Family history

Because risk for substance abuse and dependence is, in part, influenced by genetic factors, a complete family history of relatives on both sides who have experienced substance-related problems or affective disorders, antisocial personality disorder, or attention deficit/hyperactivity disorder can be illuminating.

Predisposition toward substance-related problems does not predict a consequence of a substance abuse disorder, but risk can be an important warning signal and a motivator for clients to choose consciously to be free from addictive substances.

Other psychological problems

Abuse of alcohol and drugs is frequently associated with additional psychological problems, including depression, anxiety disorders, antisocial personality, sexual problems, and social skills deficits (Miller and Rollnick, 1991). Because symptoms of intoxication or withdrawal from some drugs and alcohol can mimic or mask symptoms of some psychological problems, it is important that a client remain abstinent for some time before psychological testing is conducted.

Some psychological disorders respond well to different types of prescription medications, and it should be determined whether your client has a coexisting disorder and can benefit from simultaneous treatment of both disabilities. If you are not trained to assess clients for coexisting psychological disorders, and if your program is not staffed to handle such assessments or treatment, you should refer your clients to appropriate mental health programs or clinicians for assessment.

For more information on assessing clients who have both a substance abuse disorder and an additional psychological problem, see TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994b).

Personalize and Interpret Feedback About Assessment Results

The presentation and discussion of assessment results can be pivotal for enhancing motivation; thus, structure this session thoughtfully and establish rapport before providing your clients with individual scores from the tests and questionnaires that were administered.

First, express appreciation for clients' efforts in providing the information. Ask if there were any difficulties. Inasmuch as answering questions or filling out forms can be revealing in itself, clients may already have a new perception about the role of substances in their lives. You can raise this point by asking, "Sometimes people learn surprising things as they complete an assessment. What were your reactions to the testing?"

Make clear that you may need their help to interpret the findings accurately. Encourage them to ask questions: "I'm going to be giving you a lot of information. Please stop me if you don't understand something or want more explanation. We have plenty of time today or in another session, if need be." You may also want to stress the objectivity of the instruments used and give a bit of background, if appropriate, about how they are standardized and how widely they are used. It is also helpful to provide a written summary so that clients can have a copy.

It is helpful in providing feedback to compare clients' personal scores with normative data or other interpretive information. Clients must understand, for example, that their usual drinking level is above the normal range and that this is predictive of long-term risk for such negative consequences as stroke, liver cirrhosis, breast cancer for women, and all cancers for men (see Figure 4-1).

Both the score and the interpretive explanation are important; neither is interesting or motivational in itself. The realization that, for instance, a high score of 23 on the Alcohol Use Disorders Identification Test (AUDIT) indicates heavy--and problematic--drinking can raise questions for clients about what they previously thought was normal behavior (see Figure 4-2). The AUDIT is reproduced in Appendix B.

Although clients are often already given handouts that contain extensive information, even minimal data should be presented in written form with accompanying explanations. Also, use a motivational style in presenting the information.

Do not pressure clients to accept a diagnosis or offer unsolicited opinions about what a result might mean. Instead, preface explanations with such statements as, "I don't know whether this will concern you, but..." or "I don't know what you will make of this result, but..." Let them form their own conclusions, but help them along by asking, "What do you make of this?" or, "How do you feel about this?"

When soliciting clients' reactions, watch for nonverbal cues such as scowls, frowns, or even tears. Reflect these in statements such as, "I guess this must be difficult for you to accept because it confirms what your wife has been saying" or, "This must be scary" or, "I can see you are having a hard time believing all this" (Miller and Rollnick, 1991).

Finally, summarize the results, including risks and problems that have emerged, clients' reactions, and any self-motivational statements that the feedback has prompted. Then ask clients to add to or correct your summary.

When presented in a motivational style, assessment data alone can move clients toward a new way of thinking about substance use and its consequences. If they still have difficulty accepting assessment results and maintain that consumption levels are not unusual, you can try the "Columbo approach" (see Chapter 3): "I'm confused. When we were talking earlier, there didn't seem to be a problem. But these results suggest there is a problem, and these are usually considered pretty reliable tests. What do you make of this?"

