Alcohol and Drug Problems: Practice Interventions
Abstract and Keywords
This entry focuses on practice interventions for working with families and individuals including behavioral marital therapy, transitional family therapy, and the developmental model of recovery, as well as motivational interviewing, cognitive-behavioral therapy, relapse prevention training, and harm reduction therapy. A commonality in these intervention frameworks is their view of the therapeutic work in stages—from active drinking and drug use, to deciding on change, to movement toward change and recovery. We also identify skills that equip social work practitioners to make a special contribution to alcohol and other drug (AOD) interventions and highlight factors to consider in choosing interventions.
There are a range of practice interventions for clients with AOD problems based on well-controlled research.
Keywords: motivational interviewing, cognitive-behavioral therapy, harm reduction therapy, behavioral marital therapy, developmental model of recovery, AOD and trauma, AOD and co-occurring psychiatric disorders
Drug Abuse Treatment Principles
Social work practitioners are encouraged to consider a range of counseling methods and modalities, choosing the ones that best meet the needs of the AOD client, couple, or family. The National Institute on Drug Abuse publication, Principles of Drug Addiction Treatment: A Research-based Guide (NIDA, 2000), a valuable guide for practitioners working with AOD clients, provides the scientific evidence for a range of currently accepted treatment approaches. Organized around treatment principles, it discusses issues such as appropriate treatment goals, optimum length of treatment, treatment effectiveness, and the role of medications for AOD and co-occurring psychiatric conditions. Among the recommended supplemental supports is Alcoholics Anonymous, which can improve client outcomes when used as an adjunct to formal treatment (Tonigan & Hiller-Sturmhofel, 1994).
Decisions about how to intervene with AOD clients should be based on several factors: the severity and urgency of the client's problem (for example, hazardous use, abuse, dependence), the client's level of awareness of the problem, the client's stage of readiness to change the dysfunctional behavior (DiClemente, 1991; Prochaska & DiClemente, 1983), the client's goal for change (for example, controlling use, reducing use, or quitting), the point at which the client seeks help (for example, during active drinking/drug use, early abstinence, or ongoing recovery (Brown, 1995), and the client's cultural background, identification, and experiences. Additional considerations will be the amount of time available, the organizational setting and its view of the worker's role, the client's voluntary or mandatory status, and financial considerations.
Abstinence and Recovery
Although some individuals may be treated for misuse of AOD and return to moderate, nonproblem use, practice experience supports the need for abstinence as a treatment goal for those who have developed alcohol or drug dependence (Hester & Miller, 1995). In the U.S. AOD treatment system, abstinence is the predominant goal, however new approaches are being used to help clients moderate their use and reduce the harm associated with use. Recovery is seen as a developmental process occurring over time; although individuals may have made a commitment to abstinence, they continue to be vulnerable to relapse. Recovery is also seen as involving necessary life changes above and beyond abstinence: repairing relationships damaged through AOD use, dealing with shame and self-hatred, addressing experiences of early trauma, and giving up self-defeating patterns acquired during addiction.
Ethnoculturally Competent AOD Treatment
Ethnocultural competency (Orlandi, 1992; Straussner, 2001) includes practitioner self-awareness, a basic understanding of the ethnoculture of one's clients, and an ability to adapt one's practice to fit the client's ethnocultural background (Amodeo & Jones, 1997; Lum, 1996; Orlandi, Weston, & Epstein, 1992; Straussner, 2001). Factors such as the client's level of acculturation, the culture's view of the causes and remedies of AOD problems, and the level of shame associated with AOD problems influence the client's and family's ability to respond to typical or mainstream treatment methods (Amodeo & Jones, 1997). Effective treatment for some clients may include use of an indigenous community healer, joining the neighborhood Pentecostal church, residing at the local Buddhist temple, or going to a sweat lodge (Amodeo, Robb, Peou, & Tran, 1996; Delgado, 1994, 1995). Talking with clients about their ethnocultural background and identification is central to AOD assessment and treatment because it can point to stressors (for example, family conflict related to acculturation, workplace discrimination) and resources (for example, culturally encouraged coping methods, finding recovering individuals from the cultural group who can serve as role models) that can hinder or assist in the client's recovery.
Practice Interventions: Families
Behavioral Marital Therapy
Behavioral interventions focusing on marital interaction have been studied more extensively than family systems and psychodynamic approaches, and currently have the greatest empirical support (O'Farrell, 1995). O'Farrell (1995) describes a number of these behavioral interventions within three stages of recovery: (a) initial commitment to change, (b) the change itself, and (c) the long-term maintenance of change. Although O'Farrell's model talks explicitly about family alcohol problems, the approach fits families of drug addicts as well. Recommended interventions are behavioral contracting, structuring the spouse's and alcoholic's role in the recovery process, decreasing family members' behaviors that trigger or enable drinking, and dealing with drinking that occurs during treatment. To improve marital and family relationships, O'Farrell prescribes shared recreational activities and homework (O'Farrell, 1995).
Transitional Family Therapy
Stanton and Heath (2005), seeking a model that integrates management of the substance abuse problem, the psychosocial environment, and interventions related to how the problem originated in the family's history, have developed Transitional Family Therapy that works to intensify certain dysfunctional family interactions in order to evoke counteractions, and consequently, new behaviors, while introducing competing behaviors that block the family's typical patterns. This work occurs in six stages: (a) problem definition and contracting, (b) establishing the context for a chemical-free life, (c) halting substance abuse, (d) managing the crisis and stabilizing the family, (e) family reorganization and recovery, and (f) ending therapy. In contrast with O'Farrell's (1995) behavioral work, this model brings together various family therapy and intergenerational approaches.
Developmental Model of Recovery
A unique feature of the recovery model of Brown (1985, 1995) and Brown and Lewis (1999) is the incorporation of cognitive, behavioral, psychodynamic, and family systems theories. The model assumes that clients and families often come for treatment for reasons other than AOD problems, and the clinician needs to be active in conducting a thorough assessment and bringing AOD issues to the forefront. Although focusing on alcohol and alcoholism, the model applies equally well to drug abuse in suggesting interventions at each stage from active drinking and/or drug use, transition, early recovery, and ongoing recovery.
Practice Interventions: Individuals
The Stages of Readiness for Change
This framework can be used by practitioners regardless of their theoretical orientation (for example, psychodynamic, behavioral, 12 step) (DiClemente, 1991; Miller & Rollnick, 1991, 2002; Prochaska & DiClemente, 1983). The stages were derived from studies of addicted smokers who successfully stopped (Prochaska, DiClemente, & Norcross, 1992). Its tenets include the following. In changing significant problem behaviors, we all go through predictable stages. Movement through these stages is not necessarily linear, and sometimes individuals remain at a particular stage and do not progress. Reasons for not changing are powerful. Even when we finally effect a change, maintaining the change over time is generally very difficult. Because most people return to the addictive or habitual behavior once change has been established, relapse or recurrence is built into the model and is seen as an opportunity for the individual to identify situations to avoid in the future when change has been reestablished. The stages are (a) precontemplation (person has never considered changing), (b) contemplation (person is considering change but is very ambivalent), (c) preparation (person has made the decision to change and is preparing to do so), (d) action (person makes the change and sustains it at least for a brief period), (e) maintenance (person maintains the change over months/years), and/or (e) recurrence (person returns to addictive or habitual behavior). Heavy emphasis is placed on (a) using specific counseling techniques for each stage, (b) working through ambivalence in the contemplation stage, (c) helping clients move one stage at a time, so the treatment goals are realistic and immediate and permanent change is not routinely expected, and (d) educating clients about the stages of change and engaging them in dialogue about where they are and where they want to be.
Relying heavily on reflective listening, this counseling method emphasizes four principles: express empathy, develop discrepancy, roll with resistance, and support self-efficacy (Miller & Rollnick, 2002, p. 36). Client ambivalence about change is seen as a predictable dynamic, and clinicians are encouraged to validate its presence. Helping clients examine the pros and cons of changing a behavior and the pros and cons of leaving the behavior unchanged can tip the balance of the ambivalence, freeing clients up to make a change. The choice of whether and when to change rests with the client, as does the nature of the change (for example, quitting, cutting down, changing the circumstances). This approach contrasts with previous confrontational methods used in counseling AOD clients and has been found to be effective with populations as disparate as adolescents, medical patients, alcoholic couples, mandated clients, and clients with HIV infection (Miller & Rollnick, 1991).
Cognitive Behavioral Therapy (CBT)
Key to this counseling approach is the functional analysis, an assessment that examines the connections between the client's thoughts, feelings, and behavior leading to excessive AOD use (Beck, Liese, & Najavits, 2005; Miller, 2004). The goal is to help clients learn an array of specific skills to interrupt various thoughts–feelings–behavior cycles. Clients with AOD problems often perceive themselves to be helpless in the face of cravings or exposure to others using AOD; CBT (Beck, Freeman, Davis, et al, 2003; Beck, Wright, Newman, & Liese, 1993; Carroll, 1998, 1999) teaches that relapse to excessive use is not inevitable. Client self-education through reading and self-monitoring through the use of behavioral tools are emphasized. This approach has been found to be effective with clients from disparate age groups, racial and ethnic groups, and educational levels, and with a range of AOD problems.
Relapse Prevention Training
Relapse is the return to use after a period of committed abstinence (Daley, 1987; Marlatt & Gordon, 1985). In general, clients with AOD problems are considered to be at high risk for relapse during the first year of abstinence, and depending on the client, for periods that are much longer. Specific relapse-prevention methods, often originating in CBT, include avoiding high-risk situations, developing a drug-free peer group, identifying personal signs of impending relapse (physical, emotional, and cognitive), and utilizing a predesigned plan to avoid acting on relapse impulses. This work relies on techniques such as role playing to teach clients AOD refusal skills, worksheets to help clients identify high-risk relapse situations, sociograms to identify positive and negative influences in the client's social network, and practice in between sessions to ensure that learning is transferred to real-life situations.
