DRUG ABUSERS 99

The interpersonal factors associated with relapse usually involve some form of heightened affect. There are frequently cognitive distortions to be found in situations of conflict. The repeated cycle of reassurance seeking and rejection between Jane and Tom demonstrates this well. Jane’s feeling of rejection was a result of arbitrary inferences she made about Tom’s behaviour. He was by nature a solitary and independent person, but she interpreted this as a sign that he no longer cared for her. Tom’s difficulty in responding to the demands people made of him led him to magnify the degree of Jane’s seeking of reassurance. Therapy with the couple required them to identify the distorted thinking in these situations and to role-play alternative ways of behaving. The high-risk emotions in this couple’s relationship were not only negative. Pleasant feelings of closeness and positive expectancies about drug use also contributed to their decisions to use.

Interviewing Jane and Tom together showed that Tom was the one who usually made the final decision which led to relapse. They described a scenario in which they received their giro cheque, and both knew they had the money to ‘go and score’. There would follow a subtle non-verbal interaction, which was both pleasant and sensual, where they both had the same images in their minds of getting drugs. Without admitting what they were thinking they worked themselves into a state of craving. It was usually Tom who came out with the final statement: ‘Shall we get some then?’ He would then go and procure drugs. In the meantime Jane would stay at home thinking, ‘Will I get my fair share or will he cheat me?’ She would make a scene when he returned and the conflict would only be resolved by the mutual enjoyment of the fix. I worked with a social worker as cotherapist to help the couple handle this situation. We got them to role-play this scene in the session. Jane and Tom identified their distorted cognitions and worked hard at reinterpreting them. When they first started role-playing this scenario they both ended up agreeing to have a fix, but as they practised further it slowly became possible for them to resist.

Underlying assumptions

As therapy progresses it is often possible to recognise recurrent themes in the way patients understand themselves and their problems. The cognitive responses to different situations point to the rules by which they integrate experience and organise their world. These rules are often not verbalised directly but can be inferred by patients’ habitual reactions. They act as silent assumptions about drug use, the self, or relations with significant others. Individuals with drug problems describe assumptions concerning their ability to control their feelings and behaviour:

‘If I get a craving I have no control over myself.’ ‘I’m too weak to control myself.’

‘Getting over drugs is something I have to do without any help from anyone.’

The section on dealing with negative cognitions related to motivation (pp. 164 ff.) contains some ideas on how to deal with these assumptions.

Other themes in high-risk situations are connected with the emotional or interpersonal aspects of the situation rather than the drug itself. The analysis of one of Ted’s risk factors shows how it arises out of maladaptive beliefs about himself in relation to other people. He found that he very easily got into arguments and fights; the tension and anger he felt when this happened was only really relieved by alcohol. Conflict was sparked off by Ted thinking that he was being conned, ripped off, or treated unfairly in some way. If he was to retain his self-respect he thought it essential to come off best, resisting unjust treatment with violence if necessary. Since the arguments usually took place in pubs his judgement was already impaired by alcohol, and the scene was set for misinterpretation followed by further excessive alcohol intake. The assumption on which his reaction was based seemed to be ‘I cannot let anyone treat me unjustly and get away with it’.

When Ted was with his family he also got into lots of rows, which ended with him slamming the door and heading straight for the pub. The cognitions in these situations centred on how his wife was acting unreasonably towards him or his 21-year- old step-son. As the man of the house Ted felt compelled to intervene. He had to ‘step in and keep them in line’ or his position would be threatened. In addition to the assumption that he should not let injustice go unpunished, he also believed that he had to be in charge of his family at all times.

Ted was able to say to himself that his difficulty in complying with treatment reflected his distrust of the world in general. He often demonstrated his anxiety about misuse by professionals by saying ‘I don’t want any of this analysis, I don’t want you to shrink me’. His reluctance to come along for treatment in the first place and the compliance problems were clearly related to his belief that ‘Given half a chance people will rip you off. He also had a strong sense of self-reliance. A common cognition was ‘I have to do it on my own’, which again led to him creating his own therapy programme rather than following that laid down by the drug unit.

Ted’s beliefs that he had to do it alone, had to stand up for himself at all costs, and had to be in charge of his family were linked to a deeper assumption: ‘I have to be a “Man” in order to be worthwhile.’ He had a very stereotyped view of what ‘real men’ were like. They were rugged, tough individualists, the macho heads of submissive families. They were also constantly vigilant in a hostile world for any personal affronts and responded violently if necessary. Much of Ted’s drug abuse and maladaptive behaviour can be seen to spring from attempts on his part to retain his self-esteem through his stereotyped masculine role (Figure 7.2). Despite the difficulties in engaging him in formal cognitive therapy, it was possible to identify