Be Attentive. Remember Details About the Patients From Session to Session

Although this point may be common sense in theory, it is not always easy to enact in practice. For example, some drug-abusing patients may use slang terms the therapist doesn’t know. If the therapist doesn't ask for clarification, he or she may miss important information. This may further lead the patient to think that the therapist didn't care to understand, rather than that the therapist wasn't able to understand, and the therapeutic rapport may be harmed. 

To accurately conceptualize the patient's life situation, the therapist must be able to mentally accumulate information about the patient from week to week. In this way, understanding increases. A simple, tried-and-true method to enhance this process is to take thorough, prompt therapy notes about every contact with the patient, and to review these notes religiously before each new session.

Use Imagery and Metaphors That the Patients Will Find Personally Relevant

Once the therapist facilitates the establishment of rapport by speaking "directly, simply, and honestly" (see first item, previous section), he or she can facilitate more sophisticated understanding by using images and metaphors to communicate important but complex points.

For example, a therapist wanted to discuss the patient's tendency to isolate himself from others, including those who purported to love him and to want to help him.

The therapist conceptualized the patient's problem in terms of the patient's fear that he would inevitably hurt anyone who got close to him. Further, the patient saw himself as being very attractive and powerful, thus making his efforts to isolate himself from would-be admirers all the more difficult.

The therapist used the following metaphor in order to explain this formulation, while also appealing to the patient's narcissism: "Joe, you're like a shiny new Porsche with no brakes. You're coming down the road looking as cool and swift as you can be, and everyone wants to come up close to you to get a better look. Meanwhile, you know that you have no brakes. Therefore, you're afraid if that people get too close, you're going to run them down, and you're not sure you can live with yourself if that happens, so you drive away from everybody. Joe, I think we need to get you some brakes. What do you think?"

Then the therapist elicited feedback from the patient, who said he felt both understood and complimented. This facilitated the continued discussion of the important issue above.

Be Consistent, Dependable, and Available

Therapists typically do not earn their drug-abusing patients' trust through sudden, dramatic gestures. Rather, trust is gained through the therapist's consistent professionalism, honesty, and well-meaning actions over a long period of time.  Although drug-abusing patients often may arrive late for sessions, fail to show up at all, and otherwise demonstrate the lack of a serious involve-ment in the process of treatment, therapists (by contrast) need to demon-strate a steady commitment to helping these patients.

Therefore, it is very important for therapists to arrive on time for their appointments, even in cases when the patients habitually come late. In like manner, it is impor-tant for therapists to be available for therapy sessions on as regular a basis as possible (and to make sensible alternative arrangements if necessary), to return their patients' phone calls promptly, and to be reachable in cases of emergency. Another more powerful way that therapists can establish that they are well grounded and dependable centering points in their patients' lives is to unfailingly pursue patients who do not show up for their sessions.

If the therapist establishes a pattern whereby he or she will almost always telephone a patient within hours of their missing a session, the therapist communicates a concern that goes beyond words. Along these same lines, it is advisable for therapists to be willing to continue to treat a drug-abusing patient when he or she returns after a drug lapse or other prob-lematic hiatus from therapy. This strategy provides the most realistic means by which to treat a disorder whose course is often recurrent. Further, it provides a sense of hope for patients who otherwise might believe that they have burned their bridges with all benevolent and helpful others.

Therefore, they may be more apt to return to treatment voluntarily and more quickly following future lapses. Be Trustworthy, Even When the Patient Is Not As explained above, therapists must demand a higher standard of behavior from themselves than they can expect from their substanceabusing patients. Patients who act and think in combative, passiveaggressive, and/or mistrustful ways in their everyday life often expect that others will treat them in like fashion.

Therefore, it is a corrective experience for patients when they realize that their therapists will continue to demonstrate honesty and concern, even when the patients themselves have been less than friendly or truthful in return. As difficult as it is to gain the trust of the substance-abusing patient, it can be impaired or lost quickly and with relatively little provocation. Therefore, the therapeutic relationship must be managed in a delicate, pains-taking fashion.

