Introduction
Motivation is the Goal of Therapy, not the Prerequisite
Motivation is not something our patients either have or do not have. It exists along a continuum, from a little to a lot, and it changes over time, going up and going down. More importantly, motivation can be affected by factors outside the individual. That is, motivation is something that we can help our patients develop. If we choose to accept the challenge, motivation can become the desired outcome of therapy, rather than the necessary prerequisite. The saying, “the patient has to really want to change” is true. But for too long, this has meant that we wait until patients figure it out for themselves – often until they hit “rock bottom” – before engaging them in treatment. By doing so, we condemn our patients to further suffering. We also deprive ourselves of one of the most rewarding of psychotherapeutic experiences – helping someone realize that they want to change.
Point of View: Whose Motivation is it Anyway?
This is the essence of motivational interviewing. How often do we think of our patients, “if only they would see how damaging X or Y is to their life, if only they could know how much better life could be, then they would want to change”? Yet no matter how much we tell them, they simply do not see things from our point of view. Motivational interviewing is about seeing things from the patient’s point of view. This does not mean simply validating their suffering and supporting their blindness to the problem. Rather, we help them to see how damaging their behaviors are from their own perspective. We help them to see how much better life could be, in terms of their own values. By engaging the patient in an exploration of who they are and who they want to be, the patient finds motivation within him or herself.
Capacity, Responsibility and Freedom: “Being With”
The foundation of motivational interviewing is respect for patients as individuals who have the capacity to make decisions for themselves. Moreover, they have the responsibility to make decisions for themselves. This therapeutic stance can be incredibly freeing for the physician – perhaps like most of us – who wants deeply for the patient to get better, and so feels frustration when the patient does not take advice. This frustration is one of the reasons physicians do not like to care for patients with substance dependence. (It is also the reason physicians do not like to care for patients who are not compliant with their medications.) If we truly believe that the patient, and the patient alone, has both the capacity and the responsibility for making change, we take the burden off ourselves. In doing so, we free ourselves to engage with patients, and help them discover why they want to make change for themselves.
This stance is essential. Motivational interviewing is both a set of techniques as well a style, or a “way” of “being with” a patient. To the extent that you can integrate this spirit into your daily practice, you will have gone a long way toward helping your patients change their behavior. Whether it is substance abuse or suboptimal medication compliance, overeating or under-exercising, this stance will serve you well.
More than just “Being With”: Being Effective
Of course, some specific techniques will help you too. Although the therapeutic stance is one of “being with,” the technique is focused and directive. The therapist’s goal in the session is to maximize the amount of time the patient spends talking about things that will increase their likelihood of attempting and maintaining change.
The purpose of this manual is to provide you a basic tool-kit of practical approaches to working with patients who have substance dependence. It is intended to give you some new ways of thinking about interacting with these patients, and get you started on your way to being more effective in your work with them. I hope that with these tools, you will find working with patients on their substance dependence more interesting, enjoyable and rewarding.
How to Use this Manual
Books on psychotherapy tend to be long. As a resident in training, time to read tends to be short. This manual was made with the busy resident in mind. To read this manual in its entirety should take you between 60 and 90 minutes.
The best time in your residency to read this manual is when you are working with patients with substance abuse problems. In most general psychiatric populations, this will be all the time. So anytime in your training is a good time to read this manual.
In Chapter One, I present basic techniques for working with patients’ motivation for change, even when they appear to have little or no motivation at all. If you are doing inpatient work, on the acute ward, consult service, or emergency/on-call, I suggest you focus on this first chapter. It will give you a repertoire of skills you can practice “on the fly” even with patients you may see only once or over a few days.
In Chapter Two, I present strategies for strengthening the ability of patients who have already decided to change to do so. These are generally grouped under the heading “relapse prevention.” This chapter will be useful while you are caring for patients who have relapsed on drugs or alcohol – another common scenario on inpatient and emergency consultation settings.
In Chapter Three, I present an outline, session by session, of how a targeted course of therapy might be structured over four sessions. This will be helpful with patients for whom you can schedule regular meetings, for example in your general clinic or as part of a substance abuse treatment program. It may also be used with patients undergoing longer hospital stays. Read the chapter once through before embarking on a course of therapy. Then you may refer to the relevant section quickly before each session with a patient, to remind yourself of central tasks on which to focus.
