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Drug Avoidance Skills

Rationale

Therapists can paraphrase the following to explain self-management planning.

"Now that you have identified the triggers and consequences related to your cocaine use, we are going to work on developing strategies for dealing with the triggers. To do so, I will teach you a strategy called self-management planning. This training involves learning how to avoid the triggers or to replace them with other things that are less risky. In addition, you will learn how to rearrange your environment to reduce the likelihood of using cocaine."

Initiate Training

Before initiating self-management training, therapists should review with patients their functional analysis forms. This review should include the following.

• An explanation that external environmental events can often set off drug use.

• Categorization of triggers into places, people, time of day, activities, feeling, and so forth. Give examples and relate them back to the functional analysis (after work, weekends, watching television, others using, anticipation of sexual experience).

Therapists should then explain that there are three basic ways of handling these triggers to reduce the risk of cocaine use.

"One way is to avoid the trigger; for example, take a route home that is different from where you obtained cocaine in the past; avoid going by your dealer's house; don't go into bars; and avoid certain people. To do this successfully, you will have to engage in new or different activities."

"The second way to deal with triggers is to rearrange your environment. For example, don't keep cocaine or paraphernalia in the house, and don't carry money with you if you know you will be walking or driving past places where you might be tempted to buy cocaine."

"The third way of dealing with triggers is to develop some new coping method or plan that will help you not use when you are in a particular situation. For example, you experience a trigger such as extra cash in your pocket. Instead of using the money for drugs, engage in some incompatible behavior. For example, you might call your spouse or do some activity that you enjoy, like working out at a gym or shopping for something special for you or your family."

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Make the Plan

Using the patients' Functional Analysis forms, therapists can ask them to pick out a few triggers and then discuss how they might handle those triggers to reduce the chances of using cocaine.

Using the Self-Management Planning Sheet as a guide (exhibit 15), therapists can lead patients through the following steps.

• Choose a trigger. Start with one that often leads to cocaine use. If possible, choose a trigger that is likely to come up in the near future, before the next session, so the patient will be prepared to deal with it.

• Brainstorm and write down a list of potential strategies for either avoiding the trigger, rearranging the environment so the trigger does not occur, or identifying a new coping method for dealing with the trigger when it does occur. Any and all possibilities should be written down. Therapists should encourage patients to be open to any ideas no matter how difficult, easy, simple, complex, or crazy they sound. If needed, therapists should model brainstorming by suggesting many possibilities, some outrageous, some impossible to do, and some simple.

• Together, therapists and patients should consider the overall effects or consequences of each proposed strategy for dealing with the trigger and write these down.

• Therapists should then ask patients how hard they think it will be to carry out each strategy using a scale of 1 (not very difficult) to 10 (extremely difficult).

• After considering all the potential strategies, their consequences, and their perceived difficulties, one strategy should be selected.

• Therapists then ask patients to rehearse the chosen strategy. For example, if the plan is to avoid passing by an old friend's home, have the patient plot a different way home. If the goal is to arrange to be at a safe person's house during a high-risk time, have the patient role-play calling this person to arrange to be there. Better yet, have the patient actually call that person during the session to arrange this get-together.

• Plans for handling two or three triggers should be completed in the session until therapists feel that the patients understand how to do self-management planning.

• Set a goal for patients to complete additional Self-Management Planning Sheets during the week. If they are not completed by the next session,they should be completed during the session.

• Set a goal for patients to carry out at least one of the plans before the next session. Discuss what situations might be coming up this week and review the plan again before patients leave the session.

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Drug Refusal Training

Drug refusal training is included in most patients' treatment plans. As many as one-third of substance abusers relapse as a direct result of social pressure from friends to use. Most cocaine abusers who are trying to quit continue to have some contact, either planned or inadvertent, with friends or acquaintances who are still using. Turning down cocaine or opportunities to go places where cocaine is available will be much more difficult than most patients anticipate. The ability to refuse cocaine or other drugs when offered is a special case of assertiveness. The structure of this training is adapted from McCrady 1986 and Sisson and Azrin 1989.)

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