Consciousness raising is increasing information about the problem. Interventions could include observations, interpretations, and bibliotherapy.
Self-reevaluation involves assessing how one feels and thinks about oneself with respect to problem behaviors. Interventions could include clarifying values and challenging beliefs or expectations.
Self-liberation means choosing and committing to act or believing in ability to change. Interventions could include commitment-enhancing techniques, decisionmaking therapy, and New Year's resolutions.
Counterconditioning involves substituting coping alternatives for anxiety caused by substance-related behaviors. Interventions could include relaxation training, desensitization, assertion, and positive self-statements.
Stimulus control means avoiding or countering stimuli that elicit problem behaviors. Interventions could include avoiding high-risk cues and removing substances from one's environment.
Reinforcement management is rewarding oneself or being rewarded by others for making changes. Interventions could include contingency contracts and overt and covert reinforcement.
Helping relationships are created by being open and trusting about problems with people who care. Interventions could include self-help groups, social support, or a therapeutic relationship.
Emotional arousal and dramatic relief involve experiencing and expressing feelings about one's problems and solutions to them. Interventions could include role-playing and psychodrama.
Environmental reevaluation is the process of assessing how one's problems affect the personal and physical environment. Interventions could include empathy training and documentaries.
Social liberation involves increasing alternatives for nonproblematic behavior. Interventions could include advocating for the rights of the oppressed and policy interventions.
I don't see how my cocaine use warrants concern, but I hope that by agreeing to talk about it, my wife will feel reassured.
Contemplation
I can picture how quitting heroin would improve my self-esteem, but I can't imagine never shooting up again.
Preparation
I'm feeling good about setting a quit date, but I'm wondering if I have the courage to follow through.
Action
Staying clean for the past 3 weeks really makes me feel good, but part of me wants to celebrate by getting loaded.
Maintenance
These recent months of abstinence have made me feel that I'm progressing toward recovery, but I'm still wondering whether abstinence is really necessary.
Arguing
The client contests the accuracy, expertise, or integrity of the clinician.
Challenging. The client directly challenges the accuracy of what the clinician has said.
Discounting. The client questions the clinician's personal authority and expertise.
Hostility. The client expresses direct hostility toward the clinician.
Interrupting The client breaks in and interrupts the clinician in a defensive manner.
Talking over. The client speaks while the clinician is still talking, without waiting for an appropriate pause or silence.
Cutting off. The client breaks in with words obviously intended to cut the clinician off (e.g., "Now wait a minute. I've heard about enough").
Denying The client expresses unwillingness to recognize problems, cooperate, accept responsibility, or take advice.
Blaming. The client blames other people for problems.
Disagreeing. The client disagrees with a suggestion that the clinician has made, offering no constructive alternative. This includes the familiar "Yes, but...," which explains what is wrong with suggestions that are made.
Excusing. The client makes excuses for his behavior.
Claiming impunity. The client claims that she is not in any danger (e.g., from drinking).
Minimizing. The client suggests that the clinician is exaggerating risks or dangers and that it really isn't so bad.
Pessimism. The client makes statements about himself or others that are pessimistic, defeatist, or negative in tone.
Reluctance. The client expresses reservations and reluctance about information or advice given.
Unwillingness to change. The client expresses a lack of desire or an unwillingness to change.
Ignoring The client shows evidence of ignoring or not following the clinician.
Inattention. The client's response indicates that she has not been paying attention to the clinician.
Nonanswer. In answering a clinician's query, the client gives a response that is not an answer to the question.
No response. The client gives no audible verbal or clear nonverbal reply to the clinician's query.
Sidetracking. The client changes the direction of the conversation that the clinician has been pursuing.
Figure 3-5
Sample Questions To Evoke Self-Motivational Statements
Problem Recognition
What things make you think that this is a problem?
What difficulties have you had in relation to your drug use?
In what ways do you think you or other people have been harmed by your drinking?
In what ways has this been a problem for you?
How has your use of tranquilizers stopped you from doing what you want to do?
Concern
What is there about your drinking that you or other people might see as reasons for concern?
What worries you about your drug use? What can you imagine happening to you?
How much does this concern you?
In what ways does this concern you?
What do you think will happen if you don't make a change?
Intention to Change
The fact that you're here indicates that at least part of you thinks it's time to do something.
What are the reasons you see for making a change?
What makes you think that you may need to make a change?
If you were 100 percent successful and things worked out exactly as you would like, what would be different?
What things make you think that you should keep on drinking the way you have been? And what about the other side? What makes you think it's time for a change?
I can see that you're feeling stuck at the moment. What's going to have to change?
