– [Narrator] In this video,
we will focus on substance abuse counseling during
the active treatment stage. This type of counseling focuses on the client’s unique cues
that lead to substance use, and consequences that
result from substance use that you identified in
the contextual assessment. Cognitive behavioral
counseling and skills training are the main tasks in
substance abuse counseling. Specifically, you will
want to help your client cope with and change thoughts
that lead to substance use, unpleasant emotions that
lead to substance use, behaviors that lead to substance use, and craving, or feelings
that lead to substance use. You may accomplish these goals by counseling to change
thoughts and emotions, and by training and coaching your client to change his behavior. You may teach him coping skills, social skills, leisure skills, or help him get a job and
teach him work skills. In the following sequence, the clinician is helping a client cope
with thoughts and craving that lead to substance use. He uses two techniques: First, he helps the client
create new thoughts and behaviors that emphasize the negative
consequences of substance use. Second, the clinician helps the client come up with new behaviors that he can use to get the perceived
positive affect of substances without actually using substances. – One thing we might consider, Mark, that would give you more control, would be to work on skills at managing craving, – Skills at managing craving.
– for caffeine. In other words, as you started to feel the urge to use caffeine, developing alternative behaviors to drinking caffeine. – I don’t know how to do that. – Well, let’s start with understanding it. Okay?
– Mm-Hmm. – When you get up in the morning, what draws you to a cup of coffee? – Energy boost, and the mood elevation that I seem to be seeking instead of just thinking of coffee as being a wake-me-up tool, I’m really looking for a high out of it. – Well, Mark, the types of plans that we usually design for craving include those components
of reminding yourself of the adverse consequences, as well as, typically, finding an alternative behavior that can be successful for you. So for example, if you start to want to have a cup of coffee, and you’re, kind of thinking about it, “Oh, I’ll feel energy, I’ll feel, “my mood will get lifted.” You’re thinking about
those positive things. One step is to balance that with a recognition of the
negative consequences. “Well, I’ll feel more anxious. “I don’t really like feeling anxious, “that’s an uncomfortable feeling.” So playing back for yourself a balance of the, sort of anticipated positives with a balance of the
anticipated negatives. That the association with the drug becomes less rosy, and more accurate, more accurately reflecting
some of the pain that it causes you. – Mm-Hmm. – The other thing will be to have some specific alternatives. So that, for example, you’re
looking to lift your mood, and boost your energy with caffeine. Let’s find alternative activities that you can do that will
achieve those same things without the price that
caffeine creates for you. Can you think of any examples? Are there any other things that help you to lift your mood and boost your energy? (Mark coughs) – Well, basically, when I walk, and especially when I’m walking and listening to my radio, personal radio like a Walkman. That seems to give me more energy than I would if I was sitting around smoking cigarettes and drinking coffee. And it also lifts my spirits, because I love music quite a bit, and I enjoy walking and since I don’t have a car, I do quite a bit of walking and, – Excellent. – I enjoy different things
like going to the mall, and even if it’s just for window shopping, and taking in a movie or something. – So you’ve identified several different effective coping strategies
for avoiding a cup of coffee, if you’re craving caffeine. And I’ll separate the first two, because I think they’re important. Exercise and music both are helpful, and when you combine them, it’s even more helpful it sounds like. But exercise is something that most people find lifts mood and improves energy level, because you increase the circulation of blood to your brain
and your whole body, and it helps to energize you. So getting up and taking a walk rather than going to a cup of coffee will achieve the same things. Exercise though, actually
helps to reduce anxiety, rather than increase it. So you can have the benefits of the energy lift, the mood lift, without paying the price of suffering the anxiety down the line, and being constructive for your body, being healthy for your body. – Right. – Adding the music to it
improves the good mood, because you enjoy the music. You also mentioned a
couple other strategies, which may not be as immediately available every time of the day, but watching a movie, or
doing some window shopping, which involves getting yourself further, getting yourself to the mall, and getting yourself to a movie theater, or whatever, watching a movie on TV. As you think about those, any others that you
would add to that list? – Well– – Other things you could do that would– – Yeah, I enjoy going to the library and reading the various
magazines that they have, you know like Time Magazine
or Newsweek and newspapers. – And you know, another
thing that we didn’t mention, that might want to go on
the list of behaviors, is something that’s fairly close to, like for example,
caffeine you normally take by drinking something. So you could drink a
glass of water, you know? An alternative that gives you, you know, still the opportunity to drink something without it being caffeine containing. – Mm-Hmm. – Mark, you and I have talked before about the fact that cravings tend to come in what are described as waves, sort of like the waves in the ocean, where they come, they have a peak, and then they crash, and
then they sort of diminish. Okay?
