When skillfully handled by the therapist, the involvement of a concerned significant other
(CSO)  can enhance motivational discrepancy and commitment to change. 

The CSO should be encouraged to participate and be actively engaged in treatment whenever possible.  Emphasis is placed on the need for the client and CSO to work collaboratively on resolving the drug problem.

The MET approach recognizes the importance of the spouse, family member, close friend, or significant other in affecting the client's decision to change his or her drug use.  This emphasis is based upon recent findings from a variety of treatment studies. 

For example, alcoholics seen in an outpatient  setting  were  found  more  likely  to  remain in a spouse-involved treatment than in an individual approach (Zweben et al., 1983).  Similarly, clients maintaining positive ties with family members fared better in a relationship enhancement therapy than in an intervention focused primarily on the psychological functioning of the client (Longabaugh et al., in press). 

Szapocznik and his colleagues (1983, 1986) have shown the efficacy of family therapy as an engagement strategy in the treatment of drug abuse.

Involvement of a CSO in the treatment process offers several advantages.  It provides the SO an opportunity for first-hand understanding of the problem.  It permits the CSO to provide input and feedback in the development and implementation of treatment goals.  The client and CSO can also work collaboratively on issues and problems that might interfere with the attainment of treatment goals.

Goals for Spouse/SO Involvement

The following are general goals for the CSO's involvement in MET:

1. to establish a working rapport among the client or identified patient (IP), the CSO and the counselor

2. to raise the awareness, by the IP and CSO, of the CSO's concerns about the extent and severity of drug problems

3. to strengthen the CSO's commitment to help the client overcome the drug problem

4. to strengthen the CSO's belief in the importance of his or her own contribution in changing the client's drug use patterns

5. to elicit feedback from the CSO that might help motivate the drug user to change.  For example, a spouse might be asked to share his or her concerns about the client's past, present, and future drug use.  Having the spouse "deliver the message" can be valuable in negotiating suitable treatment goals.

6. to promote higher levels of cohesiveness and satisfaction in the relationship between the
IP and CSO.

MET does not include intensive marital/family therapy.  The main principle here is to elicit from client and CSO those aspects of their relationship which are seen as most positive, and to explore how they can work together in overcoming the drug problem.  Both client and SO can be asked to describe the other's strengths and positive attributes. 

Issues raised during SO-involved sessions can be moved toward the adoption of specific change goals.  Do not allow the client and CSO  to spend significant portions of a session complaining, denigrating, or criticizing.  Such communications tend to be destructive, and do not favor an atmosphere that motivates change.

Explaining the Significant Other's Role

Ideally, a client and CSO will come together to the client's first session.  In the beginning of the session, comment favorably on the willingness of both to come for consultation, and the caring that it reflects.  Then explain the CSO's role in treatment sessions.  The major points are that:

1. the CSO cares about the client, and changes will directly impact both their lives

2. the CSO's input will be valuable in setting treatment goals and developing strategies

3. the CSO may be directly helpful to the client by working together to resolve any drug problems

The Significant Other in Phase 1.

In the first conjoint session, an important goal is to establish rapport, to create an environment in which both  the  client and the CSO can feel comfortable about openly sharing concerns and disclosing information that may help promote change.  During the course of Phase 1, ask the CSO about her or his own (past and present) experiences with the client's drug use and problems.

What has it been like for you?
What have you noticed about [client's] drug use? What things have concerned you the most?
What has discouraged you from trying to help in the past? What do you see that is encouraging?

Emphasis should be placed on positive attempts to deal with the problem.  At the same time, negative experiences  -  stress,  family  disorganization, job and employment difficulties, etc. - should be discussed and reframed (where appropriate) as normative; that is, as events which are common in families with drug problems. 

Such a perspective should be communicated in the interview.  The counselor  might  compare  the  CSO's  experiences  to  the  personal stress experienced by families confronted with other chronic mental health or physical disorders such as heart disease, diabetes, and depression (without going into depth about such experiences).

The CSO can often play an important role in helping the client to resolve uncertainties or ambivalence about drug use and change during Phase 1.  The CSO can be asked to elaborate on the risks and costs of continued drug use. 

For example, one CSO revealed during counseling that she was becoming increasingly alienated from her partner as a result of the negative impact that the drug use was having on her children.  These questions, asked of the CSO in the presence of the client, can be helpful in eliciting such concerns:

1. How has the drug use affected you?
2. What is different now, that makes you more concerned about the drug use?
3. What do you think will happen if the drug use continues as it has been?

