A Psychotherapeutic and Skills-Training Approach to the Treatment of Drug Addiction
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Arnold M. Washton
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1. OVERVIEW, DESCRIPTION, AND RATIONALE
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1.1 General Description of Approach
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This approach integrates psychotherapeutic and coping skills-training
techniques with abstinence-based addiction counseling. The primary goals of
treatment are to enhance and sustain patient motivation for change, establish
and maintain abstinence from all psychoactive drugs, and foster development
of (nonchemical) coping and problemsolving skills to thwart and ultimately
eliminate impulses to "self-medicate" with psychoactive drugs. The
approach combines cognitive-behavioral, motivational, and insight-oriented
techniques according to each client's individual needs. The therapeutic style
is empathic, client centered, and flexible. Strong emphasis is placed on
developing a good working alliance with the client to prevent premature
dropout and as a vehicle for promoting therapeutic change. The counselor
attempts to work with and through rather than against a client's resistance to
change. Aggressive confrontation of denial, the hallmark of traditional
addiction counseling, is seen as counterproductive and antithetical to this
approach. Group and individual counseling are delivered within the context
of a structured yet flexible multistage outpatient treatment program that also
includes psychoeducation (PE) for both the primary client and his or her
family; supervised urine testing to encourage and verify abstinence; and,
where indicated, pharmacotherapy for coexisting psychiatric disorders.
Patient participation in self-help is encouraged but not mandated, and
accepting the identity of addict or alcoholic is not required.
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1.2 Goals and Objectives of Approach
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Enhance the client's motivation for change.
- Teach the client how to break the addictive cycle and establish total
abstinence from all mood-altering drugs.
- Teach the client adaptive coping and problemsolving skills required
to maintain abstinence over the long term.
- Support and guide the client through troublespots and setbacks that
might otherwise lead to relapse.
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1.3 Theoretical Rationale/Mechanism of Action
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This approach views psychoactive drug addiction as a multidetermined
addictive behavior and maladaptive (self-medication) coping style with
biological, psychological, and social components. Accordingly, treatment
must provide the structure, support, and feedback required to break the
behavioral cycle of compulsive psychoactive drug use and provide
opportunities to learn adaptive (nonchemical) problemsolving skills to
prevent relapse. |
1.4 Agent of Change
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This approach actively promotes the development of a strong therapeutic
alliance between client and counselor along with positive bonding among
clients within a group. To ensure continuity of care, each client receives both
group and individual therapy from the same counselor. |
1.5 Conception of Drug Abuse/Addiction, Causative Factors
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Drug addiction is seen as a multidetermined addictive behavior and
maladaptive (self-medication) coping style with biological, psychological,
and social components. Although initial exposure to psychoactive drugs may
have resulted largely from social and cultural factors (including peer
pressure), the driving force behind continued and repeated use of these drugs
(before pharmacological and physiological addiction set in) is an attempt to
qualitatively and quantitatively alter one's experience and internal feeling
states. Psychoactive drugs are used by certain (predisposed) individuals to
amplify, modulate, obliterate, or transform certain feelings in ways they have
been unable to achieve by other (nonchemical) means. |
2. CONTRAST TO OTHER COUNSELING APPROACHES
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2.1 Most Similar Counseling Approaches
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This approach contains many original elements (Washton 1989) and
incorporates features of other approaches, including motivational counseling
techniques described by Miller and Rollnick (1991), relapse prevention (RP)
strategies described by Marlatt and Gordon (1985), and psychodynamic
techniques described by Brehm and Khantzian (1992). |
2.2 Most Dissimilar Counseling Approaches
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The hallmarks of this approach are clinical flexibility and careful attention to
individual differences. As such, it contrasts sharply with aggressive
confrontational approaches commonly found in traditional treatment
programs. Participation in Alcoholics Anonymous (AA) or other self-help
programs is actively encouraged and is seen as helpful and highly desirable,
but it is not mandatory. |
3. FORMAT
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Treatment involves a combination of group therapy two to four times a week
supplemented by individual counseling once a week. A supervised urine
sample is taken from every client at least twice a week, and breathalyzer tests
are administered on a random basis throughout the program. Although group
therapy is the core treatment modality for most clients, those who refuse to
enter group therapy are given the option of individual counseling two to three