One good example of a format and description of the feedback process can be found in the Personal Feedback Report developed for Project MATCH (Miller et al., 1995c), reproduced in Appendix B. Another is the summary report, Where Does Your Drinking Fit In? (Sobell et al., 1996b) (parts of which are given in Figures 4-1 and 4-2), given to individuals who participate in Guided Self-Change--an assessment and feedback program developed for excessive drinkers who do not view their alcohol consumption as serious enough to warrant formal treatment but do agree to a checkup.

The materials are intended to foster self-change by encouraging drinkers to view their alcohol use from a new perspective (Sobell and Sobell, 1998).

For practitioners working in situations that do not allow an extensive drinking assessment, a free, personalized alcohol feedback program is available for use on the Internet. Three researchers (Drs. Cunningham, Humphries, and Koski-Jannes) have developed a program based on the materials used in the Project MATCH Personal Feedback Report (Miller et al., 1995c) and the Where Does Your Drinking Fit In? report (Sobell et al., 1996b).

This program can be accessed on the Web site of the addiction Research Foundation, a division of the Centre for Addiction and Mental Health in Toronto, Canada: www.arf.org. The respondent fills out a brief, 21-question survey about her drinking and submits the data. A personalized feedback report is returned that compares the respondent's drinking to others of the same age, gender, and country of origin (for people living in the United States or Canada). While brief, the feedback program is a useful tool for practitioners to use.

Providing feedback--on clients' level of alcohol or drug use compared with norms, health hazards associated with their level of use, costs of use at the current level, and similar facts--is sometimes sufficient to move precontemplators through a fairly rapid change process without further need for counseling and guidance.

Feedback provided in a motivational style also enhances commitment to change and improves treatment outcomes. For example, one study in which persons admitted to a residential treatment center received assessment feedback and a motivational interview found these clients to be more involved in treatment, as perceived by clinicians, than a control group and to have twice the normal rate of abstinence at followup (Brown and Miller, 1993).

Intervene Through Significant Others

Considerable research shows that involvement of significant others (SOs) can help move substance users to contemplation of change, entry into treatment, retention and involvement in the therapeutic process, and successful recovery.

An SO can play a vital role in enhancing an individual's commitment to change by addressing a client's substance use in the following ways:

Providing constructive feedback to the client about the costs and benefits associated with his substance use behavior

Encouraging the resolve of the client to change the negative behavior pattern

Identifying the concrete and emotional obstacles to change

Alerting the client to social and individual coping resources that lead to a substance-free lifestyle

Reinforcing the client for using these social and coping resources to change the substance use behavior

Several recognized methods of involving SOs in motivational interventions are discussed in this section: involving them in counseling, in a face-to-face intervention, in family therapy, or as part of a community reinforcement approach.

Involving a Significant Other in the Change Process

I have found that actively involving an SO such as a spouse, relative, or friend in motivational counseling can really help facilitate a client's commitment to change. The SO can provide constructive input while the client is struggling with ambivalence about changing the addictive behavior. Feedback from the SO can help raise the client's awareness of the negative consequences of substance use. At the same time, the SO can provide the requisite support in sustaining the client's commitment to change.

Have you noticed what efforts Jack has made to change his drinking?
What has been most helpful to you in helping Jack deal with the drinking?
What is different now that leads you to feel better about Jack's ability to change?

Significant Others and Motivational Counseling

In general, the SO helps to mobilize the client's inner resources to generate, implement, and sustain actions that subsequently lead to a lifestyle that does not involve substance use. The SO is expected to move the client toward generating her own solutions for change. Nevertheless, it is important to remember that the ultimate responsibility for change lies with the client.

An SO is typically a spouse, live-in partner, or other family member but can be any person who has maintained a close personal relationship with the client. Although a strong relationship is necessary, it is not sufficient for involving an SO in motivational counseling. Evidence indicates that a suitable candidate for SO-involved treatment is an individual who supports a client's substance-free life and whose support is highly valued by the client (Longabaugh et al., 1993).

Orient the client to SO-involved treatment

Ask a client about inviting an SO to a treatment session. Inform him that an SO can play a crucial role in addressing his substance use by providing emotional support, identifying problems that might interfere with treatment goals, and participating in activities that do not involve substances, such as attending church together.

