Fundamental Cognitive Therapy Skills for Keeping Drug-Dependent Individuals in Treatment

By Bruce S. Liese and Aaron T. Beck

INTRODUCTION

Dr. A is conducting his third cognitive therapy session with Mary, a depressed, cocaine-dependent 34-year-old woman. As she describes a recent relapse, Mary begins to cry. Dr. A says he has no tissues and he makes no effort to find any. Instead he urges her to think carefully: "Now Mary, what goes through your mind right before you use cocaine?"

Mary's crying escalates and in the absence of tissues she blows her nose and wipes her tears with the wrapping paper from the sandwich she ate for lunch. Dr. A persists in asking about Mary's drug-related thoughts. She responds to his queries, but does not show up for their next two scheduled sessions. Eventually she drops out of therapy.

Dr. B is meeting with Bob for their second session. Bob, diagnosed with cocaine dependence and narcissistic personality disorder, describes himself as "extraordinarily successful and gifted." As evidence of his brilliance, Bob offers a long list of accomplishments. Bob doubts whether anyone, including Dr. B, can really understand or help him.

In this session, Bob graphically describes a sexual encounter. Dr. B interrupts with the question, "What cocaine-related beliefs were you having at this moment?" Bob responds incredulously, "What the hell are you talking about?" Dr. B insists that cognitive therapy will help Bob eliminate the thoughts and beliefs that led to his drug use. Bob responds, "Good luck!" He never returns to see Dr. B.

Dr. C is conducting his first psychotherapy session with Gina, an unmarried 18-year-old woman dependent on alcohol, marijuana, nicotine, and cocaine. Gina explains that she dropped out of school at age 16 to take care of her newborn baby. She admits to using drugs when she is overwhelmed.

In this first session, Dr. C spends 35 minutes of a 50-minute session describing cognitive therapy. He gives detailed technical descriptions of schemas, conditional beliefs, cognitive distortions, facilitative beliefs, and instrumental strategies. 

Dr. C completes his lecture by asking, "Does this make sense?" Gina replies, "I guess so." Satisfied with this answer, Dr. C finishes his lecture and schedules Gina for their next session. Gina shows up for the following session, but attends only a few more sessions before she eventually drops out of treatment.

For several years, cognitive therapists have been trained to provide treatment to drug-dependent patients. These case examples reflect actual incidents observed during this training process. The authors have witnessed scenarios such as these and realized the extraordinary challenge and importance of retaining drug-dependent patients in treatment.

This chapter reviews the literature on premature termination (i.e., dropout). The cognitive model of substance abuse is presented, along with the authors’ conceptualization of missed sessions and dropout. And finally, strategies are proposed for retaining drug-dependent individuals in treatment.

THE LITERATURE ON THERAPY DROPOUTS: A BRIEF REVIEW

A substantial literature addresses the problem of dropout from psycho-therapy (Wierzbicki and Pekarik 1993). Dropout has been found to relate to several factors, including quality of the therapeutic alliance (e.g., Mohl et al. 1991; Grimes and Murdock 1989; Strupp et al. 1992; Tryon and Kane 1990) and severity of psychopathology (e.g., Avasthi et al. 1994; Kazdin 1990; Kazdin et al. 1993; MacNair and Corazzini 1994; McCallum et al. 1992; Ravndal and Vaglum 1994; Sterling et al. 1994).

Generally, research has revealed inconsistent relationships between demographic variables and dropout (e.g., Beckham 1992; Gilbert et al. 1994; Mosher-Ashley 1994; Sledge et al. 1990). Nonetheless, in a recent meta-analysis of 125 studies, Wierzbicki and Pekarik (1993) found significant relationships between three demographic variables (race, education, income) and dropout.

A number of studies have demonstrated positive relationships between substance abuse and dropout from psychotherapy. In a study of 142 outpatients with various psychiatric diagnoses, Swett and Noones (1989) found that patients with drug or alcohol problems were more likely than other patients to drop out of individual psychotherapy.

In a study of 65 depressed adolescents, Gilbert and colleagues (1994) found that those with alcohol and drug histories were more likely to drop out of a 12-week psychotherapy group than those who did not report alcohol or drug use.

MacNair and Corazzini (1994) studied 155  university students enrolled in interpersonal therapy groups and found that those with alcohol and drug problems were more likely to drop out than those without such problems. Recently, investigators (Simpson and Joe 1993; Smith et al. 1995) have begun to examine the relationships between the processes and stages of change (Prochaska et al. 1992) and dropout.

