholics Anonymous (AA) meeting or just get out of the house and take a walk.”

Next he asked himself, “Is there another way of looking at this? Do I really mean that there is nothing to do?” His response to this was, “No, it is not true that there is nothing to do, but experiencing pain and boredom makes it difficult for me to see other things that I might be able to do.” He then asked himseIf, “What are the realistic consequences if it is true that there is nothing to do?”

He responded, “Well, if it is true that there is nothing to do, then the consequences are that I feel bored and, although I do not like being bored, it is not the end of the world. The consequences are that I will feel bored, but eventually it will go away.”

Mr. C.'s fourth question was, “What are the disadvantages of my continuing to say this to myself?” He responded, “The disadvantage is that I will feel helpless, which in turn will lead to the desire for cocaine.”

By examining these thoughts, he was able to produce adaptive rational responses, such as “I have tolerated boredom in the  past in the same way that I have tolerated other feelings. There are plenty of things to do, such as going to an AA meeting.”

These responses represented Mr. C.'s early development of new, more adaptive beliefs. The final question (“What constructive action can I take?”) led Mr. C. to consider what he could do to feel better without resorting to drugs. He decided that he would begin to make a schedule for himself in preparation for a return to work following the healing of his hand. This activity made Mr. C. focus on his abilities and goals, not his helplessness, and his concomitant drug urges diminished.

Later, the therapist was able to help Mr. C. examine the remaining automatic thoughts and to come up with adaptive responses to those as well. Another strategy for developing adaptive beliefs is the advantage/disadvantage analysis. People use drugs partly because they view the advantages of doing so as outweighing the disadvantages.

Thus, the purpose of the advantage/disadvantage analysis is to direct the patient’s attention to the disadvantages of using cocaine and the advantages of abstaining.

The patient is taught to construct a 2x2 matrix where the advantages and disadvantages of using and not using are listed and explored (figure 6). Mr. C. listed the following advantages for using cocaine: “I feel like a superman.” “It takes away my shyness and insecurity.” “I feel like king of the mountain.”

Under the disadvantages for using cocaine, he listed the following: “I feel paranoid.” “I have a terrible relationship with my wife.” “I feel physically bad.” Similar work was done to generate lists of advantages and disadvantages for not using. The result was that Mr. C. learned that there were compelling reasons to remain abstinent and that his reasons for using were based on falsehoods, rationalizations, and a preoccupation with an immediate sense of power.

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FIGURE 6. Advantage/disadvantage analysis

Advantages for Using:
1. “I feel like a superman.”
2. “I takes away my shyness and insecurity.”
3. “I fell like king of the mountain.”

Disadvantages for Using:
1. “I feel paranoid.”
2. “I have a terrible relationship with my wife.”
3. “I feel physically bad.”

Advantages for Not Using:
1. “I save money.” 
2. “I do not have to lie to my family.”
3. “I will feel physically great.”

Disadvantages for Not Using:
1. “I will be lonely.”
2. “I will not do as well sexually.”
3. “I will lose friends.”
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Practice In Activating Adaptive Beliefs

Upon completion of some of the above exercises, such as the DTR and the advantage/disadvantage analysis, the patient is much more attentive to the disadvantages of using drugs. Furthermore, the patient is better able to successfully develop beliefs for resisting future drug use.

However, the patient frequently has trouble accessing these beliefs when faced with the temptation. Hence, special attention must be paid to the deliberate activation of adaptive beliefs as part of therapy. There are several methods which serve this purpose. One method involves the use of flashcards.

After the patient has formulated an adaptive belief, flashcards can be used to reinforce and activate the newly developed belief. For example, upon completing the advantage/disadvantage analysis, the patient writes the advantages for not using on one or more 3"x5" index cards.

In the case of Mr. C., he wrote, “I feel more secure and less paranoid when I do not use. I get along much better with my wife when I do not use. I feel physically great in the long run when I do not use.”

He then read and repeated this card whenever he felt an urge to use, which focused his attention on the importance of abstinence. Homework Homework involves applying the skills learned in the therapy session to everyday life. Thus, homework is a vital extension of therapy (Persons et al. 1988; Primakoff et al. 1986).

As a result of repeated use of homework in cognitive therapy, patients learn to use probing questions spontaneously in their lives, such as “What evidence do I have for this belief?” or “How else can I look at the situation?” or “What are the consequences of my beliefs?”

Homework is an opportunity to practice applying adaptive beliefs in the real world (Newman and Haaga, in press). Patients practice activating adaptive beliefs in the face of tempting high-risk stimuli, since they inevitably will be confronted with such stimuli in life outside of therapy. 

Homework also may involve testing drug-related beliefs to re-evaluate their validity, such as the belief that the only way to have fun is to use drugs. In the case of Mr. C., this belief was re-evaluated by getting him to try alternative, nondrug, pleasure-seeking activities.

Homework is assigned at the end of each session and is reviewed at the beginning of each following session. Initially, homework is quite structured. For example, many new patients are instructed to complete DTRs on a daily basis. Later, however, homework can be less formal and more creative as the patient demonstrates skill in applying adaptive patterns of thinking and action.

SUMMARY

In this chapter, the authors assert that drug-related beliefs are an important factor in drug abuse and its treatment.

Three types of acute drug-related beliefs have been described that contribute to urges, cravings, and ultimate use of drugs: anticipatory beliefs, relief-oriented beliefs, and permissive beliefs, and various ways have been described to assess more general, long-term beliefs pertinent to drug use.