In the process of accomplishing this  goal, therapists must recognize their own anger when patients lie to them, and must strive to keep such feelings in check. Instead, therapists need to find a diplomatic way to address the "apparent inconsistencies" in what the patients say and do, and to remain nonjudgmental (Beck et al. 1993).

Remain Calm and Cool in Session, Even If the Patient Is Not

When a patient becomes hostile, loud, intransigent, and/or verbally abusive, it does little good for the therapist to respond in kind (Beck et al. 1993). To deescalate a potentially dangerous situation, the therapist must stay calm, nondefensive, and matter-of-fact. It is important at such times for the therapist to express a genuine concern for the patient's well-being and best interests.

When the therapist and patient are at odds, it is extremely helpful for the therapist to call attention to their areas of agreement and collaboration. This helps to remind that patient that a single conflict with the therapist does not mean that the entire therapeutic endeavor is adversarial.

Although a certain degree of confrontation between the therapist and the drug-abusing patient is almost inevitable during the course of treatment (Frances and Miller 1991), the therapist can minimize damage to the therapeutic relationship by calmly communicating a tone of respect and concern (Newman 1988).

Be Confident, But Be Humble

One of the most fundamental ways to help patients gain confidence and hope about the process of therapy is for therapists to show confidence in themselves. This involves such behavioral components as clarity of voice, relaxed posture, nondefensiveness, and an energetic optimism.

However, the therapist does not need to go to extremes to demonstrate confidence. In fact, it is actually ill-advised for therapists to portray themselves as omnipotent and/or omniscient. A certain degree of humility is necessary to create and sustain an atmosphere of collaboration and mutual respect. For example, therapists must be willing to admit that they do not know (or were wrong about) something, if appropriate, rather than try to fake their way through.

For example, one patient repeatedly referred to a "Reverend Percy" in his first therapy session. At one point, he asked his therapist, "You're aware of Reverend Percy's work in the community, aren't you?" The therapist, not wanting to seem like he was ignorant about important civic leaders, was tempted to tell a white lie and answer "yes." Fortunately, the therapist humbly admitted that he hadn't heard of Reverend Percy, but that he was interested in learning more about him.

The patient laughed, and stated that it was a good thing that the therapist didn't know Reverend Percy, because "I just made him up!" By showing a willingness to admit that he didn't know something, the therapist passed the patient's rather clever but devious test. Therefore, the therapist preserved his credibility. Another way therapists can demonstrate humble confidence is to apologize at times.

Therapists can do this in response to misunderstandings or minor errors, such as a miscommunication about the exact date and time of a scheduled session, or a harsh sounding comment (e.g., "I'm sorry if my last statement sounded rather hard on you. Really, I'm on your side, but perhaps I got a little carried away just then because I was very concerned about you.").

The therapist communicates confidence by showing that he or she is not afraid to admit to a mistake, and that he or she is still optimistic about the course of therapy.

Set Limits in a Respectful Manner

While it is important that therapists work collaboratively with their substance-abusing patients, they must take care not to become so permissive that patients will know that they can take advantage of their therapists' good will. Limits must be set (Ellis 1985; Ellis et al. 1988; Moorey 1989)—for example, that a therapy session will not be held if the patient is intoxicated.

Therapists should establish ground rules during the first session so there will be no confusion or ambiguity later on. Therapists can set limits without sabotaging the therapeutic relationship if they adopt a respectful tone and emphasize their commitment to help patients with their problems (Newman 1988, 1990).

For example, Beck and colleagues (1993) describe the case of a patient who arrived intoxicated for a therapy session. The therapist asked the patient if he had been drinking, and the patient acknowledged that he had. The therapist thanked the patient for his honesty and then suggested that the session be postponed. When the patient protested, the therapist calmly stated, "We made an agreement that we would meet only when you were sober and able to  fully absorb the benefits of the session, and I think we should stick to our agreements."