Explain that the SO is not asked to monitor the client's substance use since the ultimate responsibility for change is the client's. The SO's role is entirely supportive, and the decisions and choices belong entirely to the client. Review confidentiality issues and tell the client that information shared between the partners should not be discussed with others outside of the sessions unless agreed on by both parties. Some settings may require a written statement giving permission for the SO to participate.

Create a comfortable, supportive, and optimistic treatment environment

In the initial SO-involved session, compliment the SO and client for their willingness to work collaboratively and constructively on changing the client's substance use pattern. Reiterate the rationale for asking the SO to participate and explain the roles and responsibilities of each of the partners, reminding them that the client is ultimately responsible for changing.

Also, it is essential to instill a sense of optimism in the SO about her own ability to effect change in the client. Often, SOs enter treatment feeling frustrated or disappointed; many do not understand the chronicity of the problem or the phases of recurrence and recovery, leading to increased frustration. As a result, the SO may feel helpless about her ability to influence the change process.

To strengthen the SO's belief about her capacity to help, you can use the following strategies:

Positively connote the steps used by the SO which have been successful, and define successful generously.

Reinforce positive comments made by the SO about the client's current change efforts.

Discuss future ways in which the client might benefit the SO's efforts to facilitate change.

The overall goal at this point is to empower the SO in helping the client change.

Provide constructive feedback

In motivational counseling sessions, a positive movement toward change often occurs after the SO has had an opportunity to point out that continuing a current pattern of substance use could potentially interfere with sustaining a highly valued relationship. A client is particularly susceptible to an SO's input because it can potentially lead to loss of or harm to important relationships.

Explain to the client that the benefits of substance use cannot be obtained without increasing the social costs. The benefits might include enhancing pleasurable activities or coping resources; the costs entail loss of or harm to highly valued relationships. Consequently, the client may feel a state of disequilibrium over his continued substance use.

To reduce the dissonance, the client must make a decision about stopping his substance use. In this context, the SO's feedback becomes a major vehicle for activating the change process.

For this reason, ask the SO to be more involved in the counseling; for example, by sharing relevant information about precipitants and consequences of the client's substance use problem and working collaboratively with the client to find strategies for change. Such information must be communicated in a constructive manner.

This is accomplished by focusing the discussion on the consequences or harm resulting from the drinking or drug use (e.g., family disruption) rather than on the client herself (e.g., "She is a bad person because of her drinking"). The feedback from the SO can cause a shift in the client's decisional balance.

Maintain a therapeutic alliance

Special efforts should be made to strengthen ties between the SO and client, especially if the SO is a spouse. Having strong family ties is considered an active ingredient in sustaining a client's commitment to change (Zweben, 1991).

Explore with the couple various activities that can contribute to improving the quality of the marital relationship, such as vacationing and dining out without the children. For some SOs, carrying out these tasks might become a cause of concern, especially if the client has a history of disrupting the household while using substances.

The SO may be afraid that the client will once again destabilize the family situation if he is given major responsibilities in the home. (Such a concern may be realistic if the client has had an unstable pattern of recovery.) The counselor must acknowledge these concerns, normalize them, and develop an incremental plan for handling these new arrangements.

A step-by-step approach should be introduced, including a procedure for handling recurrence if it occurs. This may prevent family members from feeling overwhelmed by the magnitude of the tasks involved in reintegrating the client into the household.

Problematic SOs

Despite proper screening, some SOs demonstrate little or no commitment to change. These SOs repeatedly miss treatment sessions, cancel appointments without rebooking, arrive late, and in general, display a negative attitude toward the client. Some interact negatively with the client, offering few constructive remarks without excessive prompting by the counselor. Others refuse to participate in substance-free activities.

It is important to deal with these SOs before they pose serious problems in treatment.

In such circumstances, consider the following:

Gently remind the SO about the purposes of SO-involved treatment--namely, to offer emotional support, to provide constructive feedback, to reinforce incentives for change, and in general, to work collaboratively with the client to change the substance using behavior.

Some SOs may be unaware of the anxiety they are feeling about the client's ability and willingness to change, which in turn could account for the negative feelings being expressed to the client. In such circumstances, address these underlying concerns of the SO. Using such techniques as reflective listening, normalizing, clarifying, and summarizing, you can help the SO explore the underlying reasons for her negative reactions to the client.

