A Motivational MixtureA number of new substance abuse treatment methods rethink how counselors help clients move to sobriety.
By Carl Vogel
VOLUME 21 | ISSUE 1 | WINTER 2014
The traditional image of treatment for someone with a drinking or drug-use problem is a tough-love counselor who tells addicts the hard-tohear truths about what their behavior has done to their families and their lives. The solution, according to the conventional wisdom, is complete abstinence through a 12-step program, and if and when a relapse occurs, it inevitably ends in a new low.
A number of new therapeutic techniques and approaches for substance abuse treatment are changing how counselors interact with their clients and what the expectations are for the process and sobriety. Traditionally, substance abuse treatment has been grounded in 12-step programs and a confrontational relationship built on the assumption of denial by the client. Motivational interviewing, third-wave cognitive-behavioral therapy, relapse prevention therapy and other approaches emphasize listening, empathy, collaboration and affirmation on the part of the clinician. These approaches are often used in conjunction with each other, heightening the need for a therapist to be capable of integrating different techniques and understanding the theoretical models that underpin the techniques.
A new generation of therapeutic approaches turns these traditional concepts on their head and is changing how many substance abuse counselors work with clients. Although the methods address different aspects of the path to sobriety, they share a framework of listening to and utilizing the clients’ perspective and values. During a course of treatment, many clinicians are combining these techniques, creating a wide new range of tools.
To observe the dynamics between women undergoing substance abuse treatment and their counselors, Associate Professor E. Summerson Carr spent more than three years at a Midwestern center sitting in group therapy sessions, attending program meetings, and interviewing clients and staff. In her book from the research, Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety, Carr describes a confrontational mode of treatment built on the assumption of denial.
“In the mainstream model, the central idea is that the addict suffers from a lack of insight, and the goal of treatment is to help clients to see what the therapist already presumes to know,” says Carr. “The set-up is, in essence, ‘You don’t know yourself, including the fact that you are an addict. We’re going to talk until you see what I know about who you really are.’”
Even before Scripting Addiction was published in 2010, Carr had begun investigating a method that avoids the problems she saw in mainstream American addiction treatment. Called motivational interviewing (MI), the approach radically reworks the long-held presumption that addiction is a disease of denial, and it emphasizes listening, empathy, collaboration and affirmation on the part of the clinician.
“Instead of directly articulating why the client must change, the motivational interviewer works to get the client—him or herself—to make a ‘change statement,’ like, ‘Maybe it is time for me to start thinking about not drinking so much.’ Client language is not seen as a demonstration of how much insight they have on pre-existing problems, but is rather conceived as productive of future behaviors and understandings,” says Carr, who is currently working on a new book on the culture and rise of MI.
Tim Devitt, the director of integrated dual disorders treatment at Thresholds, the largest provider of services for people with mental illnesses in Illinois, and an adjunct faculty member at SSA, says that motivational interviewing is one example of how substance abuse treatment has evolved over the last several decades. “In terms of integrative models of MI—mindfulness, cognitive-behavioral therapy, commitment therapy—they’re all informed by where the client is and what his goals are,” he says. “For all these techniques, it’s important to approach the work in a collaborative way with the client.”
In the early 1980s, Stanley McCracken was a doctoral student at SSA and working part-time with psychiatrist Edward Senay as a counselor at a methadone clinic, where the four or five full-time counselors were all recovering addicts. Now a senior lecturer at SSA and an experienced practitioner of mental health and substance abuse treatment, McCracken says that type of arrangement was common.
“For years, most substance abuse treatment was delivered by people who themselves had recovered from an addiction and used the 12-step method [most commonly associated with Alcoholics Anonymous],” McCracken says. “They focused on breaking through denial and change that came from hitting rock bottom.”
McCracken points out that the 12-step program has worked for many people and that research has shown it to be effective, particularly for people with a serious addiction who are white, middle-age and/or middle-class. “The problem is,” he says, “what do you do for people who don’t respond to that method and where it doesn’t work?”
The answer to that question began to form in 1983, when Carlo DiClemente and J. O. Prochaska published an influential paper on the transtheoretical model of behavior change. The article outlines five stages of change that someone experiencing addiction or chronic use typically moves through in achieving sobriety: from not seeing a problem to struggling with contemplating change to preparing to change to actively living new behaviors to maintaining sobriety.
“Interventions and strategies began to evolve to address where people are in the continuum,” Devitt says. “For example, motivational interviewing helps people explore ambivalence around their situation and their values, and that can help get them to a place where they’re interested in making a change in their life.”
