A Cognitive Therapy Approach

By Cory F. Newman

INTRODUCTION

A positive, collaborative therapeutic relationship is an essential component of the cognitive therapy of substance abuse (Beck et al. 1993). To engage substance abuse patients in treatment, therapists will need not only to connect with the patients but also gain their trust. Otherwise, the patients will be less likely to benefit from treatment, and their rates of no-show and dropout are apt to increase.

Therefore, therapists must work diligently to form a working alliance by demon-strating general good will and a respectful desire to help. Further, they must carefully attend to any signs that the patients are losing interest or having adverse emotional reactions, and intervene promptly.

COMMON OBSTACLES TO FORMING A THERAPEUTIC ALLIANCE

Substance-abusing patients are an especially difficult population with whom to establish a commitment to change. A glance at the troubled family life of a substance abuser is instructive. At the height of his or her use of drugs, a patient often obtains far more gratification from the drugs than from the love and companionship of significant others, friends, and relatives.

Therefore, the positive social reinforcement from a supportive therapist may pale in comparison to the high that the patient gets from a line of cocaine or a hit of crack. Thus, the therapist's capacity to act as an agent of change is more limited and fragile than with many other patient populations for whom the therapist’s approval and guidance have greater relative significance. As a result, the therapist will need to build the relationship when the patient is in a period of diminished drug use or abstinence.

During this time, the benefits of having meaningful interpersonal relationships should be underscored at the same time as the drawbacks of drug use are being highlighted. The intention of this strategy is to enhance the  patient's perceived reasons for remaining drug free, to motivate the patient to strive for relationship preservation, and to communicate the kind of therapeutic support that the patient will value.

Additionally, substance abusers often enter treatment with ambivalence about relinquishing their habits (Carroll et al. 1991a, 1991b; Havassy et al. 1991). Within the framework of Prochaska and colleagues' (1993) stages of change model, one sees that many substance abusers do not enter treatment at the stages of action or maintenance.

Instead, they commence therapy with a notion that it might be beneficial to give up the use of drugs, or with a wavering desire to cut back on their use (i.e., the contem-plative stage).

In extreme cases, such as when patients are remanded by the courts to attend drug abuse rehabilitation sessions, the patients may not acknowledge that they have a problem with drugs or even that they use them at all (the precontemplative stage).

From the very start, therapists will need to ascertain their patients' respective levels of commitment to change in order to have the best chance of communicating an empathic understanding and to minimize the risk of pushing an unwanted agenda onto patients whose resistance then will likely increase. It is generally not a good idea to accuse patients of "not really wanting to change," or of "wanting to suffer," or of "being in denial" (Newman 1994a).

It is one thing to confront patients in this manner when they are in the protective confines of an inpatient (perhaps group therapy) setting. It is quite another to do this in an individual outpatient setting where the patient can easily leave treatment and never return if he or she takes offense at the therapist's methods.

It is far more preferable to acknowledge that the patient has mixed emotions, and then to assess and get to know the part of the patient that likes to use drugs and the other part that would rather be free of them. In this manner, the therapist demonstrates that he or she is not so naive as to believe that the patient's goal is unequivocal and immediate abstinence, but instead to recognize the complexities and difficulties involved in trying to stop using drugs. Further, the therapist avoids the potentially damaging pitfall of communicating in a judgmental, unempathic tone. 

ESTABLISHING RAPPORT AT THE OUTSET OF TREATMENT

The initial interactions between the patient and therapist are extremely important, as substance abuse patients often will be silently sizing up their therapists to determine whether they can be trusted and know what they are doing (Perez 1992). The lack of a positive start to treatment may lead a patient to choose not to return for further sessions, or may foster negative expectancies in the patient that often exacerbate passive resistance or contentious behavior in session.

On the other hand, a positive start to treatment may instill hope in the patient, thus encouraging him or her to stay in treatment and to consider the prospects of therapeutic change more seriously.

