An eleven session Cognitive Behavioural

Therapy based intervention for

problematic use of Methamphetamine

and Amphetamine-Type Stimulants

With thanks to Turning Point Alcohol and Drug Centre Inc’s for permission to

adapt material from: Clinical Treatment Guidelines for Alcohol and Drug Clinicians:

No 14; Methamphetamine Dependence and Treatment (2007).

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Session one: introduction to treatment and CBT

Enhance motivation to change

Refer to the model of short term intervention using Motivational Interviewing and

Cognitive Behavioural Therapy, provided in: Interventions and Treatment for

Problematic Use of Methamphetamine and other Amphetamine-Type Stimulants (ATS),

Matua Raki. 2010.

Negotiate treatment goals

Motivational exercises such as the ‘decisional balance’ and ‘looking back and looking

forward’ can help the person to decide on treatment goals. Helping people to keep these

realistic, based on their readiness to change, can improve the chances of success which

can in turn feed into motivation to make greater changes in behaviour.

Appropriate goals for pre-contemplators and contemplators might be harm reduction

behaviours or tracking use over time.

People beginning to change patterns of methamphetamine and ATS use may need some

assistance to identify the necessary steps to achieve their goals. Selecting the goals for

each step can be an opportunity to model problem solving. Continuing to emphasise that

change is a personal choice and helping people to recognise their successes and potential

hurdles will help to enhance commitment to change.

Use Worksheet One to record the positive and negative things about methamphetamine

and ATS use for the person.

Explain the CBT model

Clinicians should:

explain the concept of how learned behaviours are rewarded and

strengthened

describe the relationship between thoughts, feelings and behaviours

discuss skill building as a technique that can be learnt

It is useful to describe the assessment process as the foundation for the development

of tailored practical tools to manage moods and behaviours.

Establish ground rules

Communicate clear expectations about the structure of sessions, attendance and mutual

responsibilities.

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Introduce functional analysis

Functional analysis assesses the person’s thoughts and feelings in circumstances where

substance use is likely. It can be used to plan strategies for high risk situations and

monitor the effectiveness of behaviour change. Worksheet Six provides a tool for

functional analysis of the steps leading to substance use and the consequences.

Session two: coping with cravings

Intense cravings can persist for weeks and months after stopping using

methamphetamine and amphetamine-type stimulants. Not knowing what cravings

are or what triggers them, and not having strategies to manage them, is a major

factor in relapse.

Understanding cravings

Normalising cravings as a typical part of methamphetamine and ATS use helps people

put their experience of cravings into perspective. Depending on their patterns of use, a

variety of situations, activities, emotions and feelings will have become associated with

methamphetamine and ATS use through conditioning and reinforcement. Using the

example of ‘Pavlov’s Dog’, or the cat running in when the fridge opens, can help explain

how this process happens. Triggers can include places, people, occasions, thoughts and

emotions. Emphasising that cravings are ‘conditioned responses’ to these triggers and

that they will fade over time, over the course of an hour for most people, can help people

to learn to tolerate them. Over time not ‘reinforcing’ cravings will ‘extinguish’ much of

the conditioned response to triggers.

Describing cravings

Ask the person to recall their last experience of cravings or get them to record the

experience as it is happening. Recording what they are like for them, how intense they

are, how much of a problem they are and how long they last? Cravings can be

experienced as thoughts, emotions, physical feelings and sensations. Some people may

struggle to recognise them for what they are and others may be overwhelmed. Asking

people how they manage cravings will help to identify how long cravings last and what

style of management they generally favour. This can help with working out further

helpful strategies and unhealthy strategies (e.g. drinking alcohol) can be identified.

Identifying triggers

Functional analysis should provide the clinician and person with a list of triggers and

these can be ordered in terms of their frequency or the degree of association with using.

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Triggers with the strongest association with using should be targeted first unless the

person has little faith in themselves, in which case picking off an easy trigger can help

develop confidence. Monitoring and identifying triggers, and high risk situations, is an

ongoing part of treatment that helps with unravelling the more subtle triggers to use

substances.

Avoiding cues

Reducing contact with using peers, avoiding certain localities, getting rid of pipes and

other paraphernalia, limiting other substance use and having small amounts of cash and

no eftpos card available at high risk times and places, are all useful early strategies to

reduce exposure to triggers and cravings. Reality testing each strategy with the person is

helpful to avoid potential problems, such as ending up having no social contact.

Managing cravings

Drawing attention away, distraction, from the experience of craving by becoming

involved in doing something enjoyable is an important tool to help manage cravings.