times a week. Many of these clients subsequently agree to enter group
therapy once they have formed a positive relationship with their individual
counselor and worked through their initial concerns about participating in a
group. Some clients are not able to tolerate group as a result of psychiatric
and/or interpersonal impairments. Treatment for these clients may consist of
individual therapy two to three times a week, including urine and
breathalyzer testing. |
3.1 Modalities of Treatment
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Group and individual counseling are delivered within the context of a
structured yet flexible multistage outpatient treatment program that also
includes PE for both the primary client and his or her family; supervised
urine testing to encourage and verify abstinence; and, where indicated,
pharmacotherapy for coexisting psychiatric disorders. |
3.2 Ideal Treatment Setting
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This approach was developed within an outpatient treatment setting and as
such recognizes that the client is continuously faced with the pressures and
stressors of daily life and with easy access to a wide variety of psychoactive
drugs. It also recognizes that in the outpatient setting the client is always free
to drop out of treatment; accordingly, strong emphasis is placed on
therapeutic engagement and retention strategies, particularly at the beginning
of treatment when outpatient dropout rates are highest. |
3.3 Duration of Treatment
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A distinguishing feature of this program is its variable-length format. The
length of a client's participation in the program from admission through
completion ranges from 12 weeks to 24 weeks as determined by objective
measures of clinical progress (i.e., providing clean urines, attending
scheduled sessions, developing a sober support network that includes
involvement in self-help, and exercising adaptive [nondrug] problemsolving
skills). A prespecified set of behavioral contingencies adjusts the length of
treatment according to individual need. The average number of sessions
from admission to completion is approximately 40. |
3.4 Compatibility With Other Treatments
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Operating from a basic philosophy of using whatever seems to work best, this
approach is naturally compatible with a variety of other treatments. The
program has no antimedication bias so long as the medications being offered
are clinically appropriate and noneuphorigenic. Where appropriate,
naltrexone and disulfiram are utilized to foster RP. Clients with diagnosed
psychiatric disorders are treated with psychotropic medication (e.g.,
antidepressants, antipsychotics) as clinically required. The program does not
dispense methadone or other addictive drugs. |
3.5 Role of Self-Help Programs
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The program actively encourages but does not mandate the client's
participation in AA, Cocaine Anonymous (CA), Narcotics Anonymous (NA),
or other self-help groups. All clients are given a basic orientation to self-help
and what it has to offer that professional treatment does not. They are also
given a list of meetings in their community and provided with a buddy
(fellow group member) if they feel hesitant or uncomfortable about attending
self-help meetings alone. Clients are not threatened with termination from
treatment for failure to attend self-help meetings, nor is their reluctance or
refusal to attend self-help meetings seen as intractable resistance or denial.
The overwhelming majority of clients in the program do, in fact, attend self-help meetings. |
4. COUNSELOR CHARACTERISTICS AND TRAINING
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4.1 Educational Requirements
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A master's degree in social work, counseling, or psychology is the minimum
educational requirement for all clinical staff. |
4.2 Training, Credentials, and Experience Required
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All counselors must have State certification in clinical social work (C.S.W.),
clinical psychology (Ph.D.), or addiction counseling (C.A.C.), plus a
minimum of 3 years of full-time clinical experience working in an addiction
treatment program (preferably an outpatient program). |
4.3 Counselor's Recovery Status
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The counselor's status is irrelevant. Counselors are chosen solely on the
basis of their demonstrated clinical competence and not on the basis of their
recovery status. |
4.4 Ideal Personal Characteristics of Counselor
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Ideally, the counselor should be warm, empathetic, engaging, tolerant,
nonjudgmental, and flexible in interacting with clients. The counselor should
have a well-developed observing ego and be able to receive and use
constructive feedback, particularly with regard to the types of
countertransference and control problems likely to arise with highly
ambivalent (resistant) clients. The counselor must have excellent verbal
communication skills and be capable of defining and implementing
appropriate behavioral limits with clients in a consistently therapeutic
(nonpunitive) manner. |
4.5 Counselor's Behaviors Prescribed
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The counselor's role is to motivate, engage, guide, educate, and retain clients
during all phases of the program. Using an array of motivational, client-centered, and problemsolving techniques, counselors are expected to:
- Emphasize the client's strengths rather than weaknesses.