McCracken says that MI can be particularly useful when the client is drinking or using drugs heavily but is still able to maintain a semblance of a normal life, or when he or she is in treatment for legal reasons or because a parent or spouse demanded it, rather than being self-motivated to change. In these instances, MI’s moderated discussion allows the patient not the practitioner to explore how drinking or drug use is impacting his or her life.
Motivational interviewing is built from behavioral and client-centered elements, and Carr says that both are apparent as she’s observed professionals being trained in MI—the focus of her current research. “In MI, there is an idea involved that people tend to act in accordance with what they hear themselves say, though MI advocates increasingly emphasize the importance getting people to express commitment to change as well,” says Carr, who uses the ethnographic approach of an anthropologist in her research. “An ‘interview’ is conceived as an opportunity to articulate different understandings of and values related to a presenting issue like drug use (that is, roughly speaking, its client centered side). But, in the behaviorist mode, the interview is also seen as an opportunity to subtly move the client to articulate an interest and ultimately investment in changing their behavior.”
Research has shown the efficacy of MI (albeit somewhat modestly compared to competing treatments), and the model has become a popular approach to help alter behavior, even beyond the field of substance abuse, including assisting smokers quit tobacco and patients diagnosed with diabetes or hypertension manage their diets. But even though many consider MI an evidence-based practice, part of its success is what William Miller, the founder of motivational interviewing, and its biggest supporters call “the spirit of MI.”
Miller’s writings summarize the spirit of MI as a mix of client/therapist partnership, honoring the client’s thoughts and ideas, and focusing on the client’s own decisions about change. Carr points out, though, that the spirit of MI has also been used to describe the force behind the model’s growth.
“A lot of MI advocates identify themselves as clinical researchers, and they’ve worked hard to establish MI as an evidence-based practice,” says Carr, who has interviewed dozens of MI practitioners, including Miller himself. “But when I ask people why MI ‘works,’ they usually don’t first refer to its scientifically demonstrated efficacy. Rather, they say that it’s the spirit of MI—the way it transforms clients and professionals alike. I’ve heard many MI practitioners say, ‘MI has changed my life as well as my professional work.’ Among the practitioners I’ve studied, the investment is often quite a deep one.”
Cognitive behavioral therapy (CBT), which focuses on helping a client recognize and manage thoughts, memories and emotions that are not constructive, is also used in many different counseling situations, including for drug or alcohol addiction. Over the last 10 years, however, a “third wave” of CBT has become more prevalent in substance abuse treatment, in part because its philosophy matches so well with motivational interviewing and similar approaches.
First used in the 1970s, cognitive behavioral therapy evolved to emphasize helping a client to challenge and revise negative thoughts. For many therapists, this is still the model—provide a client with techniques and support to push away a feeling of anxiety, depression, a desire to drink or take drugs, and other “maladaptive thinking.”
Third-wave cognitive behavioral therapy adds the concept of mindfulness. “The idea is that it’s not what you think and feel that is the problem, it’s how you respond to those things that makes the difference,” explains Nick Turner, A.M. ’09, an adjunct faculty member at SSA and clinical supervisor at Gateway Foundation Alcohol and Drug Treatment, which operates centers throughout Illinois. “The therapist helps a client to become aware of and accept his or her thoughts, emotions and experiences. The person learns to observe emotions and thoughts as they come and go, while living a purposeful life.”
Key to the use of mindfulness in substance abuse therapy is urge surfing. A desire to drink or use drugs isn’t a constant in every minute of the day; it rises and falls. With third-wave CBT, the client is aware, observant and accepting of the urge to use substances, while at the same time is non-reactive. Over time, the ability to surf through the urge gets stronger.
Turner is the co-author of a new book, Mindfulness-Based Sobriety, published in January, that gives substance abuse clinicians a step-by-step guide to using motivational interviewing, acceptance and commitment therapy, and relapse prevention therapy. The book begins with an explanation of the three approaches and how their fundamental ideas work in conjunction, then provides a session-by-session curricula for running both intensive outpatient and residential treatment group sessions.
“In motivational interviewing, a person looks at what’s important to them. Typically, for anyone involved in substance abuse, their use is incongruent with where they want to be in three or five years—they won’t say they want to be broke, jobless, homeless or estranged from their family. We’ve built on that and ask, ‘What might you do to move toward your values and make your life what you want it to be?’” says Phil Welches, the clinical director at Gateway Foundation and Turner’s co-author, with Sandra Conti, for Mindfulness-Based Sobriety.
The Gateway model also uses relapse prevention therapy (RP T) to give clinicians a way to support clients in maintaining their sobriety. The concept was introduced in the 1980s by Alan Marlatt, a psychologist who used qualitative research on alcoholics who had relapsed after successfully completing residential treatment.
