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The Addiction Counselor’s Desk Reference
- By Misc Author
- Published 11/16/2007
- Addiction Research
- Unrated
This section reviews some of the most time-tested therapeutic modalities— tools—to help clients recover from their addictions. Though not an exhaustive list, these include motivational tools, medical-pharmaceutical tools, cognitive-behavioral tools, psychosocial tools, and holistic tools. Most treatment programs use a variety of these therapeutic tools.
MOTIVATIONAL TOOLS
These therapeutic modalities aim to motivate clients to overcome their reluctance to change out of their addictive behaviors.
MOTIVATIONAL INTERVENTION
A small group of family members and friends of the client who are concerned about their loved one meet in a surprise confrontation to express their concern about his or her addiction and urge treatment.
Under the leadership of an intervention specialist, participants plan what they will say and arrange for admission to a treatment program. Prior to the meeting, the client’s bags are packed, airline reservations are made, and a designated driver to the airport is appointed.
Ideally, hearts are touched, the client agrees to set off for therapy, and all wave good-bye as they leave for the treatment center.
This type of intervention includes five steps (Storti, 1995, 2001, pp. 4–14; Storti & Keller, 1988):
1. The inquiry: A concerned associate of the addicted person contacts the intervention specialist and provides basic information.
2. The assessment: Key group members assist the specialist in tailoring the intervention to the specific patient’s needs.
3. The preparation: All group members learn their assignments and collect their thoughts.
4. The intervention: Each person, in turn, expresses love, concerns, and hopes to the patient with the guidance of the therapist.
5. The follow-up (or case management): This takes place after the client enters and leaves the treatment program.
Even when a client does not agree to treatment, group participants typically find the intervention to be therapeutic.
However, Storti and Keller (1988) advise that an intervention should not be carried out if certain conditions are present: (1) a strong tendency toward violence or vindictiveness (especially involving a spouse or children); (2) a lack of sufficient documentation of the problem; or (3) a psychiatric disorder requiring treatment in its own right.
Otherwise, motivational interventions are effective in bringing clients suffering from addictions into treatment, and also give them a foundation of support on which to rebuild their lives.
Additional Resources -- Intervention Center—Family intervention for addictions at www.intervention.com.
MOTIVATIONAL INTERVIEWING
Addicted clients are often ambivalent about changing a behavior that provides some benefits to them, even though it may be inconsistent with their basic values, beliefs, and goals.
Clients may defend themselves against the counselor’s unwanted advice and judgment because committing to, making, and maintaining changes in longstanding behavior is difficult.
Motivational Interviewing (MI) addresses this challenge (Rosengren & Wagner, 2001). It is a nondirective modality designed to help clients resolve ambivalence about their behavior without confrontation.
Miller and Rollnick report, “MI does not use confrontation or aggression of any kind,” and “MI helps clients become aware of the discrepancy between where they are and where they want to be,” (Project Match Research Group, 1997, p. 8).
To be effective, the client must first want help.
Additional Resources -- To learn more about MI’s several applications and strategies for implementation, see Miller, W. R., & Rollnick, S. (Eds.). (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
Also visit the Motivational Interviewing web site at www.motivationalinterview.org.
MEDICAL AND PHARMACEUTICAL TOOLS
These medical model tools typically involve collaboration with physicians and pharmacists who prescribe and dispense medication and disease-oriented treatment ideology.
DETOXIFICATION
Detoxification (detox), the first step in treating chemical addiction, is the removal of all harmful substances from the addicted client’s system. When physical dependence is present, medical interventions are used to counter the uncomfortable and, in some cases, high-risk symptoms of withdrawal.
These tools include medications to treat symptoms, to rebuild the patient’s damaged system, and to combat cravings (D. E. Smith & Seymour, 2001). Some addictions can be treated using a substitution and tapering process, such as phenobarbital for sedative-hypnotic detoxification or methadone for opioid detox.
Methadone is also sometimes used for maintenance purposes until a patient is better prepared for detoxification (see “Harm Reduction Programs” later in Part V).