Feedback provided by the CSO can often be more meaningful to a client than information presented by the counselor. It can help the client mobilize commitment to change (Pearlman et al., 1989).  In sharing information about the potential consequences of the drug problem for family members, a CSO may cause the client to experience emotional conflict (discrepancy) regarding his or her drug use. 

Thus, the client may be confronted with a dilemma in which it is not possible both to continue drug use and to have a happy family.  In this way the decisional balance can be further tipped in favor of changing the drug use. 

One client became more conflicted about his drug use after his wife described the negative impact it was having on their children.  He subsequently decided to quit using drugs, rather than to experience himself as a harmful parent.

At the same time, there is a danger here of overwhelming the client, if the feedback given by the  CSO  is  new,  extremely  negative, or  presented  in  a  hostile manner.  Negative information presented by both the CSO and the counselor may result in the client feeling "ganged up on" in the session, and could result in treatment drop-out. 

The MET approach relies primarily upon instilling intrinsic motivation for change in the client, rather than using external motivators such as pressure from CSOs.

Therefore, when involving the CSO in a session, it may be useful to "go slow" in presenting material to the client.  You may gauge the mood or state of the client by allowing him or her the opportunity to respond to specific items before soliciting further comments from the CSO. 

You may ask whether the client is ready to examine the consequences (i.e., both personal and family concerns) that have followed from drug use.  If the feedback provided seems to be particularly aversive to the client, then it is important to intersperse affirmations of the client.  The CSO can be asked questions to elicit supportive and affirming comments:

1. What are the things you like most about [client] when he/she is not using?

2. What positive signs of change have you noticed, that indicate [client] really wants to make a change?

3. What are the things that give you hope that things can change here for the better? Supportive and affirming statements from the counselor and CSO can further enhance commitment to change.

The client-centered nature of MET can be further emphasized by focusing on the client's responses to what the CSO has offered.  You might ask, for example:

Of these things which your husband has mentioned, which are of the most concern to you? How important do you think it is for you to deal with these concerns that your brother has raised?

CSOs can be asked for their own comments and reactions to the material being presented during feedback from pretreatment assessment:

What do you think about this?  Is this consistent with what you have been thinking about
[client's] drug use?  Is any of this surprising to you?

Such questions may help to  confirm the CSO's own perceptions about the severity of the drug problem as well as clarifying any misunderstandings about the problems being dealt with in treatment sessions.  The same strategies used to evoke client self-motivational statements can be applied with the CSO as well. 

Once an agreement is reached about the seriousness of the problem, the counselor should explore with the SO how he or she might be helpful and supportive in dealing with the problem. 

Remember that MET is not itself a skill-training approach; the primary mechanism here is to elicit ideas from the CSO and client about what could be done.  In raising the awareness of the CSO about the client's drug use and related issues, seek mainly to motivate the CSO to play an active role in dealing with the problem.

The Significant Other in Phase 2

A spouse or other significant person who is attending sessions may be engaged in a helpful way in the commitment process of Phase 2.  A CSO can play a positive role in instigating and sustaining change, particularly in situations where interpersonal commitment is high.  The CSO can be involved in a number of ways:

Eliciting feedback from the CSO.  The CSO might provide further examples of the negative effects  of  the  IP's  drug  use  on  the  family,  such  as  not  showing up for meals, missing family
 
35 celebrations like birthday parties, embarrassing the family by being impaired, alienating children and relatives, etc.  This is an extension of the CSO's role in Phase 1.

Eliciting support.  The CSO can comment favorably on the positive steps undertaken by the client to make a change in drug use, and you should encourage such expression of support.  The CSO may also agree to join with the client in change efforts (e.g., spending time in non-using settings).

Emphasize that ultimate responsibility for change remains with the client, but that the CSO can be very helpful.  It is useful here to explore tentatively, with both the CSO and the client, how the CSO might be supportive in changing drug use.  You might ask the following:

To SO: In what ways do you think you could be helpful to _________?

To SO: What has been helpful to __________ in the past?

To Client: How do you think ________ might be supportive to you now, as you're taking a look at your drug use?

Be careful not to "jump the gun" at this point.  Asking such questions may elicit defensiveness and resistance if the client is not fully ready to consider change.

Eliciting self-motivational statements from the CSO.  This strategy should be employed in the second CSO-involved session, after the client and SO have had a chance to reflect upon the information presented earlier. 

It is possible that the client has become less resistant after he or she has  had  more  time  to  think  about  drug  use  and  related  issues  (see  section  on  Asking  for Commitment). 