The role of the cognitive therapist is to assess, examine, and test these beliefs with the patient in order to ultimately develop more adaptive beliefs.

The active application of skills and homework that tap into the patient’s adaptive beliefs helps the patient to become and remain drug-free.

REFERENCES

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Beck, A.T. Cognitive Therapy and the Emotional Disorders. New York: International Universities Press, 1976. 

Beck, A.T., and Emery, G. (with Greenberg, R.L.). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books, 1985.

Beck, A.T.; Freeman, A.; Pretzer, J.; Davis, D.D.; Fleming, B.; Ottawani, R.; Beck, J.; Simon, K.M.; Pedesky, C.; and Meyer, J. Cognitive Therapy of Personality Disorders. New York: Guilford Press, 1990b.

Beck, A.T.; Rush, A.J.; Shaw, B.F.; and Emery, G. Cognitive Therapy of Depression. New York: Guilford Press, 1979.

Beck, A.T.; Wright, F.D.; and Newman, C.F. Cognitive Therapy of Cocaine Abuse. Philadelphia, PA: Center for Cognitive Therapy, 1990a.

Beck, A.T.; Wright, F.D.; and Newman, C.F. Cocaine abuse. In: Freeman, A., and Dattilio, F., eds. Comprehensive Casebook of Cognitive Therapy. New York: Plenum Press, 1992.

Beck, A.T.; Wright, F.W.; Newman, C.F.; and Liese, B. Cognitive Therapy of Substance Abuse. New York: Guilford Press, 1993.

Blane, H.T., and Leonard, K.E. Psychological Theories of Drinking and Alcoholism. New York: Guilford Press, 1987.

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Centers for Disease Control. Cigarette smoking among adults: United States, 1988. Morbidity and Mortality Weekly Report 40:757-765, 1991a.

Centers for Disease Control. Smoking-attributable mortality and years of potential life lost: United States, 1988. Morbidity and Mortality Weekly Report 40:62-71, 1991b.

Cox, W.M., ed. Why People Drink. New York: Gardner Press, 1990. Ellis, A.; McInerney, J.F.; DiGiuseppe, R.; and Yeager, R.J. Rational- Emotive Therapy With Alcoholics and Substance Abusers. New York: Pergamon Press, 1988.

Institute of Medicine. Causes and Consequences of Alcohol Problems. Washington, DC: National Academy Press, 1987.

Institute of Medicine. Treating Drug Problems. Vol. 1. Washington, DC: National Academy Press, 1990a.

Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990b. 

Marlatt, G.A. Craving for alcohol, loss of control, and relapse: A cognitive-behavioral analysis. In: Nathan, P.E.; Marlatt, G.A.; and Lobert, T., eds. Alcoholism: New Directions in Behavioral Research and Treatment. New York: Plenum Press, 1978.

Marlatt, G.A. Relapse prevention: A self-control program for the treatment of addictive behaviors. In: Stuart, R.B., ed. Adherence, Compliance, and Generalization in Behavioral Medicine. New York: Brunner/Mazel, 1982.

Marlatt, G.A. Cognitive factors in the relapse process. In: Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985. pp. 128-200.

Marlatt, G.A., and Gordon, J.R. Determinants of relapse: Implications for the maintenance of behavior change. In: Davidson, P.O., and Davidson, S.M., eds. Behavioral Medicine: Changing Health Lifestyles. New York: Brunner/Mazel, 1980.

Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985.

Newman, C.F., and Haaga, D.A.F. Cognitive skills training. In: O’Donohue, W., and Krasner, L., eds. Handbook of Skills Training. Needham Heights, MA: Allyn and Bacon, in press.

Persons, J.B.; Bums, D.D.; and Perloff, J.M. Predictors of drop-out and outcome in cognitive therapy for depression in a private practice setting. Cogn Ther Res 12:557-575, 1988.

Primakoff, L.; Epstein, N.; and Covi, L. Homework compliance: An uncontrolled variable in cognitive therapy outcome research. Behav Ther 17:433-446, 1986.

Trimpey, J. The Small Book. Lotus, CA: Lotus Press, 1989.

Weissman, A.N., and Beck, A.T. “Development and Validation of the Dysfunctional Attitudes Scale: A Preliminary Investigation.” Paper presented at the Annual Meeting of the American Educational Research Association, Toronto, Canada, 1978.

Young, J.E. Cognitive Therapy for Personality Disorders: A Schema- Focused Approach. Sarasota, FL: Professional Resource Exchange, 1990. 

AUTHORS

Fred D. Wright, Ed.D. Assistant Professor of Counseling Psychology in Psychiatry University of Pennsylvania School of Medicine and Director of Education

Aaron T. Beck, M.D. University Professor Emeritus of Psychiatry University of Pennsylvania and Director

Cory F. Newman, Ph.D. Assistant Professor of Psychology in Psychiatry University of Pennsylvania School of Medicine and Clinical Director Center for Cognitive Therapy Room 754, The Science Center 3600 Market Street Philadelphia, PA 19104-2648

Bruce S. Liese, Ph.D. Associate Professor of Family Practice and Director of Behavioral Medicine Department of Family Practice University of Kansas Medical Center 39th and Rainbow Boulevard Kansas City, KS 66103

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From NIDA Research Monograph 137 Behavioral Treatments for Drug Abuse and Dependence [pdf with multiple chapters, diagrams]