Studies have tested the hypothesis that individuals' stages of change relate to their retention in treatment; thus far, only modest support has been found for this hypothesis. Estimates of dropout from psychotherapy have ranged from approximately 30 percent to 60 percent (Wierzbicki and Pekarik 1993).

In their meta-analysis, Wierzbicki and Pekarik found the mean dropout rate of 125 studies to be approximately 47 percent. Dropout from drug and alcohol treatment is common and retention rates are extremely variable. Carroll and associates (1994) reported that only 49/121 (40 percent) of subjects in their study completed treatment for cocaine dependence.

In a study of inpatient alcoholics, Carver and Dunham (1991) reported that only 71/141 (50 percent) of subjects completed treatment. Simpson and Joe (1993) studied dropout patterns in methadone maintenance clinics participating in the Drug Abuse Treatment for AIDS-Risks Reduction (DATAR) project funded by the National Institute on Drug Abuse (NIDA).

These authors found that 12 percent of methadone maintenance patients terminated within 30 days, 24 percent within 60 days, and 35 percent within 90 days (N = 311). Sterling and colleagues (1994) found that only 43/194 (22 percent) of individuals successfully completed treatment for crack cocaine dependence. No single variable has uniformly been associated with dropout from drug or alcohol treatment.

For example, in one study (McCallum et al. 1992), severity of psychiatric symptoms predicted dropout, while in two other studies (Ravndal and Vaglum 1994; Sterling et al. 1994), no such relationship was found. Similarly, in one study (Carver and Dunham 1991) renewed drinking was predictive of dropout, while in another study (Ravndal and Vaglum 1994), renewed substance use was not predictive of dropout.

Two studies (Carroll et al. 1994; Simpson and Joe 1993) reported that being married was positively correlated with completing treatment. No such relationship was reported in the other studies reviewed above. An interesting finding, relevant to cognitive therapy, was reported in two of the above-mentioned studies. Carver and Dunham (1991) and  Simpson and Joe (1993) found that patients' expectations for success were related to reduced drug use and completion of treatment.

Expectations of success involve thoughts and beliefs about the potential effectiveness of treatment. This finding is consistent with the cognitive conceptualizations of substance abuse and dropout described in the following sections.

THE COGNITIVE THERAPY OF SUBSTANCE ABUSE: A BRIEF REVIEW

The authors’ basic model of substance abuse (Beck et al. 1993; Liese 1993, 1994a, 1994b; Liese and Chiauzzi 1995; Liese and Franz, in press; Wright et al. 1992) is presented in figure 1.
[See source article for figures.]

The model assumes that certain activating stimuli (e.g., anxiety, interpersonal conflicts) trigger basic drug-related beliefs and automatic thoughts about substance use (e.g., "Drinking/smoking relaxes me!"). These beliefs and thoughts, in turn, heighten individuals' urges and cravings to use drugs.

But not all urges and cravings lead individuals to drug use. Instead, individuals who have facilitative beliefs about drugs (e.g., "Just one won't hurt me") are likely to use drugs. In the presence of urges, cravings, and facilitative beliefs, many individuals focus on actions that prepare them for continued use and relapse, though some rare individuals are able, at this critical point, to "just say no."

COGNITIVE CONCEPTUALIZATION OF MISSED SESSIONS AND DROPOUT

The model for conceptualizing missed sessions and dropout is presented in figure 2. This model is based on extensive discussions with cognitive therapists and their drug-dependent patients. First, therapists were asked to speculate about their patients' reasons for missing sessions and dropping out.

After formulating a tentative model based on therapist responses, patients were asked: "What circumstances and thoughts would  lead you to miss sessions or drop out of therapy?" Initially, many patients denied any risk of dropout, exclaiming: "This is my last chance for recovery. I won't drop out!" These individuals would then be ask to respond hypothetically: "Let’s assume that you won't miss sessions or drop out. But if it were to happen, what circumstances or thoughts would be involved?"

Patients also were asked to reflect on the circumstances and thoughts associated with past missed sessions and dropout. The model presented in figure 2 is based on answers to these queries. According to the authors’ conceptualization of missed sessions and dropout, certain circumstances (e.g., continued alcohol or drug use) place people at high risk for missed therapy sessions and dropout.