This strategy gives the SO an opportunity to vent her anxieties about the client. Otherwise the SO may continue to respond negatively (i.e., "act out" the anxiety) to the client in the sessions. These issues are usually addressed in an individual session with the SO.
If the above approaches do not work, consider limiting the SO's role to mainly information sharing. Inform the SO only about the proposed treatment plan for the client, such as attending self-help groups, taking medications, and completing specific tasks such as finding new employment.

These matters could be covered in a single session with the option of adding another appointment if warranted. No attempt is made to involve the SO in reinforcing or decisionmaking activities related to changing the substance use behavior.

For SOs requiring or requesting additional help, a referral to individual counseling or a community support group such as Al-Anon may be in order. This can help the SO distance herself from the client's problems and prevent her from undermining the therapeutic process.

Research support

Studies of brief motivational counseling have suggested that SO participation (mainly the spouse's) can be an important factor contributing to the effectiveness of the intervention (Longabaugh et al., 1993; Sisson and Azrin, 1986; Zweben et al., 1988). Beginning with the work of Edwards, SO-involved brief motivational counseling has been found to be just as effective or more effective than more extensive conventional treatment approaches across a number of outcome measures, such as drinking and related problems (Edwards et al., 1977; Holder et al., 1991; Zweben and Barrett, 1993).

All the studies were conducted with individuals having alcohol-related problems. Nonetheless, given the favorable outcomes found in the above studies and positive experiences reported by practitioners who have used the model with clients using other substances, consideration should be given to adding an SO-involved component to motivational counseling approaches with individuals having a variety of substance abuse problems. This can help augment the potency of the intervention with certain clients, namely those individuals who have strong positive ties with their families.

However, the relative contributions of different components of brief motivational counseling (such as therapist empathy, feedback and advice, and bibliotherapy) to enhancing client motivation have not yet been determined (Zweben and Fleming, in press); it may be that such factors as therapist empathy could play a more salient role than SO involvement in effecting motivational change. Future research will have to further explore the relative contribution of the SO involvement component compared to the other treatment components (e.g., therapist empathy) in facilitating change.

The Johnson Intervention

Since its introduction in the 1960s, the approach developed by the Johnson Institute has been modified from a confrontational technique to a much less harsh strategy with numerous permutations (Stanton, 1997). The Johnson Intervention is a well-known technique in which family members and others from the user's social network, after considerable formal training and rehearsal, confront the substance user in a clinician's presence.

They take turns telling the user how substance use has affected them, urge the user to seek help, and specify what consequences will occur if change--usually treatment entry--does not happen. An element of surprise is usually part of the plan.

The basic assumptions outlined by the originator of this method are as follows (Johnson, 1973):

Meaningful, influential persons present the user with facts or personal information.

The data presented must be specific and descriptive of actual events or conditions, not opinions.

The tone of the confrontation should not be judgmental but reflect concern.

The evidence presented should be tied directly to drinking or other substance use and given in some detail.

The goal is that the substance user will see and accept enough facts to acknowledge the need for help.

The user should be offered appropriate and available choices of treatment so that dignity is retained and decisionmaking capabilities are respected.

Although the approach was originally applied to referrals for inpatient care (e.g., 28-day, Minnesota model programs), it has subsequently been used by outpatient facilities. However, it has not been extensively evaluated, and the little research reflects a small number of participants.

A recent study of people seeking help from a treatment center found that those who had experienced a Johnson Intervention were more likely to enter treatment than were those who were there as a result of coercion (e.g., by judge, employer, public assistance) or voluntary referral (Loneck et al., 1996a, 1996b).

A major problem, however, is that as many as 75 percent of families who begin counseling for a Johnson Intervention find it unacceptable or, for other reasons, fail to go through with the family confrontation meeting (Liepman et al., 1989). Families who complete a confrontation thus represent a minority, and it is among these families that 80 percent or more of drinkers enter treatment.

It also has been reported that those who enter treatment after a Johnson Intervention are more likely to have a recurrence of drinking and symptoms, relative to those entering treatment through other referral sources (Loneck et al., 1996b).

Unilateral Family Therapy

In unilateral family therapy (UFT), a counselor helps a cooperative, nonusing spouse identify and capitalize on opportunities to encourage the substance-using partner to change. This approach assumes the user's spouse is "a vital and potentially crucial point of leverage who may be the main or only rehabilitative influence accessible to the therapist" (Thomas and Ager, 1993). Different forms of unilateral family therapy are currently being used by clinicians, as described below.