The following are some common methods by which therapists can connect with their substance-abusing patients as treatment begins:

1. Speak directly, simply, and honestly.

2. Ask about the patient's thoughts and feelings about being in therapy.

3. Focus on the patient's distress.

4. Acknowledge the patient's ambivalence.

5. Explore the purpose and goals of treatment.

6. Discuss the issue of confidentiality.

7. Avoid judgmental comments.

8. Appeal to the patient's areas of positive self-esteem.

9. Acknowledge that therapy is difficult.

10. Ask open-ended questions, then be a good listener.

Speak Directly, Simply, and Honestly

The development of rapport is hindered when patients cannot understand their therapists due to the therapist’s unbridled use of psychological jargon. Similarly, patients often do not appreciate it when they perceive that their therapists are talking down to them, or  are speaking to them in the manner of a teacher addressing a grade school class.

The remedy is to endeavor to speak adult to adult, rather than authority to subordinate. For example, the cognitive therapist would be ill-advised to speak in the following manner: "I'll be assessing your thought processes so as to spot the kinds of cognitive distortions that lead you to engage in dysfunctional and antisocial activities."

Instead, the therapist might say: "If it's okay with you, I'd like to understand your point of view about things. I don't want to assume that I already understand what it's like to live your life. I'm interested in listening to your thoughts so I get the real story."

Although the therapist in the second example does not really start teaching the patient about cognitive therapy, he or she establishes some of the groundwork. More important at this early stage, the therapist comes across as being a real person who is understandable.

As the patient progresses through succeeding sessions, the therapist will be able to elaborate gradually on the specifics of cognitive therapy, and to teach some of the basic nomenclature. Additionally, it is important for therapists to share their own thoughts and opinions openly (and diplomatically) when patients ask for them, rather than remaining mysterious figures.

Substance abusers, either by virtue of their own developmental/personality issues or their experiences with dishonest drug-abusing associates, often have major problems in trusting others. A therapist who makes an earnest effort to respond to questions can provide the patient with evidence that the therapist does not have a hidden agenda.

As a qualifier to the above, it is important to note that the therapist should feel free to ask the patient many questions as well, lest the patient put the responsibility for the work of therapy entirely (and inappropriately) on the therapist.

Ask About the Patient's Thoughts and Feelings About Being in Therapy

The therapist should assume neither that the patient is highly motivated for treatment nor that he or she is resistant and hostile. The best way to obtain valid data and at the same time demonstrate that the therapist cares to understand how the patient feels is to ask the patient directly about his or her experience of coming to the therapist's office. 

Such questions can involve asking about the patient’s doubts and concerns, as well as expectations, goals, and hopes for therapy. If the patient expresses misgivings about being in treatment, these negative reactions can be addressed on the spot, thus reducing the risk of early dropout.

At the same time, the therapist can utilize this interaction to begin to teach the patient the cognitive therapy model. For example, a patient who expects to be disrespected by the therapist may harbor feelings of anger. By contrast, if the patient expects to be helped, he or she may feel a sense of relief and have a high degree of motivation.

This example begins to demonstrate one of the central tenets of cognitive therapy, namely, that the patient's thoughts will influence his or her feelings, intentions, and actions. Focus on the Patient's Distress In light of the high rates of dual diagnoses in substance abusers who present for treatment (Castaneda et al. 1989; Evans and Sullivan 1990; Nace et al. 1991; Rounsaville et al. 1991), it is likely that these patients will be suffering from affective disorders, anxiety disorders, or other psychological maladies when they enter treatment.

If therapists show an interest in sympathizing with and addressing these emotional problems, in contrast to focusing exclusively on the substance abuse per se, they can demonstrate that they are interested in the entirety of the patient's well-being. In this manner, therapists show that they are interested in getting to know the patient as a person, and not simply as an addict.

Such an approach is especially indicated for substance-abusing patients who also meet diagnostic criteria for antisocial personality disorder (ASPD). These patients typically are unmotivated to change unless they are in emotional distress, in which case there is a desire to participate in therapy to gain relief (Alterman and Cacciola 1991; Woody et al. 1990).