– Right. – And typically when a
person has a craving, most of the job is getting through a limited period of time where
that craving has its peak. And if you can get through
five or 10 minutes, even distracting yourself
with something else, the craving tends to diminish,
if you don’t feed it. If you do feed it, then it gets stronger and stronger, all right? And so a lot of what you’re doing is buying time for five and 10 minutes, and you’ve identified several things, a couple of which are more immediately available, short-term strategies, and a couple of which are more involved. And one of the problems with cravings is that it’s often difficult to think in the middle of a craving, right? Because the powerful urge to use. – Right. – And so what we typically do is advise people to get an index card, write down you know, their list of alternative activities, and we can do that together, where we’ll write down, take a walk, listen to music, go to the library, you know, go window shopping, take in a movie, okay? So you’ve got a list of
things available to you as alternatives, okay?
– Mm-Hmm. – And you’ve got those in your pocket, and you carry it with you
all the time in the beginning until you get to a point
where it’s real solid. So what we should do then
is define a stop date. Do you feel ready to do that now? – Yeah. – Or do you want to give
yourself a couple of days? What are you thinking? – No, I’ll feel less anxious by not drinking caffeine. I’ll have more positive energy in the end that doesn’t fluctuate up and down. – [Narrator] Clinicians
can also help clients identify and manage external
cues to use substances, such as people, places,
activities and things. People that cue substance
use can be friends who use, drug dealers, or others that remind a client of substance use. Places that cue substance use can include bars, hangouts, friends’ houses, or other places where
substances are being used, or have been used by
the client in the past. Activities that cue substance use can include any activity
that was associated with drug use in the past. Many clients will have given
up all other activities, and will need to learn
new leisure activities to enjoy without substances. Things that cue substance use can include drug paraphernalia, money,
and the substance itself. In the next sequence, you will see a clinician helping a client identify external cues that lead to intense craving and cocaine use. She helps him identify
and practice ways to cope. – Are you comfortable with your
ability to say no to people? – Yeah, sometimes. – Yeah. – Sometimes, yeah.
– Yeah. When are the times when
it’s easier to say no? – Depends who it is I run into. – Okay. – Yeah, yeah. – And when is it more difficult to say no? – I can say no to porn,
I can say no to alcohol. – Okay. – And all that. – Right. So if the right person came along, – Yeah. – that was really hard to say no to, and that person had cocaine in his pocket, that sound like it would be really hard for you to say no. – Yeah, sometimes Bill Heath helps me out. – Okay. – Say no, you know. – Yeah. Right. – A few people care about me there. – Yeah. So maybe something that we could work on in your treatment plan is working on how to increase your
confidence around saying no to, maybe we could identify the people that it’s really hard
for you to say no to. – Yeah, some of them come here, you know. – Well, I know, I know. That’s what makes it difficult. – Some of ’em come here.
– Is some of ’em do come here, and you see ’em every day. – Yeah, see them every day. – So that’s a trigger every day. – Yeah, yeah. – So maybe we could work on
identifying who they are, and then maybe we could
practice you saying no to them. – Right. – You know, in kind of of way so that you feel more confident when you actually see them, and they have the cocaine in their hand. – Yeah. – So, first of all, let’s
just list the people that you see the most often that you find it the most
difficult to say no to. – Yeah. – Can you tell me who they are? – Bob.
– Bob? – Bob.
– Anybody else that you see? – Daryl.
– Daryl? – Yeah.
– Anybody else? – Uh, Keith. – Keith?
– Yeah. – Anyone else? – No.
– Okay, so Bob, Daryl and Keith are the three people
that you find it the hardest to say no to.
– Yeah, right, yeah. – Okay, let’s just talk for a minute about what makes it
difficult to say no to them, when it’s real easy for
you to say no to me, and it’s real easy for you
to say no to Dr. Burnett, and it’s real easy for
you to say no to Richie, and it’s real easy for
you to say no to Bill. Okay, so there’s four of us that I know you’ve done a really
good job saying no to. – Right, yeah.
– Okay. So what is it about these three guys that makes it difficult for you? – They show me sometimes,
they get me going. They show me the money. – They show you the money.
– They show me the bag. – They show you the bag.
– They show me the bag. – They get you going. – Yeah, they get me going. – Okay.
– Yeah. – Are there other things
they do to get you going? – Uh, no I get sweaty
palms when I want to use. – Okay. – My hands turn sweaty
and everything, you know? – Do they challenge you in some way? Do they threaten you at all? – Sometimes, yeah. – Yeah? What kinds of things would
they say to threaten you? – Like Jenemi, you don’t need Jenemi, you don’t need that and all that stuff. – Okay. – Sometimes they swear at ya, or they walk away and give you the finger. – Yep.