People may require support to develop a list of realistic and achievable alternative

activities, remembering that physical activities are more distracting that inactive ones.

Worksheet Four can be used to record and plan these activities.

Talking about cravings with a supportive non using friend, family or whānau member

can help to reduce feelings of anxiety and vulnerability. Choosing who these people

could be may require some discussion. If no one is available or suitable, contact

information about the Alcohol Drug Helpline, 0800 787 797, and peer support groups

should be provided.

Going through cravings without fighting the experience, ‘urge surfing’ using imagery

such as riding a wave or allowing it to pass over them, may help some people accept

cravings. Focussing on the associated feelings and sensations and recording the intensity

can help people develop a sense of control over the experience of craving.

People tend to automatically remember the good things about using, especially from the

first few times they used and later on from the relief of withdrawal. Reminding

themselves of the costs and consequences of using and the things they have to gain

by not using can help people to maintain their motivation to change. Writing these things

down on a card and having them handy, in a wallet or handbag or on their fridge can

make this easier to do.

Assisting the person to identify emotionally charged ‘either or’ thought patterns that

accompany cravings can help them to counter these automatic processes that people can

be almost unaware of as they occur. These automatic thoughts can be accessed through

functional analysis or by deconstructing the series of thoughts and behaviours that

preceded cravings, creating a ‘verbal videotape’ of events. Once identified clinicians

need to help people to develop more realistic patterns of self talk, patterns that are not

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emotionally charged, that normalise cravings and increase the person’s belief in their

ability to manage.

Planning to reward themselves for periods of no use, or as an alternative at high risk

times can help people to maintain motivation. People are likely to need help to work out

possible activities or treats that feel good but are not risky or unhealthy.

The intensity and frequency of cravings will diminish over time using these strategies but

they will not go away all together. Helping the person to accept that life has emotional

ups and downs is an important part of them learning to challenge using thoughts

triggered by feeling depressed, anxious or sad.

Session three: encouraging motivation and commitment to

change It is important to recognise that people will wax and wane about making changes in

their use of methamphetamine and ATS, as ambivalence is a natural feature of all

change. Acknowledging and responding to this will enhance the effectiveness of

treatment interventions.

Clarify goals

Reviewing goals at the beginning of every session and ensuring that the person still

considers them worthwhile and achievable, helps to maintain engagement and

commitment. It also provides an opportunity to adapt treatment when goals change.

When motivation to change is low or is to please others, ‘rolling with the resistance’ and

‘supporting self efficacy’ are useful techniques to use. Focussing attention on the impact

of methamphetamine or ATS use on their lives, socially, emotionally and physically can

help to clarify the level of motivation at this stage.

Discuss ambivalence

Revisiting the pros and cons of both using and stopping using in a non directive manner,

can help to get clear about any barriers to change. These barriers may be beliefs about the

positive benefits of using and concern about the loss of these benefits. Once identified,

these barriers can be discussed. Use Worksheet One to help record the pros and cons.

Managing thoughts about methamphetamine and ATS

Each person develops their own thoughts and beliefs about methamphetamine and ATS

that can lead to using again. Thoughts and beliefs that are ‘pro use’ can become virtually

‘automatic’ and unrecognised as they occur. Clinicians can help people to recognise these

processes and to identify when they are based on distorted perceptions.

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Common automatic thoughts that can precede a lapse can include:

“Life will be so boring without P” – diminished pleasure

“I’m an addict” – identification with self

“Hanging out with my mates won’t be problem now I am in treatment” –

testing control

“I’ve just used so treatment’s not going to work, might as well keep using” –

abstinence violation

“This is way too hard, time for a break” – escape

“I’ve been good for week, I deserve a treat” – entitlement

“ What the fuck, once won’t hurt” – gambling

Thought challenging

People can often recognise these thoughts and beliefs as being illogical. However they

could need some help to develop responses that they can use to challenge a belief, while

continuing to acknowledge the underlying issue.

For example;

The ‘diminished pleasure’ example could be countered by,

“While using P has been really exciting, it has made me miss out on a lot of natural

buzzes”.

This acknowledges the bias of the pro use thought and then counters the belief while

indicating a benefit of not using.

The ‘entitlement’ example could be countered with

“Yeah I have done well, but if I use I will feel like shit tomorrow so I’d be better off

going out to a movie”.

Many people fail to recognise that their methamphetamine or ATS use happens in a

particular social context, believing it is a purely personal choice. Talking about

changing where people visit and who they spend time with can often bring out

previously unacknowledged resistance to change. Clarifying the availability of

methamphetamine and ATS within their peer group is an important first step to

help people develop skills to assertively manage offers of methamphetamine and

ATS in the future.

