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).
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:
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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:
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“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”.
Session four: refusal and assertiveness skills
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.
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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:
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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:
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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.
Session five: seemingly irrelevant decisions
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.
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Examples of ‘seemingly irrelevant decisions’ include:
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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.
Session six: a multi purpose management plan
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:
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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
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Session seven: problem solving
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:
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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
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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.
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“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.
Session ten: partner, family member and whānau
involvement
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:
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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
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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:
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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.
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