– Yeah. – And somehow that works in your mind as a way, that makes you want to use. – Yeah, right. – as opposed to making you feel like, wow, they’re not
respecting what I’m doing. – Right, yeah.
– They wanna– – They’re really not my friends, you know. They’re just there. – Right, right. – Yeah. – And these are three
guys you’ve used with for a long period of time. – Yeah, long period of time. – So you have a lot of history with them. – Yeah. – So not only are they
showing you the money, and they’re showing you the cocaine, just seeing them is a trigger, because of all the times you used. – Yeah, just seeing
them is a trigger, yeah. – And these are three people
that get their meds here, that you see almost on a daily basis. – Yeah, yeah. – Let’s try to pretend that I’m Daryl. – Yeah, yeah. – And I’m gonna come up to you, and I’ve got money in my pocket, and I’ve got the cocaine. I would say, “Hey Mark, I
haven’t seen you in awhile.” – Yeah. – “Look what I’ve got today.” – Wow. – “Come on with me.
– No, I’m gonna– – “You don’t need to be there, come on.” – I’m gonna go back to
Jenemi and talk to somebody. – “Oh come on, you’ve
been there lots of times. “They’re not gonna tell you anything “you haven’t already heard.”
– No– – Come on, I got this really good stuff. – Yeah, I gotta do urine samples. If I do cocaine, it’s gonna come back in the urine, you know? – “Well, we can get you
some urine from somebody. “You know, you can have tests.” – (laughs) No, no thanks. – “I’ve got John with me,
and I’ve got Keith with me. “You know, we’re gonna
go hang out in the park.” – No, that’s all right. – “It’s a great day today.” – That’s fine, no, no thanks. – Okay, all right, stop. – Walk away from it. – All right, how did you feel
when I was doing that to you? Because your face has gotten red. – Pressure, yeah. – You face has gotten red. – Yeah. – Pressure, you know? – You’re starting to move a
little bit more in your chair. It was really hard, wasn’t it? – It was hard, yeah, yeah. – But you were able to do that. – [Narrator] Next you’ll see a segment of a counseling session
where the Clinician is helping the client deal with triggers to use cocaine without actually using. Notice that she talks directly about what the client’s triggers are, and she works collaboratively
with the client to find ways to either avoid
the high risk situation, or once in the situation, to
cope with it without using. Notice also how frequently she reinforces the client’s attempts to avoid using, but then she also encourages the client to work harder at finding
healthy coping strategies. She focuses mostly on
behavioral strategies, but she alludes to using
cognitive strategies as well. – Talking about how far you’ve come. Last year you were using – Every day, all day.
– every day, all day. – Whenever I get a chance. – And now, you’ve really reduced your use. – Yep. – It’s sporadic, but we
know what things trigger it. And one of the things is gonna be getting your check, getting
your money in your hand. Another is trying to talk to people about some of the things
that you need from them. And you go two ways. You either run to your bed
and hide from everybody, or you go out and use. – Yeah, so I guess I
started early this time, running to the bed, huh? (laughs) – [Clinician] What other
things can you try? What other supports have
you started to build? – I was trying, I asked you about finding some work for me to do. – Mm-Hmm.
– And, um, – Finding me some work to do, try to keep me busy, but, I don’t know. It’s scary to do that because I don’t know if I can handle that. I want to handle it, but I, everything’s scary, ’cause it’s new. – But you’ve worked really
successfully in the past. And I think that working would be something that would make you feel better, and not feel like you’re
taking from other people. – I don’t feel like I’m
taking from other people. I’ve worked all my life, so I figure what’s given to me is owed to me. It was came out my pocket
when I was working, so, ’cause I’ve always worked. – I agree, and I think that
that’s really important. It’s important for all of us to work, and we can work with the earn team to try and help you
identify what interests you, set up your resume. You’ve got some wonderful work experience, and I know that you
have a lot of interests. Gardening is one of them. You’ve done secretarial work. There are skills that you have. You have a lot of people skills. – I also have another skill, working in a factory. I do have it, I do have it in my head. Just the only thing is, is
if I, it’s scary to get back, because I know what took me out of there. – What took you out of there? – Well, what I’m, taking me
away from the working scene. It was too much pressure for me. It got to be nasty on the job, and I didn’t know how to handle it, so I just grabbed my things
and left work one day. It happens, something pops in my brain. Back, things that
happened to me in the past on my job just pops in my brain, and then I’m not able to,
I wouldn’t be able to come and say, I’d be too late
by the time I get to you. – I don’t think this is easy. I think you’ve been working
really hard for a long time. And there’s little steps
that you have to take, and you have to set your plan. There’s gonna be slips,
there’s gonna be triggers, and I think our work is
to be always talking about what you can do when
those triggers appear. – Okay.