- Join rather than assault (confront) resistance.
- Avoid aggressive confrontation and power struggles.
- Negotiate rather than pontificate treatment goals.
- Emphasize the client's personal responsibility for change.
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4.6 Counselor's Behaviors Proscribed
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The counselor is cautioned against being dogmatic and controlling, especially
in response to reluctant and resistant clients. It is easy for the counselor to
lose sight of the fact that the first and foremost goal of treatment is to engage
the client in a friendly, cooperative, positive interaction that increases the
client's willingness to examine and change his or her drug-using behavior.
Counselors are taught how to avoid the most common therapeutic blunders
and negative countertransferential responses with drug-abusing clients.
These include:
- Predicting abject failure and misery if the client does not follow the
counselor's advice.
- Telling the client that what he or she really needs is more drug-related
negative consequences to acquire the motivation for change.
- Ignoring discrepancies between the program's goals and the client's
goals.
- Feeling frustrated and angry at clients who do not fully comply with
the program.
- Wanting to impose negative consequences on noncompliant clients
(e.g., depriving them of further help by "throwing them out of
treatment") rather than negotiating a change in a treatment plan based
on clarification of the client's ambivalence about change.
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4.7 Recommended Supervision
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The counselor's job is a demanding one, and clinical supervision is required
not only to sharpen clinical skills and ensure consistency in treatment
approach but also to provide the counselor with emotional support and
encouragement. All counselors receive 1 hour of group supervision and 1
hour of individual supervision each week. Supervisors use statistical reports
(computer printouts) to monitor each counselor's client caseload and work
performance. These reports include data on client retention/completion rates,
attendance at sessions, urine test results, and goal attainment ratings.
Measures of all counselors' work performance include data on quantity of
clinical services provided to clients (i.e., numbers of sessions), responses to
positive urine test results and missed sessions, timeliness of followup on
clients who drop out or fail to show up for sessions, and counselors'
compliance with chart-noting requirements. Supervisors pay special
attention to client dropout rates, since retention is a key factor in determining
treatment success. Supervisors occasionally sit in on counselors' group
sessions to directly observe their therapeutic skills in action. Videotaping
and audiotaping of sessions (with the client's written consent) is also used in
supervision. In addition to supervisory meetings, there is a daily case
conference attended by all counselors for assigning new cases and discussing
special problems. Once each month, there is an inservice training session on
a specific clinical topic.
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5. CLIENT-COUNSELOR RELATIONSHIP
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5.1 What Is the Counselor's Role?
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The counselor serves a multidimensional role as collaborator, teacher,
adviser, and change-facilitator.
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5.2 Who Talks More?
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In general, the client talks more. However, the counselor does not hesitate to
offer education, advice, and guidance where appropriate.
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5.3 How Directive Is the Counselor?
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The counselor takes an active role, offering specific advice and direction,
particularly during the early phases of treatment where immediate behavioral
changes are required to establish and maintain abstinence.
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5.4 Therapeutic Alliance
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One of the most important aspects of the therapeutic alliance (TA) approach
is the development of a cooperative relationship between client and
counselor. Building a positive TA requires the counselor to start where the
client is (i.e., to accept and work within the client's frame of reference). This
stands in marked contrast to traditional approaches, which demand that the
client submit to the counselor's (program's) frame of reference as the starting
point of treatment. For example, if the client at first minimizes the
seriousness of his or her drug use problem or rejects the idea that it is a
problem at all, the counselor refrains from accusing the client of being in
denial (a tactic likely to heighten rather than reduce the client's
defensiveness) and instead asks the client to cooperate in a time-limited
experiment (usually involving a trial period of abstinence) to assess the
nature and extent of his or her involvement with psychoactive drugs.
Coerced or mandated clients pose the greatest challenge to getting a TA
started. Typically, these clients appear for treatment angry, suspicious,
mistrustful, and ready to do battle. Building a relationship under these trying
circumstances requires a great deal of clinical finesse on the part of the
counselor, who makes every effort to:
- Empathize with the client's plight and the fact that no one likes to be
told what to do.
- Accept without challenge the client's primary motivation for coming
to treatmentto get the coercing agent (e.g., court, employer) "off
my [the client's] back."
- Compliment the client for facing the realities of the situation by
showing up at the session.
- Detach himself or herself as much as possible from the coercing agent
and offer to help the client solve the problem or problems that led to
the current situation.
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6. TARGET POPULATIONS
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6.1 Clients Best Suited for This Counseling Approach
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This treatment is best suited for clients who meet DSM-IV criteria for
psychoactive drug addiction and are able to show up for scheduled sessions at
an outpatient clinic. The program admits clients who are actively using
alcohol and other drugs and those who have already achieved abstinence as
inpatients or outpatients. The program treats all types of chemical addiction
and cross-addictions irrespective of the client's drug of choice (e.g., alcohol,
cocaine, heroin) and has been used successfully with both adult and
adolescent populations (treated separately). Chronically unemployed,
dysfunctional clients are treated in separate groups from clients with
substantially higher levels of psychosocial functioning. The program is
coeducational, but a special women's group is available for those who prefer
to be treated in an all-female environment. A special dual-focus group
(separate from the mainstream program) accommodates the special needs of
clients with concurrent psychiatric illness.
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6.2 Clients Poorly Suited for This Counseling Approach
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Poorly suited candidates for this approach include clients whose psychosocial
functioning is so impaired that they are unable to show up for treatment
sessions and those who are actively suicidal, psychotic, or otherwise
psychiatrically unstable and in need of more structured, intensive care such as
an inpatient or partial hospitalization program.
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7. ASSESSMENT
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The pretreatment evaluation process begins by asking the client to fill out an
extensive self-administered assessment questionnaire (the Washton Institute
Intake Evaluation Form) (Washton 1995) immediately prior to a 1-hour, face-to-face clinical interview with the intake counselor. The assessment
questionnaire covers the domains of:
- Drug use.
- Motivation and readiness for change.
- Psychiatric history and status.
- Family history.
- Vocational history.
- Criminal history.
- Treatment history.
During the subsequent clinical interview, the counselor seeks to clarify and
expand the information already provided by the client on the assessment
form. Perhaps more importantly, the counselor makes an active attempt to
motivate and engage the client in a therapeutic interaction. Where indicated,
the pretreatment evaluation process may require one or more additional
sessions and may also include a formal psychiatric assessment. An extremely
important aspect of the pretreatment evaluation is assessment of the client's
motivation and readiness for change. This involves identifying with the
client both internal and external factors currently driving him or her to at
least explore the possibility of change. It also involves helping the client
identify his or her ambivalence about stopping psychoactive drug use by
objectively exploring both the positive and negative effects of the use and by
defining the client's treatment goals and to what extent these are consistent
with the program's goals. With regard to treatment goals, some clients want
to reduce rather than completely stop using their drug of choice, while others
want to give up only the one drug causing them the most obvious problems
(e.g., cocaine) but not the drugs they view as relatively innocuous and
nonproblematic (e.g., alcohol and marijuana). Clients who want to enter an
early abstinence group must agree to stop using all psychoactive drugs (total
abstinence) for at least a trial period. Clients who do not agree to meet this
requirement are offered the option of time-limited individual counseling (up
to 6 weeks) to help move them toward accepting trial abstinence as a short-term treatment goal.
During treatment, clinical progress is measured throughout each client's
participation in the program. A computerized office management system
stores, analyzes, and reports clinical data on all clients during the course of
their participation in the program. These data include:
- Urine test results.