The therapist went further to point out the advantages of the patient's remaining in the waiting room for a couple of hours until it was safe for him to drive home. The patient was a bit disgruntled, but was mollified when the therapist gave him a newspaper to read to keep him occupied. The lesson to be learned from the above vignette is to set limits, but be neither critical nor controlling.

Emphasize that the patient's welfare is the primary concern, and that the therapeutic alliance is still active and strong in spite of the disagreement. Then, follow through.

THE THERAPEUTIC RELATIONSHIP AND THE CASE FORMULATION

Therapists who are most adept at accurately understanding their patients have the best chance of establishing and preserving positive alliances with their patients. In this sense, a good case formulation goes a long way toward helping the therapist and patient maximize their collaborative effort.

When conflicts arise between a therapist and a patient, and/or when unexpressed but problematic ill feelings exist in the therapeutic relation-ship, the therapist can explore aspects of the case conceptualization to make sense of the interpersonal tensions in session. Oftentimes, this strategy will not only shed light on the reasons for the problems in the therapeutic relationship, but will advance an overall understanding of the patient's life issues. As a result, important material is revealed, the patient feels better understood, and the therapeutic alliance is strengthened.

The following are some general guides for using the case conceptulation in the service of improving the therapeutic relationship. 1. Strive to understand the pain and fear behind the patient's hostility and resistance. 2. Explore the meaning and function of the patient's seemingly oppositional or self-defeating actions. 3. Assess the patient's beliefs about therapy.  4. Assess your own beliefs about the patient. 5. Collaboratively utilize unpleasant feelings in the therapeutic relationship as grist for the mill.

Strive To Understand the Pain and Fear Behind the Patient's Hostility and Resistance

Although the therapist may believe that change is a good thing, clients may have misgivings. Many patients, especially those with serious, longstand-ing disorders, cling tenaciously to the status quo in their lives, because to some extent it is familiar and safe (Beck et al. 1990; Layden et al. 1993; Newman 1994a; Young 1990). For many patients, it is frightening and disorienting to change patterns of cognition, affect, and behavior that they have long associated with their very identity.

Additionally, many patients believe that significant change is untenable, due to further difficulties that they expect would arise. For example, Ed and his therapist agreed that prostitutes were a highrisk stimulus for him. Whenever he would encounter a prostitute who liked to get high, he was vulnerable to seeking out drugs with which to pay the woman. Then, they would have sex and smoke crack cocaine together.

In spite of this understanding, Ed still frequented prostitutes and used drugs. At first, this exasperated the therapist, who thought that Ed was deliberately sabotaging therapy because of an opposition to change. However, when the therapist probed for Ed's fears about giving up this maladaptive pattern, Ed was able to articulate that he felt he had nothing to offer a straight woman.

He believed that because he was unemployed and not very handsome, his only means of finding female companionship would be in the context of drug use with a prostitute. In other words, underlying Ed's apparent resistance was a fear of being alone. This understanding helped the therapist to express empathy, and to encourage Ed to actively challenge the belief that he would be alone if he gave up drugs. When patients become overtly angry in session, therapists can cope with this situation best by trying to provide empathy, and by reminding them-selves that no matter how aversive this situation is for therapists, the patients almost always feel worse.

This stance helps therapists to decatas-trophize the situation, and to keep the therapists' attention squarely on the patients' needs. For example, one therapist defused a patient's hostile outburst by asking, "Do you feel I've let you down in some way?"

Another  therapist achieved the same end by saying, "I'm sorry if what I've said or done has upset you. That wasn't my intention. How did what I said hurt your feelings?" Yet another example is the therapist who "normalized" his patient's angry refusal to answer the therapist's questions by stating, "I can see that you're only trying to protect yourself. That's okay. Everybody has the right to do that."

Explore the Meaning and Function of the Patient's Seemingly Oppositional or Self-Defeating Actions

When substance-abusing patients do not appear optimally connected with the therapist or engaged in the process of therapy, it is useful to explore the factors that seem to make it in the patient’s best interest to oppose the therapist. Therapists can address this issue head on by noting that there are both advantages and disadvantages to changing one's behavior, and that it might be interesting to look at the pros and cons of attending therapy, as well as the pros and cons of using or abstaining from drugs.