The Thomas and Ager Approach to UFT

This approach includes descriptions of three foci of intervention for UFT for alcohol use disorders:

An individual focus increases the coping skills of the nonusing spouse and helps him find specific ways to address the drinking problem.

An interactive focus helps the spouse improve marital and family functioning by reducing both ineffective tactics of interaction with the substance-using partner (such as nagging or pouring out liquor) and enabling behaviors (such as buying alcohol).

A third-party focus entails preparing the spouse and other family members to conduct interventions that may motivate the person who drinks to seek treatment, stop drinking, or both (Thomas and Ager, 1993).

As practiced by Thomas and associates, UFT has three phases. The first phase, requiring three to eight weekly sessions, prepares the spouse to assume a role in rehabilitation. The spouse is educated on the effects of alcohol; monitors the extent and timing of the partner's drinking; learns how to enhance the marital relationship by trying out reinforcing, enjoyable behaviors when the person is not drinking; eliminates or modifies old and ineffective drinking control behaviors; and reduces enabling behaviors.

The second phase, lasting 5 to 18 weeks, involves assessing the suitability and feasibility of different types of user-directed interventions that are tailored to the special characteristics of the resistant drinker, then conducting either nonconfrontational interventions (e.g., sobriety support or examination by a physician for alcohol abuse) or more systematic, well-rehearsed confrontations or requests in the presence of the clinician.

The interventions are marked by their firm and compassionate tone. Followup interventions can occur if the drinker does not follow through on her commitment.

The third phase, which entails three to six weekly sessions, focuses on maintaining spouse and partner gains. The nondrinking spouse receives help in adjusting to the partner's sobriety--or reduced drinking--and learns to play a positive and appropriate role in deterring renewed or increased drinking (Thomas and Ager, 1993).

Two studies of this approach to UFT indicate that the coping skills of participating spouses were improved, as indicated by reductions in associated life distress and psychopathology; the marital relationship was enriched, as indicated by measures of spousal happiness and adjustment; and the drinking persons who had mediating spouses also entered treatment and moderated drinking or became abstinent more frequently than did members of the control groups (Thomas and Ager, 1993).

Orford's Approach to UFT

The World Health Organization has used Orford's work to guide clinicians responding to the needs and pleas of family and friends of alcohol and drug users. This approach stresses that family and friends are at risk for stress-related physical and psychological disorders (Orford, 1994).

To understand how to empower them to deal effectively with their situation, as well as to help them bring the substance user into treatment, Orford studied coping strategies commonly used by families, each of which has advantages and disadvantages.

The eight common strategies he identified are as follows:

Emotional reactions express emotion about use.

Tolerant strategies support use.

Inactive efforts neither support nor discourage use.

Avoidance techniques put distance between oneself and the user.

Controlling approaches attempt to control use directly.

Confronting tactics communicate openly about one's own needs and the effects of use.

Supporting strategies help the person who drinks or takes drugs achieve alternative goals such as family involvement.

Independent reactions show a lack of dependence on the drinker or drug user.

Orford concluded that "some of the ways in which relatives cope are better than others for reducing the risks of ill health for themselves" and for "influencing drinking or drug use" by the loved one (Orford, 1994, p. 428). Which strategies work best depends on a relative's circumstances. Orford believes the clinician's most important role is to help relatives find effective ways of coping that reduce the risk to their own health and help reduce the substance-using person's excessive use. To do this, clinicians should

Listen nonjudgmentally and provide reassurance.
Provide useful information.
Counsel nondirectively about ways of coping.
Help strengthen social support and joint problem solving in the family.

Community Reinforcement Approach

The Community Reinforcement Approach (CRA) is a comprehensive therapeutic system originally developed in the 1960s to address a broad spectrum of areas affected by alcohol use, including unemployment, marital problems, social isolation, poorly developed social networks, and a lack of positive recreational activities (Hunt and Azrin, 1973).

See also the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Abuse (CSAT, in press [a]). The CRA seeks to reduce or stop drinking by working through legitimate employment, family support, and social activities.

In this behavioral treatment program, the clinician teaches a nondrinking family member--usually the spouse--the following skills:

Reduce physical abuse by recognizing signs of possible violence and taking self-protective action.