Detoxification can only be done under the supervision of a physician. Not until the drug is fully eliminated can the brain return to its preaddiction potential. “When there is physical dependence, medical interventions may be needed to counter withdrawal symptoms and make full detoxification possible. The tools of detoxification include a pharmacopoeia of medications that work to ease withdrawal symptoms and help the patient’s system regain a healthy balance,” (D. E. Smith & Seymour, 2001, p. 63).
Additional Resources -- For further information on detoxification services see Morse, G. R. (1999). Detoxification: A guide for medically assisted withdrawal from chemical addiction. London: Mark Allen Publishing.
For a detailed description of the Detoxification Services Definitions that explains the levels of care for Substance Abuse and Mental Health Services visit www.treatment.org/taps/tap22/TAP22TOC.htm.
MEDICATIONS
In addition to minimizing withdrawal symptoms during detoxification, medications are used to treat co-occurring psychiatric disorders—some 25% to 75% of all clients have a current or past comorbid psychiatric disorder (Ziedonis & Krejci, 2001).
Addiction recovery medications are effectively used in three ways:
1. Symptomatic treatment: Using a drug whose pharmacological action is unrelated to the abused drug but whose effects ameliorate emotional or physical symptoms related to the use of the abused drug (e.g., to ease discomfort when detoxifying).
2. Agonist substitution: Treatment with a medication that has pharmacological actions similar to that of the abused drug (e.g., nicotine chewing gum for tobacco dependence).
3. Antagonist treatment: Utilizing pharmaceuticals to inhibit or block the chemical effects of the abused drugs (Coombs, 1997). Antagonist medications commonly prescribed to facilitate addiction recovery include Antabuse for alcoholism, which creates an unpleasant physical response to drinking; naltrexone (Revia) and nalmefene, which block the opiate receptors for heroin/opioid and alcohol dependence; and agonists methadone, levo-alpha acetyl methadol (LAAM), and buprenorphine for addiction to heroin and other opiates, which reduce cravings and block euphoria (Ziedonis & Krejci, 2001).
Additional Resources -- For a detailed review of pharmacotherapies, see Barber, W. S., & O’Brien, C. P. (1999). Pharmacotherapies. In B. S. McCrady and E. E. Epstein (Eds.), Addictions: A comprehensive guidebook. New York: Oxford University Press.
DISEASE ORIENTATION
In the past, drug dependency was viewed as a sin committed only by people with weak moral character. In 1956, the American Medical Association (AMA) published a statement saying, “Alcoholism must be regarded as within the purview of medical practice” (N. S. Miller, 2001, p. 104).
The Council on Mental Health, the AMA’s Committee on Alcoholism, promoted the idea that alcoholism is an illness that requires the participation and attention of physicians. This realization is based on the pioneering work of Jellinek (1960) who observed that alcoholics are more likely to have alcoholic family members.
In these studies, environmental influences cannot be separated from the genetic influences, because alcoholic parents raise alcoholics. Defining addiction as a disease relieves addicts of the overwhelming shame and responsibility for having caused the addiction and its devastating consequences.
At the same time, it empowers the client to take corrective action. Refuting the discouraging idea that addiction is a moral failure allows clients to focus on getting better by accepting the hard truth: Abstinence is their solution.
Just as lung cancer patients are expected to stop smoking and diabetics to avoid sugar, addicts must altogether avoid ingesting alcohol and other psychoactive drugs as part of their recovery.
Additional Resources -- For further information, see Jellinek, E. M. (1960). The disease concept of alcoholism. New Haven, CT: College and University Press; and Miller, N. S. (1991). Drug and alcohol addiction as a disease. In N. S. Miller (Ed.), Comprehensive handbook of drug and alcohol addiction. New York: Marcel Dekker.
DRUG TESTING
Promoting accountability, determining compliance, and measuring success, drug testing is most often used in three settings: among employees whose contracts require them to remain drug-free, in criminal justice applications such as DUI or probationary screenings, and in clinical treatment programs (Coombs & West, 1991; Mieczkowski, 2001).
