Meg Lovejoy

Patients' perspective on the process of change in substance abuse treatment

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patients view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

An enhanced positive reinforcement model for the severely impaired cocaine abuser.

This article describes a cognitive-behavioral treatment approach that has been extensively modified to work with inner-city methadone-maintained cocaine users. Modifications were deemed essential to address the problems of engagement and retention in treatment that are typically encountered with this population. While this approach relies on such basic tenets of treatment as relapse prevention, cognitive restructuring, and psychoeducation, an understanding of the particular psychological vulnerabilities of this population has been incorporated into the model. The modified approach utilizes positive reinforcement extensively. This includes use of concrete reinforcers to facilitate initial engagement, and use of interpersonal reinforcers (therapist positive regard, attention, and respect) to increase program retention and sustain posttreatment change. Preliminary results indicate that 63% of patients can complete this intensive 6-month program, with considerable reductions in cocaine use and significant change in drug injection behavior.

Video Techniques with Chemically-Dependent Patients

This paper describes the use of videotaping as an adjunctive intervention in the treatment of substance-dependent patients. In the context of a cognitive-behavioral treatment extensively modified to work with inner-city, methadone-maintained cocaine users, videotaping in both individual and group formats is described. Video sessions create an opportunity for patients to reflect on their experience, enhance their self-esteem, aid in teaching social skills, and help hard-to-engage patients begin to participate in treatment. In order to compete with both the powerfully reinforcing qualities of cocaine and the extreme degree of avoidance exhibited by this population, therapy has to provide intense capturing experiences at the outset of treatment. Patients reactions indicate that the experience they have is captivating and stimulating more than most other early therapy experiences. It is additionally concluded that the use of video can be instrumental in addressing the severe psychological deficits of this population that otherwise impede treatment efforts. While the role of video was not independently evaluated for its contribution to patient retention, 62% of patients were retained through completion of an intensive 6-month protocol.