Encourage sobriety by reinforcing periods of sobriety through rewarding behavior and by allowing the drinker to experience negative consequences of drinking--as long as they are not life-threatening. The clinician counsels the family member on how to behave when drinking is occurring and provides suggestions about appealing outside activities that do not involve alcohol.

Encourage the drinker to seek treatment by identifying the best times to suggest seeking professional help (e.g., after occasions when the alcohol use was especially severe and the individual is keenly aware of the negative consequences of drinking). When the person who drinks agrees to come in, the clinician is available to meet with the marital couple immediately.
Assist in treatment by participating with the drinker in couples counseling and helping him find work and discover alcohol-free activities. The drinker also receives a medical exam and disulfiram (Antabuse).

In a study of its effectiveness, this CRA required an average of 7.2 sessions compared with 3.5 for a more traditional program in which the clinician provided a spouse with supportive counseling and a referral to local Al-Anon self-help groups.

Although requiring a greater time commitment, the CRA approach resulted in six of seven drinking persons entering treatment, whereas none entered treatment in the traditional approach (Sisson and Azrin, 1986). See Chapter 7 for discussion on the use of CRA during the maintenance stage.

Community Reinforcement Approach to Family Training

CRA has been modified by enhancing its proven features (Meyers and Smith, 1997). Referred to as the Community Reinforcement Approach to Family Training (CRAFT), this approach contends that a concerned SO can have an impact on a loved one's drinking or drug use and can influence that person to enter treatment, if appropriate. See also the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Abuse (CSAT, in press [a]).

Using this approach, the clinician's tasks are to

Encourage the SO to express frustration about the loved one's substance use and also assure the participant that the responsibility for the situation lies with the person who drinks or takes drugs.

Work with the SO to identify the triggers for and consequences of the loved one's substance use and analyze these for ways in which the SO can modify coping responses.

Identify positive reinforcers the SO can use when the user is sober or working toward change and negative consequences of substance use that the SO may have unknowingly supported.

Teach the SO to recognize the potential for domestic violence in response to behavioral changes in the home and to take appropriate precautions that reduce the risk of harm.

Train the SO in seven communication rules that have been found effective for interacting with persons who misuse alcohol and drugs:
Be brief
Be positive
Be specific and clear
Label your feelings
Offer an understanding statement once an issue has been viewed from the drinker's perspective
Accept partial responsibility, when appropriate
Offer to help

Encourage the SO to find meaningful and rewarding activities that reduce stress and build a better quality of life regardless of whether the substance-using person changes.

Coach the SO on nonthreatening ways to approach the loved one and suggest treatment through role-playing, rehearsing the language and voice tone to provide the best chance of success, and developing a "road map" of the best times to talk with the substance-using person.

Make certain that treatment is available when a decision is made to begin treatment and also help the SO to support the client in treatment.

A clinical trial of CRAFT found this approach to be substantially more effective than either Al-Anon or the Johnson Intervention for engaging unmotivated problem drinkers and drug users in treatment (Miller and Meyers, in press).

The combination of behavioral skills enhancement, well-chosen moments for bringing up the topic of change, techniques that the SO can use for positively reinforcing appropriate behavior by the drinking or drug-using loved one, and rapid intake into counseling are promising ways of moving precontemplators toward serious contemplation of change (Meyers and Smith, 1997).

Albany-Rochester Interventional Sequence for Engagement

The Albany-Rochester Interventional Sequence for Engagement (ARISE) was developed at a large outpatient treatment facility in Albany, New York. Following this approach, the clinician intervenes through family members with persons who abuse either drugs or alcohol, using a slower, less distressing way of introducing change rather than confrontation.

The developers of this strategy were responding to three limitations of similar, currently available techniques: the expenditure of considerable time and effort in preparing for and rehearsing encounters with the substance-using person; the ultimatums in full-blown, traditional interventions that frighten some family members away; and a recent study in which clients who participated in formal interventions were twice as likely as those who did not to return to drinking or drug use while in treatment (Stanton, 1997).

The ARISE process unfolds through three stages:

Stage 1: Informal intervention without a therapist present. When a concerned person calls the clinic, an intervention specialist talks to her by telephone to determine the family configuration and to identify who should be involved. The clinician sets up a time to meet with all concerned persons, making clear that the substance user should also be invited.