These circumstances activate certain beliefs about therapy or the therapist (e.g., "Therapy won't help me," or "My therapist doesn't understand me.") that are manifested as automatic thoughts (e.g., "Why bother?" or "What a jerk!"). These beliefs and thoughts lead to emotions and behaviors associated with dropout. The thoughts, feelings, and behaviors associated with missed sessions and dropout tend to be self-reinforcing (i.e., they function in a cyclic fashion; see figure 2).

Certain emotions (e.g., despair, anger, anxiety, guilt) and behaviors (e.g., drug use, missed sessions) function as circumstances that increase the likelihood of future missed appointments and dropout. Beckham (1992), for example, found that missed sessions early in therapy were highly predictive of later dropout. In the typical course of outpatient treatment for drug dependence, individuals may become skeptical, believing that "treatment isn't working" (especially in response to strong urges, craving, or lapses).

This belief may lead to missed sessions. Missed sessions may lead to increased emotions of apathy, discouragement, or guilt. These emotions may lead to additional missed sessions until eventually this vicious cycle ends in dropout. In the following paragraphs the authors’ conceptualization of missed sessions and dropout is described in more detail, including the associated circumstances, beliefs, automatic thoughts, emotions, and behaviors associated with missing sessions and dropping out.

Circumstances Related to Missed Sessions and Dropout

Many circumstances potentially relate to missed sessions and dropout. These circumstances include (but are not limited to) continued alcohol or drug use, extended periods of abstinence, legal problems, medical problems, psychological problems, family/relationship problems, logistical problems, and therapeutic relationship problems.

It is  important to note that these circumstances do not necessarily result in missed sessions or dropout. Instead, they may activate beliefs or thoughts that in turn result in missed sessions and dropout. Some individuals drop out of therapy when they have lapses or relapse, while others continue to attend therapy sessions when they are using drugs or alcohol. Some individuals drop out of treatment when they have legal, psychological, medical, or relationship problems, while others drop out of treatment when they resolve these problems (especially if they have entered treatment to avoid the negative consequences of using, such as loss of children).

Continued Alcohol or Drug Use.

Unfortunately, relapse is prevalent among individuals attempting to abstain from alcohol and drugs (Hunt et al. 1971; Marlatt and Gordon 1985, 1989). Lapses and relapses may trigger distress, discouragement, helplessness, and hopelessness in patients that, in turn, may lead to dropout.

In addition to distress, continued drug use may result in other problems in patients' lives, which may further contribute to missed sessions and dropout. For example, drug use can cause legal problems, medical problems, psychological problems, family problems, logistical problems, and problems in the therapeutic alliance.

These circumstances (listed in figure 2) are all discussed in this section. Extended Periods of Abstinence. Just as there are individuals who have slips, lapses, and relapses, there are others who succeed at being abstinent from drugs and alcohol. These individuals, despite their abstinence, are likely to have residual skill deficits.

For example, they may lack effective communication skills or mood-management strategies that facilitate abstinence. If these individuals do not perceive therapy as offering relevant skill development, or if they perceive themselves as not needing to develop skills, they are likely to miss sessions and drop out of treatment.

Abstinent individuals with substantial family or personal responsibilities are at even higher risk for dropout. For example, consider Gina, the young mother described above. At present Gina is struggling to manage multiple life demands. She is likely to view time, rather than therapy, as being her most precious resource. While abstaining from drugs and alcohol, she is likely to view addiction treatment as taking time away from her baby rather than being beneficial to her continued abstinence.

Legal Problems.

Drug-dependent individuals are at heightened risk for legal problems. Many psychoactive drugs (e.g., cocaine, heroin,  hallucinogens) are illegal; the purchase, sale, and possession of these drugs constitutes a punishable crime. Likewise, the use of legal drugs, like alcohol, may also be associated with illegal behaviors (such as driving under the influence).

Psychoactive drugs are also expensive and some individuals resort to illegal activities (e.g., robbery, theft, prostitution) to acquire them. Even nicotine dependence can lead to shoplifting if the smoker does not have the financial means to purchase cigarettes. Chronic drug use may also lead to significant impairment in judgment, resulting in uncharacteristic illegal behaviors.