Optimism
What makes you think that if you decide to make a change, you could do it?
What encourages you that you can change if you want to?
What do you think would work for you, if you needed to change?
Figure 5-1
Tips for Moving Clients Through Contemplation to Preparation
Do not rush your clients into decisionmaking.
Emphasize client control: "You are the best judge of what will be best for you."
Acknowledge and normalize ambivalence.
Examine options rather than a single course of action.
Describe what other clients have done in a similar situation.
Present information in a neutral, nonpersonal manner.
Remember that inability to reach a decision to change is not a failed consultation.
Make sure that your clients understand that resolutions to change often break down; clients should not avoid future contact with you if things go wrong.
Expect fluctuations in your client's commitment to change--check commitment regularly and express empathy concerning the client's predicaments.
At the end of decisional balance exercises, you may sense that the client is ready to commit to change. At this point, it is important to summarize once more the client's current situation as reflected in your interactions thus far. The purpose of the summary is to draw together as many reasons for change as possible, while simultaneously acknowledging the client's reluctance or ambivalence. Your recapitulation should include as many of the following elements as possible:
A summary of the client's own perceptions of the problem, as reflected in self-motivational statements
A summary of the client's ambivalence, including what remains positive or attractive about the problem behavior
A review of whatever objective evidence you have regarding the presence of risks and problems
A restatement of any indication the client has offered of wanting, intending, or planning to change
Your own assessment of the client's situation, particularly at points where it converges with the client's own concerns
The recapitulation outlined in Figure 5-2 is a final step before the transition to commitment and leads directly to strategic, open-ended questions intended to prompt the client to consider and articulate the next step. The following is a list of possible key questions:
What do you think you will do?
What does this mean about your drinking?
It must be uncomfortable for you now, seeing all this. What's the next step?
What do you think has to change?
What could you do? What are your options?
It sounds like things can't stay the way they are now. What are you going to do?
Of the things I have mentioned here, which are the most important reasons for a change?
How are you going to do it?
Where do we go from here?
How would you like things to turn out now for you, ideally?
What concerns you about changing your use of drugs?
What would be some of the good things about making a change?
What do you do when your client's goals differ from yours or those of your agency? This issue arises in all treatment but is particularly apparent in a motivational approach where you listen reflectively to your clients and actively involve them in decisionmaking. As you elicit goals for change and treatment, some clients may not reflect what you think is best for them. How you handle this sensitive clinical situation can determine whether the client continues to pursue change.
Before exploring different ways of handling this common situation, try to clarify the differences and boundaries between the client's goals and your own (or your agency's). For clients, goals are by definition the objectives they are motivated (ready, willing, and able) to work toward. If the client is not motivated to work toward it, it is not a goal. You or your agency, on the other hand, may have particular aspirations, plans, or hopes for the client. It is important to realize that goal can have different meanings to you and to your client. You cannot impose your hopes and plans on a client. If you want your client to adopt a goal, your task is to motivate.
What are your clinical options when goals collide? You can choose from the following tactics:
Give up on the client. Although it sounds unappealing, this option is surprisingly common. If clients do not accept the goals prescribed by the clinician or agency, they are dismissed. This often amounts to discharging clients for the same reasons they were admitted. In the past, this option arose from (or at least was rationalized by) a mistaken view of motivation as a slowly progressing linear process. Clients were actually told, "Go away and come back when you're ready [i.e., to do what I tell you]."
Negotiate. Find goals on which you and your client can agree and work together on those. Start with areas in which the client is motivated to change. Women with alcohol or drug problems, for example, often come to treatment with a wide range of other problems, many of which they see as more pressing than making a change in substance use. Clinicians have had good results by starting with the problems that are most urgent from the client's perspective and then addressing substance use when its relationship to other problems becomes apparent.
Approximate. Even if a client is not willing to accept all your recommendations, it is often possible to agree on a goal that constitutes a step in the right direction. Your hope, for example, might be that the client would eventually become free from all psychoactive substance use. The client, however, is most concerned about cocaine and is not ready to talk about changing marijuana, tobacco, or alcohol use. Rather than dismiss the client for not accepting a goal of immediate abstinence from all substances, you can focus on stopping cocaine use and then consider a next step.
Refer. If your client's goals are personally unacceptable to you even after trying to negotiate or approximate, you can refer.
Sometimes a client might benefit from working toward a goal, but the clinician is personally uncomfortable (e.g., for ethical or professional competency reasons) in continuing treatment.
For example, some clients are unwilling to consider immediate abstinence when they enter treatment.