Two kinds of tests are commonly used: (1) immediate outcome drug tests (e.g., home drug testing kits that test marijuana, cocaine, amphetamines, morphine/ opiates, PCP, alcohol, and nicotine) that provide immediate results and are economical and easy to use, and (2) confirmation tests sent to a lab to determine test accuracy and reliability.
To minimize errors such as contamination, clerical error, improper execution, or cross-reactivity, select a sophisticated laboratory with a proven track record.
Additional Resources -- For detailed information, see Mieczkowski, T. (1990). The accuracy of selfreported drug use: An evaluation and analysis of new data. In R. Weisheit (Ed.), Drugs, crime, and the criminal justice system. Cincinnati, OH: Anderson.
To learn more about these tests visit www.drugdetect.com/index.shtml.
COGNITIVE-BEHAVIORAL TOOLS
Active, directive, time-limited, and structured, these therapeutic modalities assume that clients’ behaviors are largely determined by the ways in which they think.
CONTINGENCY MANAGEMENT
Based in the theoretical underpinning of Skinner’s operant conditioning, Contingency Management (CM) enforces desired behaviors that strengthen recovery. Positive reinforcement means delivering a reward. Negative reinforcement, not to be confused with punishment or a negative outcome, means removing an undesirable restriction or situation.
Positive punishment means delivering an undesirable consequence, whereas negative punishment means removing a desirable one.
In CM, reinforcements are generally considered more effective than punishments. CM gives the recovery more firepower by competing with the rewards of the addict’s drug or behavioral habit. This is especially important for the many users who resent authority figures and regulations (Coombs, 2001).
In designing CM plans, first determine the desired target outcome and criteria for success (e.g., weekly urine test). Incentive programs can use voucher systems where clients can earn points and then select a reward purchased or provided through the treatment practitioner.
The list of incentives should be long enough to please a variety of clients, and its focus should be recreational (e.g., going to a movie). Although CM can be used with goals such as attendance at therapy sessions, Budney, Sigmon, and Higgins (2001) encourage treatment professionals to use this strategy first and foremost to reward clients for staying free from addictive behaviors.
Additional Resources -- Higgins, S. T., Wong, C. J., Badger, G. J., Ogden, D., & Dantona, R. L. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow up. Journal of Consulting and Clinical Psychology, 68, 64–72.
CUE EXPOSURE
Recognizing drug use as a habit, with addicts responding to accustomed cues and contexts by ingesting their substance of choice, Cue Exposure (CE) treatment trains clients to stop responding habitually to their traditional triggers.
Called “extinction,” it is the unconditioning of conditioned triggers and responses (e.g., local bars linked with drinking) by repeatedly exposing a client, in a controlled environment, to these potential triggers. Repeated exposures erase reaction to the cue (Coombs, 2001).
When administering cues, the counselor will need to track clients’ responses, usually by asking them to self-report cravings, negative mood, and physiological responses on a scale of 1 to 10 (Conklin & Tiffany, 2001).
Treatment for a particular cue is ended when a client no longer responds to the cue though an occasional review to ensure continued extinction is helpful. Properly administered, cue exposure treatment can strengthen the client’s resistance to relapse.
Additional Resources -- Bouton, M. E. (2000). A learning-theory perspective on lapse, relapse, and the maintenance of behavior change. Health Psychology, 19, 57–63.
AFFECT-REGULATION -- COPING SKILLS TRAINING
Coping skills training acknowledges that addicts generally use addictive substances or behaviors to regulate their own moods; they self-medicate to avoid uncomfortable feelings (Scott et al., 2001).
This technique focuses on helping clients learn positive coping skills for addressing challenges and the unpleasant emotions they invoke.