Therapeutic collaboration is facilitated when therapists show that they are willing to look at the cons of change (Grilo 1993). Patients then become more apt to cooperate in the exercise of reviewing the long-term costs involved in not changing. Thus, patient receptivity to change is enhanced.

Rita's behavior at the start of therapy was quite contentious. She contra- dicted or made sarcastic remarks about much of what the therapist would say. After experiencing much frustration and consternation, the therapist finally said: "Rita, given that you frequently disagree with me, my first guess would be that you don't like to meet with me—and yet, you always come to your sessions. What are you getting out of these sessions? How is therapy meeting your needs, given that we seem to be at odds so often?"

Rita didn't know what to make of this at first. Upon further reflection, however, she admitted that she gained a sense of power out of being able to intellectually spar with the therapist. In her view, it would take the fun out of therapy if she agreed with her therapist. This admission led to a fruitful discussion of power, control, and counter-control in relationships.

Assess the Patient's Beliefs About Therapy 

An assessment of how patients idiosyncratically interpret various situa-tions is part and parcel of the process of case conceptualization in cogni-tive therapy (Persons 1989). One such situation is therapy itself. Some patients expect that therapy will be an adversarial process, especially when they perceive their therapists to be from a more privileged socio-economic background. Here, they may perceive their therapists to be agents of the system who will continue to oppress them.

Naturally, this viewpoint is laden with mistrust, and will need to be addressed in order for treatment to proceed in a collaborative and amicable fashion. Another problematic belief about therapy to which some drug-abusing patients subscribe is that the process should always feel good.

This belief ignores the fact that taking part in treatment is hard work, and often involves the discussion of emotionally painful issues. If this belief is unassessed and unaddressed, a patient may bolt from therapy at the first sign of discomfort, perhaps before a positive therapeutic alliance can even be established. Yet another maladaptive cognitive stance that some patients adopt is that therapists cannot be of any help unless they have gone through the problem of substance abuse in their lives too.

Therefore, instead of looking at their therapists as positive role models who have the personal and technical skills to help the patients with their problems, patients may discount the thera-pists' comments and reject their help because "they just don't understand."

Therapists need to be aware of some of these (and other) dysfunctional presuppositions that drug-abusing patients sometimes have about therapy and therapists. Towards that end, it is extremely useful in the first session for therapists to ask two series of questions, one during the early stages of the session and the other at the end of the session.

The first question is: "What are your thoughts about coming in to meet with me today? I'm not sure whether you feel good or bad about seeing me, and I'm not sure what your expectations or hopes about treatment are. But I'd like to know, if you're willing to share your thoughts with me." The second question is: "What are your impressions about how things went in today's session? Was there anything that I said that you didn't like or didn't agree with? Was there anything about today's session that was particularly helpful? What should we make sure we  continue to talk about in our next session in order to get the most out of being here?"

Assess Your Own Beliefs About the Patient

Therapists are human beings, and therefore are subject to their own dysfunctional beliefs at times. This is most problematic when the therapist's maladaptive beliefs center on their patients, and the therapist fails to take stock of these beliefs.

Some of the more commonly encountered therapist beliefs (cf. Beck et al. 1993) include: • "This patient is a loser." • "This patient is beyond help." • "This patient will never listen to me." • "Why can't I reach this patient? What am I doing wrong? I'm going to have to give up on working with this patient." • "You can't be collaborative with this type of patient. If you give them an inch, they'll take a mile. Therefore, I will not budge from my position one iota." • "This case is more trouble and responsibility than I can bear."

When therapists find themselves having such thoughts, it presents them with an excellent opportunity to use cognitive therapy techniques on themselves (Newman 1994b). This strategy can help therapists moderate their own hopelessness and frustration enough to still be able to provide good will and an earnest effort.

The end result is that the therapeutic relationship will continue to have a positive effect on the process of treatment, rather than being a hindrance. Additionally, the therapist will have gained a deeper understanding of the nature of the patient's typical interpersonal difficulties in everyday life.