If, in the second interview, the client still appears to be hesitant or reluctant about dealing with the drug use and related matters, then an attempt should be made to acknowledge the feelings of frustration and helplessness experienced by the CSO while at the same time allowing him or her the opportunity to examine alternatives in order to handle these frustrations:

I know that you both want to do what's best for the family.  However, there are times when there are differences in what the two of you want.  It can be frustrating when you can't seem to agree about what to do.  (Turning to the spouse). 

In this case, you have a number of options.  You can try to change your [husband/wife's] attitude about drug use - I think you've tried that in the past without much success, right?  Or you could do nothing and just wait. But that still leaves you feeling frustrated or helpless, maybe even hopeless, and that's no good. 

Or you can concentrate your energies on yourself and other members of your family, and focus on developing a lifestyle for yourself that will take you away from the drug use. What do you think about this third option?  What things could you do to keep from being involved in drug use situations yourself, and to develop a more rewarding life away from drugs?

In response to this question, one spouse determined that she would no longer accompany her spouse to the homes of friends who use drugs.  Another went a step further and indicated that he would not be involved in any drug-related activities with his wife.  By eliciting such self-motivational statements and plans from CSOs, it is possible to tip the client's balance further in favor of change (cf. Sisson & Azrin, 1986).

Addressing  the  CSO's expectations.  When goals and strategies for change are being discussed, the CSO is invited to  express his or her own views, and to contribute to generating options.  Any discrepancy between the client and SO with respect to future drug use should be addressed.  Information from the pretreatment assessment may be used here to reach a consensus between client and CSO (e.g., severity of problems, consumption pattern, etc.). 

If agreement cannot be reached, a decision may be delayed, allowing further opportunity to consider the issues (see section on Asking for Commitment).  The objective is to establish goals that are mutually satisfactory.  This can further reinforce commitment to the relationship, as well as the resolution of drug problems.

Handling CSO Disruptiveness

In some cases, CSO involvement could become an obstacle in motivating the client to change, and could even lead to a worsening of the drug problem.  It is important to identify these potentially problematic situations and to deal with them.  The following scenarios are provided to illustrate circumstances where CSO involvement might have a negative impact on MET:

Comments are made by the CSO that appear to exacerbate an already strained relationship and to evoke further resistance from the client.  Your efforts at eliciting verbal support from the CSO are met with resistance.  Your own efforts to elicit self-motivational statements from the client are hindered by CSO remarks that foster client defensiveness.

Comments made by the CSO suggest an indifferent or hostile attitude toward the client.  The CSO demonstrates a lack of concern about whether the client makes a commitment or is attempting to resolve the drug problem.  The involvement of the CSO appears to have little or no beneficial impact to elicit self-motivational statements from the client.  When the client does make self-motivational statements, the CSO offers no support.

The CSO seems unwilling or unable to make changes requested by the client, which might facilitate an improvement in the drug problems or their relationship.  For example, despite strong requests from the client (and perhaps from you) to place a moratorium on negative communication patterns, the CSO continues to harass the client about past drug use.

In these or other ways, involvement of the SO may prove more disruptive than helpful to treatment. The first approach in this case is to use MET procedures (reflection, reframing, etc.) to acknowledge and highlight the problematic interactions. 

If usual MET strategies do not result in a decrease in CSO disruptiveness, intervene directly to stop the pattern.  The following are potentially useful strategies for minimizing CSO interference with the attainment of treatment goals, and are consistent with the general MET approach.  Note that these are departures from the usual procedures for MET spouse involvement, and are implemented for "damage control."

1. Limit the amount of involvement of the CSO in sessions.  You might explicitly limit CSO involvement to (1) providing collateral information about the extent and pattern of drug use, and (2) acquiring knowledge and understanding about the severity of the drug problem and the  type  of treatment  being offered. 

Your interactions with the CSO can be limited to clarifying factual information and ensuring that the CSO has a good understanding of the client's drug problem and the plan for change.  Typical structuring questions of this kind would  be,  "Do  you  understand  what has been presented thus far?"  "Do you have any questions about the material we have discussed so far?"

2. Focus the session(s) on the client.  You can announce that the focus of discussion should be on the client in terms of helping to resolve the concerns that brought him or her to treatment.  Indicate that the drug use needs priority of attention, and that other concerns are best  dealt  with  after  the  client  has competed this phase of treatment.  Then direct the discussion to the client's concerns.

3. Limit the CSO's involvement in decision-making activities.  If CSO participation is problematic, allow the CSO to be a witness to change, without requesting his or her direct involvement  inside  or  outside  of  sessions.   

Avoid  requesting  input  from  the  CSO  in formulating change goals and developing the plan of action.  Do not request or expect CSO affirmation of decisions made by the client with regard to drug use and change.