- Attendance at scheduled sessions.
- Counselor ratings of the client's progress toward achieving specified
treatment goals.
- Client's self-ratings of progress toward achieving treatment goals.
The data are reviewed monthly (or weekly, if needed) to continuously adjust
the treatment to individual client needs, provide supervisory feedback to
counselors, and improve overall treatment effectiveness.
Followup treatment studies have been conducted on sample populations at 1-
to 2-year intervals after treatment. Followup measures include assessments
of:
- Drug use.
- Psychosocial functioning.
- Involvement in self-help.
- Utilization of other treatment resources.
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8. SESSION FORMAT AND CONTENT
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8.1 Format for a Typical Session
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A typical group session in the early abstinence phase of the program begins
with each client stating the length of his or her clean and sober time (i.e., how
long ago the client last used any psychoactive drugs whatsoever) and what
issue he or she wishes to discuss in that session. Every client is expected to
identify at least one issue for discussion at each session. The therapist (group
leader) may pull together the issues of two or more group members into a
theme for that session or, alternatively, may begin the session with a specific
topic as part of a revolving PE sequence. In general, two group sessions per
week are devoted to day-to-day concerns and struggles raised by the clients
themselves (with appropriate guidance and framing of the discussion
supplied by the group leader); one session is devoted to a specific PE or
skills-training topic where the counselor presents a brief lecture and guides a
focused discussion.
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8.2 Several Typical Session Topics or Themes
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Following is a partial list of topics and themes in the PE sequence (Washton
1989, 1991): tips for quitting; finding your motivation to quit; how serious is
your problemtaking a closer look; identifying your high-risk situations;
coping with your high-risk situations; dealing with cravings and urges; why
total abstinenceis it really necessary to give up everything?; warning signs
of relapse; rating your relapse potentiala realistic assessment; tips for
handling slips; managing anger and frustration; finding balance in your life;
how to have fun without getting high; defining your personal goals;
managing problems in your relationships; building your self-esteem; nutrition
and personal health; AIDS and other sexually transmitted diseaseshow to
avoid them; overview of treatment and recovery; how your family can help
without hurtinga look at coaddiction.
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8.3 Session Structure
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The purpose of each session is to enhance the client's motivation for change
and improve his or her ability to cope adaptively with the problems of
everyday life without reverting to psychoactive drug use. To accomplish this
task success-fully, sessions are neither highly structured nor totally
unstructured. The PE sessions serve more to stimulate discussion than
present material in a didactic manner. The group leader takes an active role
in helping each group member relate the lecture topic to his or her own
personal situation. The goal is to foster emotional and behavioral change
rather than merely supply factual information.
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8.4 Strategies for Dealing With Common Clinical Problems
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Lateness and absenteeism are addressed therapeutically as behavioral
manifestations of a client's ambivalence about change. The importance of
clients arriving at sessions on time and attending reliably is emphasized
throughout the program, starting with the initial intake interview. Clients are
instructed not to come to the clinic within 12 hours of any alcohol or other
drug use. If a client arrives showing clear-cut behavioral signs of
intoxication (e.g., slurred speech, uncoordinated movements, breath smelling
of alcohol), he or she is asked to leave the premises and return the next day.
If the client is severely intoxicated, a counselor will try to contact a family
member to escort the client home. According to the program's variable-length treatment protocol, each unexcused absence extends by 2 to 4 weeks
the time required for program completion. On the occasion of a third
unexcused absence or fifth unexcused lateness, the client is transferred from
the early abstinence group to a stabilization group that focuses more
intensively on overcoming early obstacles to change.
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8.5 Strategies for Dealing With Denial, Resistance, or Poor
Motivation
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Enhancing a client's motivation for change is an essential part of the
counselor's role in this approach. Labeling a client as being in denial,
resistant to change, or poorly motivated is seen as distinctly unhelpful.