The following is a sampling of rational response flashcards that therapists can personally develop to help them modify counterproductive beliefs about drug abusing patients (cf. Beck et al. 1993): • "There have been a number of sessions in which the patient and I have worked very well together. Those were rewarding experiences that I must not forget."  • "Let me try to understand my patient's resistant thoughts and behaviors, rather than simply label her a troublemaker." • "This power struggle is a great opportunity to get at some really hot interpersonal cognitions!" • "If I keep my cool, present my point of view calmly, and also show that I'm willing to be flexible within reason, I'll probably get a lot more therapeutic mileage out of this conflict than I will if I become strident or stubborn."

Collaboratively Utilize Unpleasant Feelings in the Therapeutic Relationship as Grist for the Mill

Tension and conflict between a patient and therapist need not be gratuitously disruptive to the process of therapy. In fact, if handled skillfully, such episodes can shed light on the patient's negative beliefs and actions regarding interpersonal relationships (cf. Layden et al. 1993).

This information, in turn, can be used to help the patient make important discoveries, and can inspire him or her to experiment with new adaptive behaviors. For example, a therapist noticed that the patient was looking glum, not making eye contact, and sounding a little sarcastic. To explore the meaning of this behavior, the therapist forthrightly said, "Things seem a little tense between you and me today. Did you notice that?"

This led to the patient's becoming uncharacteristically silent; therefore the therapist knew that she had hit home. She added, "Can we talk about it? If something is wrong I'd like to try to work it out, if that's okay with you." Upon further discussion, the patient stated that the group therapy leader (in another setting, though still part of the patient's treatment package) had said something that "he could only have known if he spoke to you."

In other words, the patient thought that his individual therapist was saying things about him behind his back to the group therapy counselor. This, in fact, was not the case at all. The therapist and patient discussed all the possible alternatives to his mistrustful point of view, including the possibility that the group counselor and individual therapist were independently reaching similar clinical judgments about the patient.

The therapist added that she would certainly talk to the patient directly about the prospect of sharing information with the group counselor if the need arose. Then she demonstrated empathy for the patient, stating, "It must have been difficult for you, thinking that I betrayed your trust. I can imagine how disillusioned you must have felt. I'm glad we can set the record straight, because I have enjoyed working with you, and things seemed to be going well until this misunderstanding."

Furthermore, this episode became grist for the mill in that it highlighted one of the patient's characteristic patterns—namely, to jump to con-clusions about the ill motives of another person, and then to keep these suspicions to himself. This would then prevent the possibility of talking things out and resolving or clarifying the matter with the other person, and the relationship would deteriorate.

It was little wonder that the patient felt he had so few friends, and believed that he could never depend on anyone. Because the therapist succeeded in uncovering the nature of the rupture in the therapeutic relationship, the patient-therapist alliance was preserved, and an important aspect of the patient's dysfunction became a clinical topic for the session.

CONCLUSION

The treatment of substance-abusing patients poses a great set of challenges to therapists. One of the most fundamental and vital of these is the establishment and maintenance of a positive therapeutic relationship. If therapists succeed in communicating a spirit of acceptance, collaboration, respect, good will, and optimism to their drug-abusing patients, the process of treatment will be enhanced.

If, by contrast, these goals are not achieved, the likelihood of the patients' demonstrating spotty attendance, poor punctuality, and premature termination will increase, thus diminishing the prospects that therapy will have an appreciable effect. Therapists can facilitate the formation and maintenance of a positive therapeutic alliance with drug-abusing patients by consistently adhering to principles that are part and parcel of a cognitive therapy approach.

Such principles include working with the patient as a team, giving clinical rationales in a clear fashion, eliciting feedback from the patient, exploring the belief systems of the patient, being aware of one's own belief systems and how they may impinge on the therapeutic process, and utilizing the case conceptualization and other strategies that require a thoughtful, empathic, and pragmatic approach.

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AUTHOR

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

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From NIDA Research Monograph 165 - Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment