Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
Therapist : Mr. Aber, as you know, your primary care physician, Dr. Wellbe, asked you to talk to me because he has some concerns about your use of alcohol. Would it be all right with you if we talked about that for a while? Client : Yeah. I guess it would be OK, but I don’t see what all the fuss is about. I don’t drink more than most people I know. Therapist : I understand that you don’t think that your drinking is a problem, and that’s fine. But there probably isn’t any harm in talking about it a bit. Do you agree? Client : I guess it would be all right. What do you want to know? Therapist : Well, to begin, could you just tell me a little about your drinking? Client : I’m not sure what you mean. Therapists : Well, when did you first start drinking? Client : Ah, well, I guess I first started drinking when I was pretty
For those who do need treatment, it is critical for clinicians to determine the most appropriate forms of treatment for a given client and to become familiar with the evidence for the effec- tiveness of a recommended treatment. Before discussing the various treatment approaches, it is important to acknowledge the value of motivational interviewing (MI) as a helpful frame- work for increasing the individual’s motivation to change his or her behavior (Mignon, 2015). Research supports the use of the more caring approach in MI, as traditional confrontational approaches have not been found to be effective (Mignon, 2015). MOTIVATIONAL INTERVIEWING Several key principles of MI help clients through the stages of change. These principles include: • Expressing empathy • Developing discrepancy • Avoiding argumentation • Rolling with resistance • Supporting self-efficacy (Miller & Rollnick, 1991) While discussing substance use with a client, providers listen for change talk and highlight the change talk to clients to help motivate them for change. It is also the job of the provider to hold the ambivalence toward substance use that many clients have. Clinicians should present the ambivalence to clients to encourage them to engage in more change talk. For example, if an individual wants to be a better, more supportive parent and recognizes that continued use of a substance is likely to make that difficult or impossible, the person has a powerful incentive to examine the substance-using behavior and change it. Rather than telling a client what to do or being confron- tational, it is important to provide empathetic feedback that helps guide the client to change and supports his or her self- efficacy, without forcing or pushing change on the individual (Miller & Rollnick, 2013). The historical use of “forced inter- vention” contradicts the MI model, which has been found to be the most effective form of treatment, in which individuals conclude, based on their own values and decision making, to change their behavior. Indeed, MI does not require a separate treatment component. The decision making is the therapy. One modification of MI is motivational enhancement therapy ( MET ), a counseling approach that helps individuals resolve their ambivalence about a problematic behavior, for example, their misuse of alcohol. MET typically includes an initial assess- ment of motivation and one to three individual sessions. In an empathetic and nonconfrontational, yet directive, approach, the clinician discusses the need for treatment and tries to elicit self-motivational statements from the client to strengthen his or her motivation for stopping or decreasing his or her use of a substance and build a plan for change. The following vignette provides an example of an initial session using MI techniques:
young. Probably about the time I was 12 or 13. Therapist : Can you tell me a bit more about that?
Client : My father was a pretty heavy drinker, and he always had a lot of booze around the house. So, I used to steal some of it and go behind the garage with my buddy, Joey, and we would drink it there. Therapist : Can you help me understand, how often did you do that? Client : Maybe a couple times a week. That went on for about a year until my dad found out and beat the shit out of me. Therapist : That must have been scary. Can you tell me more? Client : Well, I almost never talk about this, but you seem OK. My father was a real mean drunk. He would drink and then find some reason to pick a fight with my mom and slap her around. She never complained, but it really bothered me. I was the oldest, and once when I was about 10 years old, I tried to stop him. Therapist : That took a lot of courage on your part. What happened? Client : He threw me against the wall, and I hit my head so hard I was out cold for a while. The next thing I knew, my mom was hold- ing an ice bag to the back of my head and telling me never to do that again. I remember her lip was split and there was a nasty bruise on her cheek, but she wasn’t concerned about herself, only me. After that, whenever he would take after her, I would run to my room and turn my stereo up and try to pretend nothing was happening. I had bad dreams about what my father did for a long time. I still do once in a while. I swore to myself that I would never be like him, and so far, I have never laid a finger on my wife or any of my kids. Therapist : I want you to know how much I appreciate and admire your willingness to talk about that experience. It sounds like you had it hard growing up.
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