Session four: refusal and assertiveness skills

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Assessing availability

Assessing their ease of access to methamphetamine, ATS and other substances helps

people and the clinician to map risks and develop strategies to avoid temptations to score.

People who are manufacturing or dealing may find it more difficult to make the decision

to stop because of the financial costs of doing so and also because of the status this gives

them. Other people who use may also put pressure on them to remain in these roles.

Getting detailed knowledge of the person’s networks where methamphetamine and ATS

use is common will help to tailor recommendations about avoiding risks. Helpful

questions could be:

If you wanted to use today where would you go to get it?

Have you got any methamphetamine, pipes or other equipment at home?

Thinking about the last few times you used when you did not plan to, what

could you say or do to avoid using in those sorts of circumstances?

What else could you do to make it harder to score?

Handling people who use

In some cases where ongoing social contact is unavoidable people can be supported to

deliver clear and assertive messages about not using or wanting to use. Clinicians will

need to emphasise to people that it will be difficult to avoid using when

methamphetamine and ATS are being used in front of them or when it could be available

very quickly. It is useful to explore the concept that people can put themselves at risk of

using without consciously being aware of making the decision to use. For example;

“I haven’t seen John for ages and he owes me some money, I really should catch up”.

Making the decision to avoid certain people and places may be the only realistic way to

avoid allowing these processes to happen.

Clinicians will need to explore patterns of using with partners and the nature of the

relationship. If possible getting both people together to discuss this can improve the

possibility of successful treatment. If this is not possible it can be very difficult for one

party in a relationship to stop, or even reduce their patterns of use, if the other person is

still committed to using. People who are more vulnerable emotionally will find changing

their behaviours even more difficult. However, specifically talking about these issues and

their thoughts and beliefs about the relationship can lead to the development of strategies

to reduce the risks and empower the person to make changes.

Encouraging and then role playing sensible and assertive language and behaviour to use

with partners can have flow on benefits for also learning how to handle other people.

Effectively turning down offers of methamphetamine and ATS requires people to

communicate in a direct and unambiguous manner. If done well this will reduce the

likelihood of future offers without being stressful or embarrassing for either party.

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Statements need to:

be delivered as quickly as possible without any indication that the offer is

being considered, such as a hesitation or a maybe

be delivered with assertive body language – keeping eye contact and

standing straight, face on to the person

make it clear that future offers are unwanted

avoid explanations or reasons for stopping, which may be embarrassing or

can leave the way open for future offers

Role playing refusal skills can help the person become more comfortable and confident

with using them. While role playing can seem artificial and contrived, the clinician can

frame it as being a safe way to practise the skills, while emphasising that there is no

perfect way to do it. Taking the part of the methamphetamine or ATS user provides an

opportunity for the clinician to role model refusal skills and can make it easier for the

person to engage in a role play. Once the skills have been demonstrated then roles can be

reversed. As the person becomes more confident using the skills then the clinician can

become more insistent and or seductive in their attempts to get the person to use.

Practising handling questions about physical and mental health, comments about the

hopelessness of treatment and offers of free methamphetamine or ATS can help the

person have a better chance of succeeding in real situations.

Many people will struggle to be able to communicate in an assertive manner, believing it

to be rude or aggressive. Other people will find it easier to be aggressive as they may find

it difficult to formulate statements that address the behaviour of the person rather than the

person themselves. Developing and becoming comfortable with assertiveness skills may

require separate training or significantly more practise.

When using the concept of ‘seemingly irrelevant decisions’ people need to have

reasonably intact cognitive functions. They also need a reasonable ability to reflect

on their own thought processes and behaviour. This approach is particularly

helpful for people who are impulsive and have problems thinking through the

consequences of their behaviour, though it can take time to be absorbed.

A ‘seemingly irrelevant decision’ is a decision to do something that is apparently

harmless but which could ultimately put people in a high risk situation, where using is

more likely. These decisions are sometimes made at an ‘unconscious’ level and are

driven by subtle cravings. While they can seem unrelated to using on the face of it,

careful questioning will be able to identify how they put the person at risk.