While many drug-dependent individuals do not engage in illegal activities themselves, they may associate with others who do. Mary (described above), for example, has never engaged in significant illegal behaviors. However, when she is actively using cocaine she is drawn to one particularly violent, aggressive, antisocial, drug dependent man who deals drugs. As drug-dependent individuals become increasingly involved in illegal activities, they are at heightened risk for dropout for several reasons.

First, they may be ashamed of their behaviors. Second, they may be afraid of the potential legal consequences of discussing their behaviors with others (e.g., therapists). And third, they may be incarcerated for their illegal behaviors, making treatment inaccessible. It is important to acknowledge that some individuals are mandated to enter treatment as a result of their legal problems.

These individuals are particularly prone to drop out when their legal problems are resolved (for example, when criminal charges against them are dismissed). Medical Problems. It is well known that psychoactive drugs are associated with numerous medical problems. For example, cigarettes are associated with almost half a million deaths per year (from heart disease, pulmonary disease, a variety of cancers, and numerous other medical problems).

Alcohol is associated with almost 100,000 deaths per year (from liver disease, gastrointestinal disorders, vascular diseases, malnutrition, and trauma). Cocaine has been linked to heart attacks, strokes, hypertension, and trauma. Marijuana smoking is associated with pulmonary disease, depression, and amotivational syndrome.

Medical problems resulting from drug abuse often result in the initiation of drug treatment. However, when individuals become seriously ill or hospitalized they are less likely to continue treatment and more likely to drop out.

Psychological Problems.

Just as psychoactive substances lead to medical problems, they may also lead to psychological problems. Many psychoactive drugs act as central nervous system stimulants and  depressants and their chronic abuse may lead to serious psychological problems which may, in turn, lead to missed sessions and dropout.

For example, Mary suffers from recurrent depressive episodes, exacerbated by her cocaine use. One of the most salient symptoms of Mary's depression is hopelessness. Any indications that Mary is "failing" in therapy might activate hopeless thoughts (e.g., "It's useless to attend therapy; I'll never improve."). Hopelessness may eventually lead to complete withdrawal from treatment.

Family/Relationship Problems.

It is well known that chronic substance use has a negative impact on families and interpersonal relationships. These problems may lead to missed sessions or dropout. Gina, for example, currently has almost no social or family support. At one time Gina's mother would help her with money and child care so Gina could work and attend therapy.

However, Gina's mother decided to stop providing assistance to Gina after discovering that Gina was using her money and free time to use drugs. At the urging of her Al-Anon group, Gina's mother elected to take a tough love stance with Gina by withdrawing all support from her.

The inadvertent effect was the escalation of missed sessions and eventual dropout. Similar to legal and medical problems, family and relationship problems may also result in the initiation of treatment. Many individuals enter treatment to avoid the negative consequences of their drug use (e.g., loss of a marriage or children).

These individuals are particularly vulnerable to dropout when they believe that their family problems are resolved. Logistical Problems. Many drug-dependent individuals are vulnerable to logistical problems, including difficulties with finances, transportation, and child care. It is common for addicted individuals to lose their drivers' licenses, jobs, and even homes as a result of their drug use.

At one time, Bob was a financially successful attorney. However, as a result of his drug use he lost his wife, job, savings, car, and home. Like Mary and Gina, Bob did not have enough money to pay the taxi fare to attend treatment. Given his narcissistic personality, he attributed these problems to events outside of himself (e.g., getting "ripped off" by others who were envious of him). He dropped out after concluding that he had "more important things to do than go to therapy."

Therapeutic Relationship Problems.

Given the numerous problems encountered by drug-dependent patients, the development and  maintenance of collaborative therapeutic relationships may be difficult. Patients are likely to feel ashamed, depressed, or angry at themselves for their problems. They may fear that therapists will judge them or be upset with them.

Therapists may, indeed, have strong negative feelings towards their drug-dependent patients and convey these to patients. When this occurs, therapy becomes aversive and patients are likely to drop out. Most treatment models strongly encourage, require, or demand that patients be fully abstinent from drugs and alcohol during and after treatment.

These models may convey the messages: "If you use drugs or alcohol we can't help you," or "If you use drugs or alcohol you have failed and disappointed us." Such messages may intimidate, discourage, frustrate, and anger drug-dependent individuals, who may drop out of treatment following any drug use.

In each of the three case examples described above, therapists viewed drug or alcohol use as catastrophic and intolerable. While they did not overtly express anger or frustration, they conveyed disappointment and disapproval in subtle ways.