– Okay? We know some of the warning signs. – I know, I walk out, and then I disappear. – But I think you know the warning signs before the walking out even happens. – Yeah, now I know the warning signs. – Mm-Hmm. – Working with you, yeah,
I learned a whole lot, a whole, whole lot. Yeah, a whole lot. But it’s a big fear to go back there, but I have to do it, and
I’m gonna try and do it. I believe if I do that, then
I wouldn’t even slip anymore. I really do. That’s why I said I need help again. – Yeah, I think that– – But the, yeah. – There are slips. And there may be slips in the future. We’re still gonna keep working together, even when there’s slips, to keep you from relapsing, to going back to where
you were a year ago. – Yeah. – How are things at home right now? – It’s okay. I guess I’m sleeping
away them, too. (laughs) I just, I just sleep when
I’m not here with you, or working in the garden,
that’s what I’m doing. I tried working, I told
you, for a friend of mine, but I realize I’m not no man, and I shouldn’t have to be out there pulling on trees and stuff like that. So I asked her if I could
do work in the house, and don’t pay me, don’t pay me once. – You don’t want to be paid in cocaine. – I need a job where I
can see progress like– – I think what concerns
me is you’re going back to a place where, that’s a
trigger, it is a trigger. That job is a trigger,
because they’ve always paid you in drugs instead of money. – Yeah. – And I’m not sure why you keep setting yourself up to go back there. – I sure didn’t, I sure didn’t wake up or nothing to make sure I went back. I could have, I got the phone number. – You could have gone back
there yesterday, you mean? – Yeah. – And that’s why you stayed in bed. – Yeah, and so, but that’s not fair to
me either, you know? – No, I think there’s
probably a different way of handling avoiding that trigger. – Oh I’m tired of running to the bed, too. – Mm-Hmm. Well yesterday was Wednesday, – Yeah, I coulda came here.
– and what were you, what was, what group do
you go to on Wednesday? – My drug NA group.
– Yeah. I didn’t go there, I
mean, it’s a good group, but I kind of, if you
ask me, it triggers me. The group I go to on
Friday does not trigger me. – But yesterday, I mean, I
think that that’s important that you didn’t go to that job yesterday, because you did recognize that that would be a trigger for you. – [Client] Yeah. – But I think it would have been better, even if you came to the group, even if it’s difficult for you. It would have been better
coming to the group. It would have been
better going to a friend. Who could you have called? – What, you mean to
make me go to the group? – [Clinician] Or to get some support so you didn’t have to stay in bed. – The warm line, yeah. – [Clinician] Or Ray? – Yeah, I coulda went
down and talked with her. – [Clinician] Mm-hmm. You have friends, you have other things that you can do besides just go to bed. – Yeah, there are other things, but the easiest thing is just to lay down. But you’re right, I do
have other places to go. – I think the most important
thing is that you didn’t use, and you recognized that
going to work yesterday would have been a trigger. I think that was important. But I think there is
other things you can do. – And there’s work out there
to be done for nothing. And it also brings beauty. It’s like artwork working in her garden. So I like to do that. And there’s nobody really knocking me down for what I’m doing, and
I make my own creation. – [Clinician] Mm-hmm. – So I like that. – [Clinician] I think that’s important. – That’s why, I always say,
that’s her Mother’s Day present, for me to have that fixed. – [Clinician] To work her garden for her. – Yeah, to work her garden. Yep.
– Yeah, I think that you’re giving her something,
but it’s something for you too, because it makes you.
– Yeah, there’s peace of mind. It makes me feel real peaceful, and it, I don’t even feel
like using afterwards. I don’t even feel like saying, “Hey lady, how much you’re gonna give me?” I don’t, you know, for
working in the yard. That’s for nothing, so, as you can see, the expression on my face has changed because– – ‘Cause it’s peaceful. – It’s peaceful. – Mm-Hmm.
– Yep. – Yep. – So, but back to the drug part again. I have to keep going
back to that, you know? – Mm-Hmm. – Because, – Because why? – Because I know I can do it. I think I can really do it, but it’s gonna be hard. It’s gonna be real hard. – It has been hard work. You have to keep
remembering what you were– – It’s just really– – doing a year ago, or
even six months ago.