Session five: seemingly irrelevant decisions

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Examples of ‘seemingly irrelevant decisions’ include:

using alcohol and or other drugs

keeping alcohol and or other drugs in their home

not destroying paraphernalia

going to visit a friend who lives with or next door to a dealer

going to parties where methamphetamine and ATS might be available

spending time with or talking to people who use methamphetamine and ATS

not telling associates and friends who use of the decision to stop using

not planning how to spend free time

lack of self care: not eating regularly, not sleeping enough, etc

Talk about times in the past when they have used despite not wanting to and unravel the

path that led to using. Help the person to identify where ‘seemingly irrelevant decisions’

were made, making it clear that this is not an exercise in blame.

Once the person has grasped the concept of a ‘seemingly irrelevant decision’ discuss how

they could go about becoming aware of these as they occur and how to make safer

decisions. Practising becoming aware of and recognising the apparently minor decisions

they make every day, then thinking through the safe and unsafe consequences of those

decisions, will help people to become less vulnerable to ‘unwittingly’ putting themselves

in high risk situations. Worksheet Seven can provide a framework to guide practise

between sessions.

Help the person to identify a range of potential high risk situations and develop

concrete management plans for each situation. As not all situations can be predicted

a back up plan for unexpected high risk situations is necessary.

A management plan might include:

a list of numbers for support people for emergencies, including the Alcohol

Drug Helpline: 0800 787 797

keeping the list of negative consequences from Session one handy to read

when needed as a reminder

a range of reliable distractions, some of which need to be immediately

doable

a list of ‘safe’ places to spend time when in a crisis

Session six: a multi purpose management plan

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Introduce the basic steps of problem solving:

recognising the problem

identifying and specifying the problem

considering a range of approaches to solving the problem

selecting the most promising approach

assessing the effectiveness of the approach

if it did not work trying another approach and assessing that

With the person identify two or three recent life problems, one of which should be related

to methamphetamine or ATS use, and work through the problem solving steps for each

one. Start with a relatively straight forward problem and support the person to work

through the steps, clearly identifying the problem, rather than straight away coming up

with solutions.

Session eight: case management

People who use methamphetamine and ATS can often also have a range of

associated problems. Issues such as domestic violence, psychosis, income and

housing need to be addressed before people can actively engage in and concentrate

on treatment. Other issues can be more safely addressed once the person is more

settled and not using methamphetamine or ATS. Many of these issues are

psychosocial and contribute to use and are high risk areas for lapse and relapse.

Case management in this context means:

identifying the problems that could be barriers to staying off methamphetamine

and ATS

prioritising problems for ongoing treatment

identifying solutions and resources to address problems

developing a support plan

Session seven: problem solving

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Session nine: blood borne virus risk reduction

If the person is an intravenous drug user discuss the risk of contracting HIV, HCV and

HBV. Screen for risky behaviour and practices: re-use of injecting equipment, equipment

sharing, sharing rinsing water or other paraphernalia.

Discuss sexual behaviour and risk taking, being very specific with questioning, e.g.

“Do you always use condoms?”

“Do you share razors or toothbrushes?”

Use motivational interviewing techniques and strategies to elicit behaviour change

statements from those people ready to make changes, again emphasising that change is a

personal choice.

When the person is ready to act help them to set concrete behavioural risk reduction goals

and identify any potential barriers to change. If barriers are identified, use problem

solving strategies to work through them.

Involving partners and family and whānau members in the person’s treatment helps

to demystify what treatment has been about and to encourage support for the

person to make changes in their behaviour and lifestyle.

Partners, family and whānau members will probably need the opportunity to ventilate

about the impact of the persons using on them. If their feelings are extreme and likely to

undermine the changes the person has been making they may require the opportunity to

talk with a different clinician about how they feel. This would also provide an

opportunity to assist the family and whānau to discuss how to set boundaries and general

self care.

Explain how the CBT model of behaviour change works.

With the person and their partner and or family and whānau members work out:

what specific changes the person can make to meet the needs of their partner

and or family and whānau members

how they can support the person to stop using methamphetamine or ATS

Session ten: partner, family member and whānau

involvement

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Once there is an agreement on what behavioural changes and strategies are needed this

can form the basis of a contract between the person and their partner and or family and

whānau members.

Session eleven: closure

Review the treatment plan:

what the persons goals were

how they have changed

what has been achieved

what still needs to be done

Particularly focus on the skills that the person has developed and those that could be

worthwhile developing further. Discuss what the possible indicators of the steps to

achieving their goals would be, and how to recognise and celebrate them.

Talk about what were the most and least helpful parts of treatment and ask the person if

they are concerned about finishing treatment. Those people who have not met their goals

or have not developed stable behavioural changes may need ongoing counselling, referral

to a support group, referral to a day programme or referral to residential treatment.