Stage 2: Informal intervention with a therapist present. In one to three sessions, as needed, the clinician works with the family to determine how best to urge the substance user to engage in treatment. Usually, the clinician suggests they telephone this person from the meeting.

Stage 3: Formal intervention. If neither Stage 1 nor

Stage 2 results in the substance user entering treatment, the clinician uses an intervention derived from the Johnson Institute model but less negative and more gentle than the original model.

This intervention also incorporates attention to intergenerational patterns of alcohol problems.

In a retrospective analysis, 55 percent of drug users who participated in some phase of ARISE entered treatment, as did 70 percent of those with drinking problems. The success rates for other small studies of ARISE ranged from 25 to 92 percent. Tentative conclusions are that the strategy works best when the clinician is readily available to catch the identified substance user at the right moment for enrolling in treatment and when a large number of persons are assembled for an intervention (Stanton, 1997).

Motivational Enhancement and Coerced Clients: Special Considerations

An increasing number of clients are mandated to begin treatment by an employer or employee assistance program. Others are influenced to enter treatment because of legal pressures. In such cases, failure to enter and remain in treatment may result in specified sanctions or negative consequences (e.g., job loss, probation or parole revocation, prosecution, prison), often for a specified time or until satisfactory completion.

Although generalizations are difficult to make from a number of separate studies, legal status at treatment entry does not seem to be related to treatment success (Anglin et al., 1992; CSAT, 1995b; Leukefeld and Tims, 1988). Mandated clients generally respond as well as those who are self-referred.

Your challenge is to engage coerced clients in the treatment process. As noted by Leukefeld and Tims, external pressures (e.g., legal) serve to influence an individual into treatment, but motivation and commitment to change must come from within the client (internal pressure) in order to effect and maintain recovery (Leukefeld and Tims, 1988).

Although many of these clients are at the precontemplation stage of change, the temptation is to use action-oriented interventions immediately that are not synchronized with the client's motivation level. As already noted, this can be counterproductive. Clients arrive with strong emotions as a result of the referral process and the consequences they will face if they do not succeed in changing a pattern of use they may not believe is problematic. As always, remember that their perceptions may be accurate. It may be true that they rarely drink excessively but did so on a particular occasion that led to the referral.

In spite of these obstacles, coerced clients are at least as amenable to a motivational counseling style as any other. If you provide interventions appropriate to their stage, they may become invested in the change process and benefit from the opportunity to consider the consequences of use and the possibility of change, although that opportunity was not voluntarily chosen.

You may have to spend your first session with a coerced client "decontaminating" the referral process. Some clinicians say explicitly, "I'm sorry you came through the door this way." Important principles to keep in mind are as follows:

Honor the client's anger and sense of dehumanization.
Avoid assumptions about the type of treatment needed.
Make it clear that you will help the client derive what the client perceives is needed and useful out of your time together.

TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (CSAT, 1994e), offers suggestions for engaging offender clients as full participants in their treatment and recovery.

A critical requirement in working with coerced clients is establishing what information will be shared with the referring agency. This must be formalized with both clients and the agency through a written consent for release of information that adheres to Federal confidentiality regulations. Clients must be informed about and agree to exactly what information (e.g., attendance, urine test results, treatment participation) will be released. Be sure they understand what choices they have about the information to be released and what choices are not yours or theirs to make (e.g., information related to child abuse or neglect).

It is wise to take into account the role of the client's defense attorney (if any) in releasing information. Finally, clearly delineate different levels of permission.

Other publications in the TIP series provide more specific guidance regarding legal and ethical issues affecting coerced clients and how to handle confidentiality issues. See Chapter 8 of TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System(CSAT, 1995b); Chapter 5 of TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases(CSAT, 1994d); TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (CSAT, 1994e); and TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community(CSAT, 1998b).

An Opening Dialog With a Coerced Client

This dialog illustrates the first meeting between a counselor and a client who is required to attend group therapy as a condition of parole.

The clinician is seeking ways to affirm the client, to find incentives that matter to the client, to support the client in achieving his most important personal goals, and to help the client regain control by choosing to engage in treatment with a more open mind.
 
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From SAMHSA/CSAT  Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Chapter 4 From Precontemplation to Contemplation: Building Readiness