Unfortunately, inexperienced cognitive therapists are likely to underestimate the difficulty and importance of developing collaborative relationships with their drug-dependent patients.

In response to certain patient behaviors (e.g., missed appointments, relapse, dropout), therapists are likely to experience emotional distress, including feelings of frustration, irritation, anger, boredom, and despair. Therapists' distress, of course, can be attributed to their negative beliefs.

Among the therapist beliefs that lead to distress are the following (Liese and Franz, in press): • This patient is a typical drug addict! • After detox this patient will just relapse again! • This patient thinks I'm stupid! • This feels like a waste of my time! • All addicts are the same! • Lapses and relapses are catastrophic! • Missed sessions are awful/terrible/intolerable! • This patient doesn't want to change! • I'm working harder than this patient!

Hence, a vicious cycle may emerge wherein both therapist and patient reinforce each other’s worst fears. When patients sense their therapists' distress they, of course, become vulnerable to dropout.  To illustrate the cyclic nature of missed sessions and dropout, consider the example of Mary, presented earlier.

At the beginning of her third session with Dr. A, Mary felt discouraged about her recent drug use. During the session she became visibly distressed. Instead of attending to her despair and responding empathetically, Dr. A focused exclusively on Mary's recent drug use. By the end of the session Mary felt ashamed, confused, and angry at herself for "being so weak."

As Mary's fourth session approached she thought, "I never succeed at anything I do, so why bother with therapy? Besides I don't like my therapist." She canceled her fourth and fifth sessions, which heightened her belief that therapy would not help her. Eventually she made another therapy appointment, but in this session Dr. A was very confrontive about Mary's missed sessions and her commitment to therapy.

Mary again felt extreme despair. Her corresponding thoughts were, "It's hopeless. I can't quit using drugs. Talking about my problems only makes me feel worse. If I return to therapy I'll only disappoint Dr. A." When it was time to return for her next scheduled appointment, Mary reflected on the last visit and decided, once and for all, "I'm just not getting anything out of therapy."

She never again returned for therapy and her drug abuse worsened. Beliefs Activated As the model was being developed, the authors began to search for the idiosyncratic beliefs leading to dropout, for example: "Therapy isn't likely to help me," "My therapist doesn't understand me," "I don't want to quit using drugs yet," and "It's uncomfortable to talk about my problems."

It was assumed that knowledge of these beliefs would facilitate increased empathy for drug-dependent patients and lead to specific techniques for retaining patients in treatment. With the help of therapists and patients, the search generated hundreds of beliefs associated with missed sessions and dropout. From these, a list of 50 beliefs was distilled (see appendix).

In the following paragraphs, the three case examples are used to illustrate these beliefs. Mary, discussed earlier, began crying in her third therapy session. When the therapist did not offer tissues or act in a conciliatory manner, she probably began to think: "I can't quit using drugs" (item 7); "I'm helpless, so what's the point of trying to quit?" (item 12), and; "I never succeed at anything I set out to do" (item 22).

Of course these beliefs, consistent with her depression, put her at high risk for missing future sessions and dropout. Unfortunately, these beliefs also put her at high risk for continued drug use.

As Mary continued to use drugs while in therapy, she developed such additional  beliefs as: "I really, really can't quit using drugs" (item 7); "I don't deserve help since I'm still using drugs" (item 25), and; "I'll just get upset if I go to a therapy session" (item 38). Bob, who was narcissistic, was likely to hold the following beliefs: "My therapist doesn't understand me" (item 11), "I don't really like my therapist" (item 23), and "I have more important things to do than go to therapy" (item 39).

As a result of these beliefs, he would feel annoyed at his therapist and see little value in attending sessions. Gina, an educationally and economically disadvantaged young mother, was likely to react to her therapist's lecture with such beliefs as "I'm not smart enough to benefit from this therapy" (item 8), "I don't like this type of therapy" (item 24), and "I can't make the necessary arrangements so I won't go to therapy" (item 41).

Naturally, these beliefs led her to avoid therapy until she eventually dropped out. Automatic Thoughts As previously mentioned, automatic thoughts are brief, abbreviated versions of basic beliefs.

Automatic thoughts exert powerful effects on emotions and behaviors, yet they often manifest themselves in ways that are undetectable to the person experiencing them. Examples of automatic thoughts leading to missed sessions and dropout include, "Not today," "It's hopeless," and "He's a jerk!" (referring to the therapist).