Harm Reduction Therapy
The primary focus of this approach is helping clients reduce harm associated with their AOD use. Harm reduction (Denning, 2000; Marlatt, 1996, 1998) recognizes that some clients are unable or unwilling to work toward abstinence, but can be helped to limit the harm they do to themselves and others. This approach is especially helpful with clients who have multiple problems (for example, substance abuse, psychiatric problems, HIV+ diagnosis, and homelessness) and limited emotional and material resources to deal with them. Principles include working closely with the stated goals of the client rather than pressuring the client to change, valuing small accomplishments (for example, the client uses drugs in a safe place rather than a shooting gallery or uses clean rather than dirty needles to inject), and assisting clients in making more substantial changes when and if they choose to do so. Moderation management is an approach that shares similarities with harm reduction (Vanicelli, 2001).
AOD and Co-Occurring Psychiatric Disorders
One of the most challenging issues for the AOD treatment field is addressing the chronic relapsing behavior of clients with dual disorders. General themes in approaching treatment are educating clients and their families about the symptoms of both disorders; monitoring client adherence to medications, since stopping medications is a significant risk for relapse; reinforcing small accomplishments; and engaging in active outreach if clients miss sessions (Busch, Weiss, & Najavits, 2005; Drake, Essock, et al. 2001; Drake & Mueser, 2000). Further, clients need an integrated treatment approach, that is, several evidence-based interventions such as medications, psychosocial treatments, family support, urine testing used in combination, and delivered by the same clinicians working in one setting. The agency or providers take responsibility for combining the service interventions into one coherent package (Drake, Goldman, et al., 2001; Drake et al., 1998). In the absence of such resources, practitioners need to identify programs that treat each condition separately and the practitioner needs to supplement this dual focus with case management services. The helping relationship is a critical factor (Owen, Rutherford, & Jones, 1997) that spans the range of interventions for people with co-occurring disorders (Minkoff & Regner, 1999).
AOD Disorders and Trauma
Posttraumatic Stress Disorder (PTSD) often accompanies AOD disorders; many addicted women in treatment have extensive trauma histories. For at least some clients, AOD use seems to have suppressed the trauma memories and provided temporary help with the anxiety, panic, depression, sexual dysfunction, and other PTSD symptoms. Relapse has been common among such clients if the trauma work is done too soon, for example, in the first 3 months of abstinence. On the other hand, some clients may relapse because the trauma work is not done soon enough. A differential assessment is necessary, and clinical tools and guidelines are still evolving. Thought containment, visualization, and stress reduction methods common to CBT are recommended in early abstinence until clients are emotionally and physically stable (Najavits, 2002, 2004; Najavits, Weiss & Liese, 1996; Rosenthal, Lynch, & Linehan, 2005). Many AOD and trauma experts are now questioning the benefits of requiring that clients recall the trauma in detail and work through the associated feelings.
From Micro to Macro Practice Interventions
There are additional AOD practice interventions at the micro, mezzo, and macro levels. These include screening and brief intervention, case management, and advocacy at the micro level. There are also a variety of group therapies, organizational interventions, community mobilization methods, primary and secondary prevention approaches, and activities directed at policy change in which social workers engage (McNeece & DiNitto, 2005; Straussner, 2001, 2004).
Social Work Skills
Among the social work skills contributing to effective work with AOD clients and their families are the ability to (a) use differential treatment approaches depending on client and family needs, (b) engage and assist the family whether or not the drinker or drug user comes to treatment, (c) partner with clients to assess the problem, choose appropriate goals, and implement changes, (d) anticipate client ambivalence about changing habitual behavior, (e) choose culturally and linguistically appropriate interventions, (f) utilize such resources as 12-step programs, natural support networks, and community service systems, and (g) identify and manage countertransference reactions that can hinder the therapeutic relationship (Amodeo, 1997). The ecological perspective of the social work profession increases the likelihood that they will adopt a holistic approach. Rather than assuming that the problem resides only in the individual or the environment, the ecological perspective looks at the interaction between both (van Wormer, 1995). Social workers need to be aware of their own reactions and attitudes toward AOD since countertransference reactions are common (Amodeo & Drouilhet, 1992).
The coming years will see several challenges as well as scientific and clinical advances in AOD treatment. The stigma that keeps individuals and families from seeking treatment is likely to continue, although to a somewhat diminished degree. PTSD diagnoses are likely to increase as family-, community-, and combat-related violence and exposure to natural and man-made disasters continue. Medications will increasingly be used in AOD treatment. This will be a welcome advance for the field but practitioners will need to become knowledgeable about these medications to ensure the judicious use of them as a complement rather than a substitute for psychosocial treatments. More extensive use of evidence-based practices should improve client retention and recovery rates, and services research should assist us in better matching clients with clinicians and treatment modalities.
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