Even though alternatives exist (e.g., tapering down, trying problem-free moderate use, agreeing on a short trial period of abstinence [Miller and Page, 1991]), not all clinicians are comfortable working toward any goal other than immediate abstinence.
In such cases, it often is preferable to refer these clients to another clinician who will work with them, rather than terminate treatment altogether.
Coping strategies are not mutually exclusive (i.e., different ones can be used at different times) and not all are equally good (i.e., some more than others involve getting close to trigger situations). The point is to brainstorm, involve the client, reinforce successful application of coping strategies, and consider it as a learning experience if a particular strategy fails.
Example #1: Client X typically uses cocaine whenever his cousin, who is a regular user, drops by the house. Coping strategies to consider would include (1) call the cousin and ask him not to come by anymore, (2) call the cousin and ask him not to bring cocaine anymore when he visits, (3) if there is a pattern to when the cousin comes, plan to be out of the house at that time, or (4) if someone else lives in the house, ask them to be present during the cousin's visit.
Example #2: Client Y typically uses cocaine when she goes out for the evening with a particular group of friends, one of whom often brings drugs along. She is particularly vulnerable when they all drink alcohol. Coping strategies to consider might include (1) go out with a different set of friends, (2) go along with this group only for activities that do not involve drinking, (3)leave the group as soon as drinking seems imminent, (4) tell the supplier that she is trying to stay off cocaine and would appreciate not being offered any, (5)ask all her friends, or one especially close friend, to help her out by not using when she is around or by telling the supplier to stop offering it to her, or (6)take disulfiram [Antabuse] to prevent drinking.
Example #3: Client Z typically uses cocaine when feeling tired or stressed. Coping strategies might include (1) scheduling activities so as to get more sleep at night, (2)scheduling activities so as to have 1 hour per day of relaxation time, (3)learning and practicing specific stress relaxation techniques, or (4)learning problem-solving techniques that can reduce stressful circumstances.
Figure 7-3
Case Study 1: Client With Drug-Using Social Support
Client context: Mary is a pregnant 30-year-old woman who lives with her young son. Her boyfriend, the father of both children, visits frequently and provides total financial support for Mary. He is a crack dealer and user. Mary's urine test, administered in routine prenatal care, was positive for cocaine. Her health care provider referred Mary to a treatment clinic.
Therapeutic realities: In Mary's situation, the goal of ending her relationship with the boyfriend is not realistic, although, in the long term, she may be able to break away from this man. A direct confrontation on this issue would be counterproductive.
Therapeutic strategies: It is possible to use motivational counseling to encourage Mary's progress. Functional analysis can be used to develop some discrepancy and tension between her goal to cease cocaine use during pregnancy and the realities of her living situation. The pros of maintaining the relationship include continued financial and emotional support. The cons include exposing her son and unborn child to cocaine. Given the situation, what is Mary willing to do?
Developing options: Mary never uses cocaine in front of her son, but she doesn't feel she can ask her boyfriend not to. Through therapy, Mary does some problem solving and develops coping strategies to allow her to continue seeing the father of her children without having drugs in her house. The therapeutic relationship is used to enhance her motivation to take some kind of positive action, to revisit her motivation and commitment (which currently is to the boyfriend), and to explore potential responses that will begin to put limits on this situation.
Note that you might be legally required to report to the child welfare agency any concern about drug use occurring in front of the woman's son. (For more information on this issue see the forthcoming TIP, Substance Abuse Treatmentfor Persons With Child Abuse and Neglect Issues [CSAT, in press (b)]).
Figure 7-4
Case Study 2: Client Lacking Social Support
Client context: Susan is a 41-year-old woman in an abusive marital relationship. She has suffered from alcohol dependence most of her adult life but has initiated recovery efforts through five counseling sessions. Her mother has paranoid schizophrenia, and therapy reveals that her father, also suffering from alcohol dependence, molested Susan for years when she was a child.
Therapeutic realities: Susan is estranged from her mother and abusive husband. Therapy now reveals that Susan's sole source of support is the father who molested her. She telephones him and cuts off contact. As she progresses in recovery, however, she is no longer numbed and made compliant by alcohol and begins to have serious problems with her own children. They do not support her recovery efforts--they want her to return to being an easygoing drinking mom. The therapeutic reality is that now, because of the recovery process, Susan has less emotional and social support.
Therapeutic strategies: As a starting point, Susan can be brought into a 12-Step program or similar mutual-help group to replace the support for recovery she has lost. Additionally, your support as a clinician is integral to her recovery. Provide support, referral, and followup, and make special efforts to be available to her.
