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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.
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An explanation that external environmental events
can often set off drug use.
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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.
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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.
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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.
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Together, therapists and patients should consider
the overall effects or consequences of each proposed strategy for
dealing with the trigger and write these down.
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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).
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After considering all the potential strategies,
their consequences, and their perceived difficulties, one strategy
should be selected.
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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.
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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.
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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.
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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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