Problems in complying with the treatment program are framed in terms of the
client's ambivalence, reluctance, and fears about change. The counselor
works collaboratively and cooperatively with the client to overcome these
obstacles. In the face of noncompliance, the counselor actively seeks to join
the client's resistance and find creative ways around it. This approach
recognizes that, especially in the outpatient setting, aggressive confrontation
is likely to precipitate dropout from treatment and may nullify efforts to
engage and retain clients. It is important to mention that although this
approach avoids the use of confrontational tactics, it does not promote a
laissez-faire, anything-goes attitude toward client noncompliance. Limit
setting and constructive feedback are essential features of the approach that
are used in the spirit of enhancing a client's motivation for change rather than
insisting that he or she admit to being an addict in serious denial.
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8.6 Strategies for Dealing With Crises
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In the event of emergencies or crisis situations during nonclinic hours,
counselors and supervisors can be paged via a 24-hour telephone answering
service. Crises are met with supportive interventions to stabilize the crisis
situation and prevent relapse and dropout. The client is provided with
frequent individual counseling sessions until the immediate crisis situation is
stabilized.
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8.7 Counselor's Response to Slips and Relapses
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Slips are treated as avoidable mistakes and manifestations of ambivalence.
The thoughts, feelings, circumstances, and chain of setup behaviors leading
up to the slip are carefully reviewed. The first goal of this debriefing is to
help the client recognize and accept the role of personal choice and
responsibility in determining drug-using behavior. To decrease the
likelihood of further use, an abstinence plan is formulated that incorporates
specific decisionmaking, problemsolving, and behavioral avoidance
strategies. The variable-length treatment protocol stipulates that each slip
increases a client's length of stay in the program by 2 to 4 weeks. On the
occasion of a third slip (or sooner if the counselor deems it necessary), the
client is transferred to a stabilization group. This group focuses intensively
on developing day-by-day (hour-by-hour) behavioral action plans for
achieving abstinence. Upon achieving 2 consecutive weeks of total
abstinence and perfect attendance in the stabilization group, the client is
eligible to return to his or her early abstinence group. In the event of a
second slip while in the stabilization group, the client is suspended from
group treatment for at least 2 weeks and may be referred for inpatient care.
During the suspension, the client may also be given the option of attending
the clinic for twice-a-week urine testing and once-a-week individual
counseling for a maximum of 4 weeks. If the client achieves 2 consecutive
weeks of abstinence during the suspension period, he or she can return to the
early abstinence group.
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9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT
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Active efforts are made to involve significant others (SOs) in the treatment.
All newly admitted clients are encouraged to attend a family program
together with their SOs (e.g., partner, family members, best friend). The
program consists of a conjoint multiple family group that meets once per
week for 12 consecutive weeks. The group provides support, education, and
counseling geared toward enhancing family members' ability to cope
adaptively with their loved one's addiction and teaching them how to break
the vicious cycle of enabling and provoking behaviors that perpetuate the
problem. Participants learn and practice specific problemsolving and
communication skills using guided role-play exercises. Couples and family
therapy are also used to deal with problems that require more individualized
attention.
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REFERENCES
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Brehm, N.M., and Khantzian, E.J. A psychodynamic perspective. In:
Lowinson, J.H.; Ruiz, P.; Millman, R.B.; and Langrod, J., eds. Substance
Abuse: A Comprehensive Textbook. 2d ed. Baltimore: Williams & Wilkins,
1992. pp. 106-117.
Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance Strategies
in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985.
Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People
to Change Addictive Behavior. New York: Guilford Press, 1991.
Washton, A.M. Cocaine Addiction: Treatment, Recovery, and Relapse
Prevention. New York: Norton, 1989.
Washton, A.M. Cocaine Recovery Workbooks. Center City, MN: Hazelden
Educational Materials, 1991.
Washton, A.M., ed. Psychotherapy and Substance Abuse: A Practitioner's
Handbook. New York: Guilford Press, 1995.
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AUTHOR
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Arnold M. Washton, Ph.D., C.S.A.C.
Founding Director
The Washton Institute
18 East 41st Street
New York, NY 10017
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