Client context: Joseph is a member of the Mohawk, living on tribal lands in New York State. Along with the other members of the band, Joseph receives regular payments from the Federal government for land use and treaties, as well as checks for his share of the proceeds from the group's casino. Receipt of these checks is often a trigger for substance use. The checks have replaced Joseph's motivation for gainful employment; they also have removed the need for criminal behavior to procure drugs. Because casino checks are becoming larger, the issue is becoming increasingly severe for Joseph.
Therapeutic reality: Joseph uses his casino checks as sole support, yet receiving them may serve as a trigger to his drinking.
Therapeutic strategies: The paychecks in this case are an example of ongoing support that occurs regardless of substance abuse. Elicit from the client other ways in which the money could be used that would be rewarding, consistent with the client's life goals, constructive to family or community, health-promoting, and so forth. Elicit from the client practical ideas about how to prevent the receipt of checks from triggering substance use. Consider how supportive others might help the client redirect income from substance use to other reinforcing options.
John and Mary Red Fox, surviving through part-time jobs and seasonal work, lived in fairly impoverished circumstances on a reservation with their three children. Both were high school dropouts. John, age 27, and Mary, age 22, abused alcohol, although John completed an inpatient treatment program for alcoholism just prior to his recent return to use. The children were described by their parents as unmanageable, easily distracted, difficult to communicate with, and hyperactive. There were indications that Mary had been physically and sexually abused as a child and that Mary's stepbrother had sexually abused her two older children.
The Tribal Law Enforcement Center made the referral to a rural social work agency after John was arrested for suspicion of spouse abuse. As he began an assessment, the social worker learned that members of the family had periodically received counseling from various agencies and that John and Mary had sporadically attended AA meetings. Apart from medical and dental services, however, the services they had received were deemed ineffective.
On the face of it, the problems seemed overwhelming: (1) family instability and crisis were heightened by the couple's use of alcohol and John's threatening behavior to Mary; (2) the couple's lack of job skills and education elevated their risk of poverty; (3) frequent marital discord was partly a result of alcohol abuse and inconsistent parenting; (4) the children were struggling with significant impairments, perhaps contributed to by fetal alcohol syndrome; and (5) alcohol abuse was ubiquitous in the community in which they were living.
However, there were also several strengths. The family had remained intact, with both parents eager to salvage their relationship. John and Mary had developed their talents, and their neat and orderly home was colorfully decorated with Native American arts and crafts. Finally, the recent establishment of a program in their community, designed to revitalize traditional Indian beliefs and culture, offered an alternative to traditional agency-oriented interventions. This program included a summer camp for children in beautiful surroundings with canoes, wigwams, tepees, and an earth lodge.
The social worker encouraged the school system to refer John and Mary's children to this camp, and then encouraged the camp director to reach out to John and Mary and invite them to become teachers. Mary responded positively and helped teach skills in making Indian dance regalia. While initially hesitant, John eventually agreed to help with the planning of a children's powwow, including building a sweat lodge. Both parents became invested not only in their children's experiences in the camp but also in earning respect for themselves. John participated in many sweats and aspired to live his recovery and life to earn the honor to become a pipe carrier and to take part in the Sun Dance Ceremony.
As the family became more involved in the program, there were no further instances of alcohol abuse or domestic violence. Both parents rejoined AA, completed their general equivalency diplomas, and began college, and their children had fewer problems in school.
Figure 7-7
Therapeutic Workplaces for Individuals With Substance Abuse Disorders
The opportunity to learn and work can be reinforcing for persons with substance abuse disorders, particularly if they are paid for participating. Remedial academic programs, vocational training, and actual worksites all can be places where skills are enhanced while abstinence is sustained. This is done by allowing these individuals to participate and be paid only when their urine tests are drug free.
A therapeutic workplace developed by Dr. Kenneth Silverman in Baltimore, Maryland, illustrates this principle. This workplace offers intensive remedial academic training and job skills to drug users who grew up in an impoverished inner city environment and may never have learned basic reading or mathematics. So far, the program has been tested only with women who are concurrently enrolled in a comprehensive program for pregnant drug users. Participants report every weekday for 3 hours of training and can earn voucher points at a rate that corresponds to their duration of abstinence and participation (average compensation is roughly $10 per hour). A skilled remedial education teacher conducts an intensive class, where participants can rapidly improve their academic skills and learn job-related skills.
Research has shown that the women who participate in this program have long periods of abstinence from heroin and cocaine and that they have much better drug use outcomes than a similar sample of control women who were not invited to participate in the therapeutic workplace. The women who join this program are happy with their chance to improve their academic and job skills and believe that this training will better prepare them to compete in the job market.
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