The objective of coping skills training is to enhance and develop clients’ internal locus of control. When clients achieve this control, they will possess the requisite skills to take charge of the emotions that influence positive behavioral choices. Clients learn that they can alter their unwanted moods and increase their self-confidence more by taking constructive actions than by using psychoactive drugs (Kern & Lenon, 1994).
Clinicians use the following five-step model: (1) Assessment; (2) Establishing commitment (to stay clean and away from unwanted emotions); (3) Identifying feelings (to learn how to identify emotions); (4) Homework (e.g., daily journaling); and (5) Setting goals that meet client needs and measuring progress (Scott et al., 2001).
Additional Resources -- For a detailed review of this recovery tool, see Scott, R. L., Kern, M. F., & Coombs, R. H. (2001). In R. H. Coombs (Ed.), Addiction recovery tools. Thousand Oaks, CA: Sage.
RECOVERY CONTRACTS
Behavioral contracts reinforce positive behaviors and monitor supportive recovery. Talbott and Crosby (2001) explain, “The chemically dependent patient requires psychological, physiological, and spiritual frameworks to guide him or her through the recovery process. Contracts are an essential part of this external structure” (p. 127).
These contracts provide the client with a detailed road map of the daily actions needed to deal with life stress and to reduce distractions.
An effective recovery contract has seven key components: (1) Presentation of the contract in a serious and compassionate manner, preferably with the significant other and any program representatives in attendance; (2) Releases of information— the patient must sign off on privacy releases for family members, coworkers, and others to be involved in contract reporting; (3) Leverage through clearly understood consequences when expectations are not met (behaviors should be highly specific); (4) Organization of a client’s support system; (5) Statement of short treatment time frame so that the client feels capable of compliance.
Most contracts are designed to cover a 5-year span, but they are renewed annually, biannually, or even quarterly; (6) Contract review, which should take place formally at least every 6 months and informally on an ongoing basis; and (7) A “slip” relapse clause.
Clients should be educated regarding warning signs so they can seek help before they head into a full-blown relapse (Talbott & Crosby, 2001).
Additional Resources -- For a detailed chapter on this topic, see Talbott, G. D., & Crosby, L. R. (2001). Recovery contracts: Seven key elements. In R. H. Coombs (Ed.), Addiction recovery tools: A practice handbook. Thousand Oaks, CA: Sage.
MOTIVATIONAL TOOLS
These therapeutic modalities aim to motivate clients to overcome their reluctance to change out of their addictive behaviors.
MOTIVATIONAL INTERVENTION
A small group of family members and friends of the client who are concerned about their loved one meet in a surprise confrontation to express their concern about his or her addiction and urge treatment.
Under the leadership of an intervention specialist, participants plan what they will say and arrange for admission to a treatment program. Prior to the meeting, the client’s bags are packed, airline reservations are made, and a designated driver to the airport is appointed.
Ideally, hearts are touched, the client agrees to set off for therapy, and all wave good-bye as they leave for the treatment center.
This type of intervention includes five steps (Storti, 1995, 2001, pp. 4–14; Storti & Keller, 1988):
1. The inquiry: A concerned associate of the addicted person contacts the intervention specialist and provides basic information.
2. The assessment: Key group members assist the specialist in tailoring the intervention to the specific patient’s needs.
3. The preparation: All group members learn their assignments and collect their thoughts.
4. The intervention: Each person, in turn, expresses love, concerns, and hopes to the patient with the guidance of the therapist.
5. The follow-up (or case management): This takes place after the client enters and leaves the treatment program.
Even when a client does not agree to treatment, group participants typically find the intervention to be therapeutic.
However, Storti and Keller (1988) advise that an intervention should not be carried out if certain conditions are present: (1) a strong tendency toward violence or vindictiveness (especially involving a spouse or children); (2) a lack of sufficient documentation of the problem; or (3) a psychiatric disorder requiring treatment in its own right.
Otherwise, motivational interventions are effective in bringing clients suffering from addictions into treatment, and also give them a foundation of support on which to rebuild their lives.
Additional Resources -- Intervention Center—Family intervention for addictions at www.intervention.com.