Welches notes that for most addicts, maintaining sobriety is even more difficult than achieving it in the first place. Finding a way to support clients to keep sober—and to quickly recognize and respond to any relapse—was the initial genesis for building Gateway’s integrative practice. “Marlatt didn’t make a curriculum, he had a theoretical model. We wanted to add a RPT element to our work, though, and that’s where the book started,” Welches says. “We developed standards and practices for a clinician to use.”
Turner and Welches say that combining the different therapeutic theories and techniques in mindfulness-based sobriety was not difficult because key concepts—respecting the patient’s point of view, open communication, using the patient’s values as a bedrock for sobriety, self-reflection, acceptance—are inherent in or easily adopted into all three methods.
Mindfulness-Based Sobriety is not thefirst or only attempt tomarry the many therapeutictechniques that arechanging substance abusetherapy. Practitionershave built interventionsthat mix motivational interviewing, CBTand a wide array of treatments, includingpsychophysiological feedback, communityreinforcement approach and alcohol behavioralcouples therapy. In fact, a survey ofthe field finds that use of MI in conjunctionwith other interventions has becomemore common than use of MI alone.
This isn’t surprising to experts such as Carr, who says that the spirit of MI includes a willingness to explore and use other techniques. “Being devoted and being dogmatic are two different things,” she says. “The practitioners I spoke with are very open and intellectually curious in finding what works best for the client.”
William Borden, a senior lecturer at SSA whose courses at the School include comparative psychotherapy and social work practice, says that over the past 25 years, practitioners who subscribe to the different foundational schools of thought for substance abuse treatment—psychodynamic, cognitive, behavioral, humanistic—have come to appreciate the strengths of the different approaches. “Clinicians are integrating core methods and techniques from quite different points of view,” he says.
In “Pragmatism as Orienting Perspective in Clinical Social Work,” a paper recently published in the Journal of Social Work Practice, Borden argues that, despite few discussions of integration of different techniques in academic articles on social work, “the pragmatic attitude has been a defining feature of the social work tradition, from the start of the profession, and most clinicians endorse eclecticism as their fundamental approach to practice.”
“If I’m working with a client with an alcohol addiction, I may decide to draw on elements from harm reduction, motivational interviewing, dialectical behavior therapy and Alcoholics Anonymous over the course of the treatment in light of the client’s changing needs, capabilities and circumstances,” Borden says. “As clinicians, we need to always stay attuned, responsive and flexible.”
This type of flexibility is a feature of the new realm of substance abuse therapeutic techniques. For example, Mindfulness-Based Sobriety, which provides specific steps for how to organize each three-hour session of group counseling treatment, is written to elicit mindfulness, reflection and open-ended conversations. “We wanted to be as specific as possible, to provide guidance and ideas to someone who’s new to running a group or to using these concepts in treatment,” Turner says. “But typically the clinician won’t be 100 percent compliant with each step. It’s important that they stay with what is happening in the group.”
Borden emphasizes, however, that clinicians need to be aware of the theoretical underpinnings of the techniques that are being used, a concept he explores in his two recent books, Contemporary Psychodynamic Theory and Practice and Reshaping Theory in Contemporary Social Work. “In my teaching and training, I believe it’s really important to think about the ways theories help us understand what we’re doing,” he says. “For example, in motivational interviewing, one of the core concepts is the ability to ‘roll with resistance’ with the ways a client will challenge change. Well, it’s crucial that a clinician in this situation understand what we mean by resistance and defensive behavior.”
In his SSA classes, Borden has his students start by developing a “home base,” a provisional model, that serves as a center of gravity. Clinical students at SSA have to take courses that cover at least two different foundational schools of thought, choosing between psychodynamic, cognitive- behavioral or family systems practice methods. “One of the distinguishing features of learning clinical practice at SSA is the emphasis on theory that informs a student’s critical thinking skills and analytic capacities,” Borden says.
With more and more students trained in these eclectic new approaches, the field of substance abuse treatment continues to expand. “When I first started talking about motivational interviewing with clinicians, people would say, ‘You’re basically contributing to the problem. People are going to die because of this,’” McCracken says. “That’s not the case anymore. There’s no doubt that there’s movement and recognition by many of the usefulness of these new techniques.”
William Miller, the founder of motivational interviewing, will deliver the 2014 Ruth Knee Lecture on Spirituality and Social Work on Thursday, July 17 at SSA. For details, visit http://ssa.uchicago.edu/ruth-knee-lecture.