By helping these ASPD/depressed drug abusers to improve their mood, therapists may be able to form an interpersonal alliance with patients who otherwise might not bond with a helper. Even when patients do not technically meet criteria for dual diagnoses, they may often experience emotional suffering related to having reached points of crisis in their lives (Kosten et al. 1986; Newman and Wright 1994; Sobell et al. 1988).

Therefore, it is quite appropriate for therapists to put such topics as current areas of stress and family problems on the thera-peutic agenda. In addition to providing the patients with understanding and empathy, this approach also calls patients' attention to the fact that substance abuse is an  important cause of their general malaise in life. This may further motivate patients to consider the cessation of substance abuse as a major goal of treatment.

Acknowledge the Patient's Ambivalence

Anecdotally, some drug-abusing patients report that they doubt (at least early on) that therapists who have not had drug problems themselves can truly understand their patients' plights. However, upon further questioning, it typically becomes apparent that this misconception arises when the patients perceive that their therapists take the view that, "Of course you want to quit using drugs. You have everything to gain and nothing to lose by becoming clean and sober."

Patients then conclude that their therapists don't understand the power and allure of drugs such as cocaine. Therefore, it is advisable for therapists to admit that cocaine is a difficult drug to relinquish, and that it would be reasonable and understandable for the patients to have a sense of grief about having to give up the drug (Jennings 1991).

By acknowledging and asking about the patients' ambiv-alence, therapists communicate more accurate empathy, and open up a vital area of discussion that patients otherwise might believe it best to conceal. In fact, one of the standard techniques in the repertoire of the cognitive therapist depends on the therapist's awareness of the patient's mixed emotions and attitudes—the advantages/disadvantages analysis (Beck et al. 1993).

Here, therapist and patient explore the pros and cons of both using and not using drugs. Many patients express pleasant surprise that their therapists really are willing to discuss the pros of continuing to abuse drugs. Although the ultimate goal obviously is to strengthen the patients' resolve, know-how, and commitment to be drug free, an exploration of the seductive aspects of drug use can help the formation of a trusting, collaborative therapeutic relationship.

Explore the Purpose and Goals of Treatment

Cognitive therapy contains a significant psychoeducational component (Beck et al. 1979). A long-term goal of treatment is to empower the patient—to increase a sense of self-efficacy and to teach the patient to becomes his or her own therapist. One way to achieve this goal is to make the patient a full partner in charting the course of therapy.

This entails discussing the purpose of meeting with  the therapist, the goals of treatment, and the types of methods that will be used to achieve these goals. By exploring the purpose and goals of treatment, therapists take some of the mystery out of the process of change, and minimize the chances that mistrustful patients will view their therapists as playing mind games or being on power trips.

If the therapist and patient determine that their respective goals are at odds, at least the problem will be on the table, and not a conflict of hidden agendas. They can then agree to find some common ground, and work toward shared goals until the thornier issues can be discussed and explored at greater length. Therapists can stress that the process of change requires teamwork, and that the therapist and patient are not adversaries.

Discuss the Issue of Confidentiality Because illicit drug use is by definition illegal behavior, patients have learned to be very cautious in what they will divulge about their activities. Thus they often are highly motivated to be dishonest in reporting their substance abuse.

Although the vast majority of therapeutic interactions represent privileged communications, drugabusing patients may not understand or trust the extent to which their admissions of drug use will be kept confidential. To facilitate more open communication and mutual trust, therapists should spell out the nature and limits of confidentiality from the very start. Patients may not be pleased to hear about the limits, but they will appreciate the explanation and the warning. Therapists will need to emphasize that their primary role is to help patients confront their drug use and improve the quality of their lives; therapists do not serve as society's watchdog, or punish, or oppress.

Avoid Judgmental Comments

A longstanding and well-known fact is that it is important for the therapist to communicate a sense of positive regard and respect for the patient (e.g., Bergin and Solomon 1970; Egan 1975; Truax 1963; Truax and Carkhuff 1967; Truax and Mitchell 1971). Nevertheless, it is all too easy for the therapist to fall into the trap of sounding accusatory and judgmental toward a patient who is abusing drugs.