MOTIVATIONAL INTERVIEWING
Addicted clients are often ambivalent about changing a behavior that provides some benefits to them, even though it may be inconsistent with their basic values, beliefs, and goals.
Clients may defend themselves against the counselor’s unwanted advice and judgment because committing to, making, and maintaining changes in longstanding behavior is difficult.
Motivational Interviewing (MI) addresses this challenge (Rosengren & Wagner, 2001). It is a nondirective modality designed to help clients resolve ambivalence about their behavior without confrontation.
Miller and Rollnick report, “MI does not use confrontation or aggression of any kind,” and “MI helps clients become aware of the discrepancy between where they are and where they want to be,” (Project Match Research Group, 1997, p. 8).
To be effective, the client must first want help.
Additional Resources -- To learn more about MI’s several applications and strategies for implementation, see Miller, W. R., & Rollnick, S. (Eds.). (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
Also visit the Motivational Interviewing web site at www.motivationalinterview.org.
MEDICAL AND PHARMACEUTICAL TOOLS
These medical model tools typically involve collaboration with physicians and pharmacists who prescribe and dispense medication and disease-oriented treatment ideology.
DETOXIFICATION
Detoxification (detox), the first step in treating chemical addiction, is the removal of all harmful substances from the addicted client’s system. When physical dependence is present, medical interventions are used to counter the uncomfortable and, in some cases, high-risk symptoms of withdrawal.
These tools include medications to treat symptoms, to rebuild the patient’s damaged system, and to combat cravings (D. E. Smith & Seymour, 2001). Some addictions can be treated using a substitution and tapering process, such as phenobarbital for sedative-hypnotic detoxification or methadone for opioid detox.
Methadone is also sometimes used for maintenance purposes until a patient is better prepared for detoxification (see “Harm Reduction Programs” later in Part V).
Detoxification can only be done under the supervision of a physician. Not until the drug is fully eliminated can the brain return to its preaddiction potential. “When there is physical dependence, medical interventions may be needed to counter withdrawal symptoms and make full detoxification possible. The tools of detoxification include a pharmacopoeia of medications that work to ease withdrawal symptoms and help the patient’s system regain a healthy balance,” (D. E. Smith & Seymour, 2001, p. 63).
Additional Resources -- For further information on detoxification services see Morse, G. R. (1999). Detoxification: A guide for medically assisted withdrawal from chemical addiction. London: Mark Allen Publishing.
For a detailed description of the Detoxification Services Definitions that explains the levels of care for Substance Abuse and Mental Health Services visit www.treatment.org/taps/tap22/TAP22TOC.htm.
MEDICATIONS
In addition to minimizing withdrawal symptoms during detoxification, medications are used to treat co-occurring psychiatric disorders—some 25% to 75% of all clients have a current or past comorbid psychiatric disorder (Ziedonis & Krejci, 2001).
Addiction recovery medications are effectively used in three ways:
1. Symptomatic treatment: Using a drug whose pharmacological action is unrelated to the abused drug but whose effects ameliorate emotional or physical symptoms related to the use of the abused drug (e.g., to ease discomfort when detoxifying).
2. Agonist substitution: Treatment with a medication that has pharmacological actions similar to that of the abused drug (e.g., nicotine chewing gum for tobacco dependence).
3. Antagonist treatment: Utilizing pharmaceuticals to inhibit or block the chemical effects of the abused drugs (Coombs, 1997). Antagonist medications commonly prescribed to facilitate addiction recovery include Antabuse for alcoholism, which creates an unpleasant physical response to drinking; naltrexone (Revia) and nalmefene, which block the opiate receptors for heroin/opioid and alcohol dependence; and agonists methadone, levo-alpha acetyl methadol (LAAM), and buprenorphine for addiction to heroin and other opiates, which reduce cravings and block euphoria (Ziedonis & Krejci, 2001).