If this happens, the formation of a healthy therapeutic relationship is seriously hindered. Further, the patient may become less inclined to view the therapist as an effective professional when the therapist's comments resemble those heard from exasperated relatives.  Instead, therapists need to explain that they wish to ally with their patients in a mutual struggle against the patients' drug use and concomi-tant life problems. Patients need to be helped to understand that they are not viewed as bad people, but rather as people with a highly troublesome habit with which to deal.

Similarly, therapists need to take care not to spew forth judgmental or hostile comments about anybody else. For example, when a therapist treats a substance-abusing patient who is involved in a romantic relation-ship with another substance abuser, there is a great temptation for the therapist to criticize the significant other, especially when the significant other sabotages the patient's progress toward abstinence.

However, by doing this the therapist runs the risk of triangulating the patient between the loved one and the therapist (in essence, putting the patient in the position of having to take sides). When this happens, patients frequently choose to be loyal to the significant other, which may precipitate a flight from treatment.

Even if the therapist makes judgmental comments about impersonal third parties, the patient may wonder whether this is also how the therapist truly feels about the patient when he or she is not around. This will impede the formation and maintenance of a positive therapeutic alliance. It is much more prudent to evaluate the relative merits and drawbacks of the behaviors and attitudes of people, rather than make pat statements about their characters.

Appeal to the Patient's Areas of Positive Self-Esteem

Although substance-abusing patients typically present with a host of problems, including chaotic lifestyles and skills deficits, it is important for therapists to assess their patients' areas of strength and competence. By doing so, therapists show that they have respect for their patients' individual talents and assets.

Further, they can appeal to areas in which the patients feel a sense of pride, thereby eliciting greater cooperation in other therapy tasks. For example, Walter (all names have been changed) was a patient who was very mistrustful of authority figures, and his collaboration in the process of therapy at the start of treatment was tenuous at best. Although he seemed to be quite hostile and resistant, he did prove himself to be rather intelligent (in spite of his limited education).

When Walter would engage in high-risk behaviors (e.g., drive while intoxicated), the therapist would appeal to the patient's intelligence to get him to reconsider this maladaptive behavior. For example, the  therapist would say: "Walt, you and I have discussed how you have survived to this point, mainly due to your smarts. You seem to be someone who thinks fast under pressure. That's why I'm so perplexed that you would risk your safety and freedom by driving drunk. It just doesn't seem to fit. What's your opinion about all of this? I'm interested to hear your views."

Aside from noting the patients' intelligence, therapists can encourage patients to collaborate in the work of therapy by focusing on other attributes such as their survival skills, the love of their friends and family, their spirituality, their integrity, their potential abilities to be positive role models for others, their advanced vocational skills (when sober), and other legitimate personal attributes.

Acknowledge That Therapy Is Difficult

Therapists can help to build rapport with their patients by noting that it takes courage and hard work to participate fully in therapy. This stance can help to counteract patients' beliefs that it is a sign of weakness and incompetence to be in treatment. In essence, the therapist tries to help the patient to take the shame out of being a patient.

Additionally, by establishing the baseline notion that therapy will be difficult, the therapist reduces the chance that a patient will bail out of treatment at the first sign of discomfort. The therapist can liken the pain of going through therapy to the pain of receiving medical treatment for a wound or a broken bone. Although the procedures hurt, they enable the patient to heal and to be strong.

The adage, "If it hurts, you know the medicine is working," is appropriate in this regard. By contrast, if the patient comes to learn that he or she actually enjoys and looks forward to therapy sessions, it will seem like a bonus benefit.

Ask Open-Ended Questions, Then Be a Good Listener

One of the defining features of cognitive therapy is the spirit of collaboration that the therapist attempts to foster in working with the patient (Beck et al. 1979). A central method for enhancing an atmo-sphere of collaboration is to encourage the patient to actively talk and think aloud in the session, and for the therapist to listen carefully and reflect accurately.