Additional Resources -- For a detailed review of pharmacotherapies, see Barber, W. S., & O’Brien, C. P. (1999). Pharmacotherapies. In B. S. McCrady and E. E. Epstein (Eds.), Addictions: A comprehensive guidebook. New York: Oxford University Press.
DISEASE ORIENTATION
In the past, drug dependency was viewed as a sin committed only by people with weak moral character. In 1956, the American Medical Association (AMA) published a statement saying, “Alcoholism must be regarded as within the purview of medical practice” (N. S. Miller, 2001, p. 104).
The Council on Mental Health, the AMA’s Committee on Alcoholism, promoted the idea that alcoholism is an illness that requires the participation and attention of physicians. This realization is based on the pioneering work of Jellinek (1960) who observed that alcoholics are more likely to have alcoholic family members.
In these studies, environmental influences cannot be separated from the genetic influences, because alcoholic parents raise alcoholics. Defining addiction as a disease relieves addicts of the overwhelming shame and responsibility for having caused the addiction and its devastating consequences.
At the same time, it empowers the client to take corrective action. Refuting the discouraging idea that addiction is a moral failure allows clients to focus on getting better by accepting the hard truth: Abstinence is their solution.
Just as lung cancer patients are expected to stop smoking and diabetics to avoid sugar, addicts must altogether avoid ingesting alcohol and other psychoactive drugs as part of their recovery.
Additional Resources -- For further information, see Jellinek, E. M. (1960). The disease concept of alcoholism. New Haven, CT: College and University Press; and Miller, N. S. (1991). Drug and alcohol addiction as a disease. In N. S. Miller (Ed.), Comprehensive handbook of drug and alcohol addiction. New York: Marcel Dekker.
DRUG TESTING
Promoting accountability, determining compliance, and measuring success, drug testing is most often used in three settings: among employees whose contracts require them to remain drug-free, in criminal justice applications such as DUI or probationary screenings, and in clinical treatment programs (Coombs & West, 1991; Mieczkowski, 2001).
Two kinds of tests are commonly used: (1) immediate outcome drug tests (e.g., home drug testing kits that test marijuana, cocaine, amphetamines, morphine/ opiates, PCP, alcohol, and nicotine) that provide immediate results and are economical and easy to use, and (2) confirmation tests sent to a lab to determine test accuracy and reliability.
To minimize errors such as contamination, clerical error, improper execution, or cross-reactivity, select a sophisticated laboratory with a proven track record.
Additional Resources -- For detailed information, see Mieczkowski, T. (1990). The accuracy of selfreported drug use: An evaluation and analysis of new data. In R. Weisheit (Ed.), Drugs, crime, and the criminal justice system. Cincinnati, OH: Anderson.
To learn more about these tests visit www.drugdetect.com/index.shtml.
COGNITIVE-BEHAVIORAL TOOLS
Active, directive, time-limited, and structured, these therapeutic modalities assume that clients’ behaviors are largely determined by the ways in which they think.
CONTINGENCY MANAGEMENT
Based in the theoretical underpinning of Skinner’s operant conditioning, Contingency Management (CM) enforces desired behaviors that strengthen recovery. Positive reinforcement means delivering a reward. Negative reinforcement, not to be confused with punishment or a negative outcome, means removing an undesirable restriction or situation.
Positive punishment means delivering an undesirable consequence, whereas negative punishment means removing a desirable one.
In CM, reinforcements are generally considered more effective than punishments. CM gives the recovery more firepower by competing with the rewards of the addict’s drug or behavioral habit. This is especially important for the many users who resent authority figures and regulations (Coombs, 2001).
In designing CM plans, first determine the desired target outcome and criteria for success (e.g., weekly urine test). Incentive programs can use voucher systems where clients can earn points and then select a reward purchased or provided through the treatment practitioner.
The list of incentives should be long enough to please a variety of clients, and its focus should be recreational (e.g., going to a movie). Although CM can be used with goals such as attendance at therapy sessions, Budney, Sigmon, and Higgins (2001) encourage treatment professionals to use this strategy first and foremost to reward clients for staying free from addictive behaviors.
Additional Resources -- Higgins, S. T., Wong, C. J., Badger, G. J., Ogden, D., & Dantona, R. L. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow up. Journal of Consulting and Clinical Psychology, 68, 64–72.
CUE EXPOSURE
Recognizing drug use as a habit, with addicts responding to accustomed cues and contexts by ingesting their substance of choice, Cue Exposure (CE) treatment trains clients to stop responding habitually to their traditional triggers.
Called “extinction,” it is the unconditioning of conditioned triggers and responses (e.g., local bars linked with drinking) by repeatedly exposing a client, in a controlled environment, to these potential triggers. Repeated exposures erase reaction to the cue (Coombs, 2001).
When administering cues, the counselor will need to track clients’ responses, usually by asking them to self-report cravings, negative mood, and physiological responses on a scale of 1 to 10 (Conklin & Tiffany, 2001).
Treatment for a particular cue is ended when a client no longer responds to the cue though an occasional review to ensure continued extinction is helpful. Properly administered, cue exposure treatment can strengthen the client’s resistance to relapse.
Additional Resources -- Bouton, M. E. (2000). A learning-theory perspective on lapse, relapse, and the maintenance of behavior change. Health Psychology, 19, 57–63.
AFFECT-REGULATION -- COPING SKILLS TRAINING
Coping skills training acknowledges that addicts generally use addictive substances or behaviors to regulate their own moods; they self-medicate to avoid uncomfortable feelings (Scott et al., 2001).
This technique focuses on helping clients learn positive coping skills for addressing challenges and the unpleasant emotions they invoke.
The objective of coping skills training is to enhance and develop clients’ internal locus of control. When clients achieve this control, they will possess the requisite skills to take charge of the emotions that influence positive behavioral choices. Clients learn that they can alter their unwanted moods and increase their self-confidence more by taking constructive actions than by using psychoactive drugs (Kern & Lenon, 1994).
Clinicians use the following five-step model: (1) Assessment; (2) Establishing commitment (to stay clean and away from unwanted emotions); (3) Identifying feelings (to learn how to identify emotions); (4) Homework (e.g., daily journaling); and (5) Setting goals that meet client needs and measuring progress (Scott et al., 2001).
Additional Resources -- For a detailed review of this recovery tool, see Scott, R. L., Kern, M. F., & Coombs, R. H. (2001). In R. H. Coombs (Ed.), Addiction recovery tools. Thousand Oaks, CA: Sage.
RECOVERY CONTRACTS
Behavioral contracts reinforce positive behaviors and monitor supportive recovery. Talbott and Crosby (2001) explain, “The chemically dependent patient requires psychological, physiological, and spiritual frameworks to guide him or her through the recovery process. Contracts are an essential part of this external structure” (p. 127).
These contracts provide the client with a detailed road map of the daily actions needed to deal with life stress and to reduce distractions.
An effective recovery contract has seven key components: (1) Presentation of the contract in a serious and compassionate manner, preferably with the significant other and any program representatives in attendance; (2) Releases of information— the patient must sign off on privacy releases for family members, coworkers, and others to be involved in contract reporting; (3) Leverage through clearly understood consequences when expectations are not met (behaviors should be highly specific); (4) Organization of a client’s support system; (5) Statement of short treatment time frame so that the client feels capable of compliance.
Most contracts are designed to cover a 5-year span, but they are renewed annually, biannually, or even quarterly; (6) Contract review, which should take place formally at least every 6 months and informally on an ongoing basis; and (7) A “slip” relapse clause.
Clients should be educated regarding warning signs so they can seek help before they head into a full-blown relapse (Talbott & Crosby, 2001).
Additional Resources -- For a detailed chapter on this topic, see Talbott, G. D., & Crosby, L. R. (2001). Recovery contracts: Seven key elements. In R. H. Coombs (Ed.), Addiction recovery tools: A practice handbook. Thousand Oaks, CA: Sage.