Additionally, it is important to add structure to this process by asking clinically relevant questions that allow the patient to expound his or her feelings and thoughts. Openended questions serve this purpose well.  A common trap to avoid is lecturing the patients and/or bombarding them with yes/no questions that are reminiscent of interrogation. It is much more collaborative to employ a Socratic style (Overholser 1987, 1988, 1993) in which the therapist gently guides the direction of the session material by punctuating the patients' comments with thoughtful, open-ended questions.

The following short dialog serves as an example.

Therapist: I see on your responses to the questionnaires that you haven't used any drugs or alcohol since our last session. What do you think has helped you to do this?

Patient: I don't go past that house no more.

Therapist: The crack house?

Patient: Yeah.

Therapist: What do you say to yourself—how do you manage to keep yourself from going to that house?

Patient: I just remind myself that my life falls apart whenever I start to go there. I just remind myself that I'm kidding myself if I think I can just stop in and say "hi" and shoot the breeze and then just go home. It don't work that way. I just have to stay away.

Therapist: So you remember the problems that you had when you used to go there, and how your life changes for the worse when you use drugs.

Patient: That about sums it up. (Frowns)

Therapist: You looked a little sad just then. What went through your mind?

Patient: Ahhh. I don't know. (Pause) It's a lonely feeling. I got friends who hang out at the house, and I can't see them no more.

Note that in the example above, the therapist gets a lot of useful information from the patient by asking open-ended questions and by carefully listening to the patient's responses. A good rapport seems  to be present in the interaction, with the patient implicitly acknowledging that the therapist understands.

MAINTAINING A POSITIVE ALLIANCE OVER THE COURSE OF TREATMENT

It is often difficult to establish rapport and a collaborative working set with substance-abusing patients; moreover, it is very easy to lose that rapport once it is there. Therefore, even when things seem to be going smoothly in the therapeutic relationship, the therapist must be vigilant in consistently doing what is necessary to maintain the positive feelings between therapist and patient.

The following are some general principles that therapists can employ throughout treatment to preserve a productive and healthy therapeutic alliance. 1. Ask patients for feedback about every session. 2. Be attentive. Remember details about the patients from session to session. 3. Use imagery and metaphors that the patients will find personally relevant. 4. Be consistent, dependable, and available. 5. Be trustworthy, even when the patient is not. 6. Remain calm and cool in session, even if the patient is not. 7. Be confident, but be humble. 8. Set limits in a respectful manner. 

Ask Patients for Feedback About Every Session

The best cure for a damaged therapeutic relationship is prevention. One of the easiest and most reliable methods for avoiding misunderstandings between the therapist and patient is for the therapist to check on what the patient perceives and feels about the session. This can be done during the course of the session (e.g., "What do you think about what I've been saying so far today?") and/or at the completion of the session (e.g., "How do you feel about today's session? Is there anything I said that rubbed you the wrong way?")

If the patient states that he or she is disgruntled, or demonstrates nonverbal reactions that seem to indicate discomfort (e.g., sighing, reticence), the therapist can address this immediately, providing a heavy dose of nondefensive empathy along the way. For example, one patient misconstrued the therapist's discussion of high-risk situations as an attempt to plant the idea into the patient's head that he was going to succumb to his urges.

Once the therapist asked for feedback and ascertained that the patient thought the therapist was trying to sabotage the patient's sobriety, the therapist was able to explain his actual intentions, which were to educate and help the patient. For good measure, the therapist apologized for not being more clear. It is important for the therapist not to assume that everything is okay in the therapeutic relationship just because the patient hasn't openly complained.

Patients who have mistrust issues and/or live in dangerous neighborhoods often conceal their negative feelings extremely well. They adopt a "street smile" that hides both their vulnerability and their desire to strike back without warning. Therefore, the therapist should make an effort to ask for feedback on a regular basis, as both a preventive and a reparative measure.