Chapter One: Motivational Interviewing
The Motivational-Interviewing Style
|
Key Points
|
Empathic listening
Because motivational interviewing (MI) is grounded in respect for the patient, an MI approach involves listening rather than telling. It seeks to understand the patient’s point of view, and their own motivations for change. Particularly, it is important to elicit and validate the patient’s experience of suffering. As in all psychotherapies, a positive therapeutic alliance is requisite. The technique of reflective listening communicates an acceptance of patients as they are. At the same time a commitment to changing the conditions that lead to suffering is developed, and support is communicated for the process of change. Any persuasion is gentle, subtle, and non-aggressive.
Affirming the patient
A fundamental positive regard is communicated for the patient through each interaction. Shame and inadequacy are common among substance-dependent persons. MI seeks to communicate a hope and optimism in the patient’s ability to make change.
Avoiding argumentation
Because the method of MI relies on getting patients themselves to want to change, the worst strategy is one that causes the patient to become defensive. Therefore, confronting patients with all the reasons they should change is avoided. In fact, when a patient begins to argue, it may be a sign that the therapist has gone astray. To maximize effectiveness, the arguments for change must come from the patient.
Communicating free choice
The therapist continually communicates through his or her careful choice of words and tone, that the patient has both the responsibility and the freedom to choose. Communications that imply the physician “knows what is best” for the patient are not helpful. The stance is that of a supportive, equal and knowledgeable consultant. Physician recommendations, when given, are given cautiously, and always with the caveat that ultimately the patient must decide for themselves.
Eliciting Motivation
|
Key Points
|
Helping people talk about change
Motivational interviewing gets its name because the therapist seeks to elicit motivation from the patient. The idea is that people come to believe what comes out of their own mouth, “As I hear myself talk, I learn what I believe” (Miller, 1995). In other words, if we can get patients to talk about possible reasons for changing, they are more likely to hear themselves, and to believe what they are saying.
The best way to elicit self-motivational statements is to ask the patient for them directly, using open-ended questions:
I assume, from the fact that you are here, that you have some concerns
or problems related to your alcohol/drug use. Tell me about those.
What concerns do you have about your alcohol/drug use?
What sorts of troubles has your drinking/drug use caused?
What’s making you think you might want to make a change in your
drinking/drug use?
Once the interview has started, keep the process rolling by asking “What else?” or “Could you give me an example?”
For the patient who appears more resistant, or who is coming in under pressure from the legal system or a significant other:
Tell me what you've noticed about your
alcohol/drug use. How has it changed over time?
What things have you noticed that concern
you, that you think could be problems, or might become problems?
What have other people told you about your
alcohol/drug use? What are other people worried about?
This last question is useful for patients who respond as if they have no concern themselves. If you are lucky enough to have a significant other present, it can be useful to ask them these types of questions as well.
If the technique above is not fruitful, or if the interview stalls out, you may try inquiring in a more directed manner about problems in specific areas. Many of these are obvious, but the alphabetical mnemonic below can help prompt you (Adapted from Miller, 1995):
Amount and tolerance - How
has the amount of your use changed over time? Do you seem to need larger doses
of drugs to experience the same effect as before, or to tolerate large doses
without showing much effect? What do you make of this?
Behavior - Has drug
use caused you any trouble with the law? Any neglect of responsibilities?
Inconveniences like having to move? Financial problems? Embarrassing behavior?
Coping - Do you use
drugs to cope with problems and stresses? How well does it work in reducing
(versus escaping) problems? Do you find it ever creates new ones?
Dependence - What
happens to you if you have to go without drugs? How difficult is it for
you? What do you think about the drugs
when you don’t have them?
Emotions - How does
your drug use affect your emotions? Do you find yourself feeling more anxious,
guilty, upset, depressed or paranoid because of drug use?
Family - What effects
does drug use have on your family?
Feeling Good (Self-Esteem) - How does using drugs affect how you feel about yourself? Do you ever
feel ashamed, guilty, out of control?
Health - Has using drugs resulted in any health problems? Injuries? Dental problems? Weight gain or loss? Poor eating habits? Giving up exercise?
Important Relationships - How does drug use affect your relationships with loved ones and
friends? Co-workers? Your boss?
Job - Work and School - How
does drug use affect your school/work?
Key People - What do
your friends/family think about your drug use?
Loving Relationships and Sexuality - How does drug use affect your physical attractiveness, sexual drive,
sexual relationships? How about safe sex practices?
Mental Abilities - How
has drug use affected your memory, ability to focus/concentrate, ability to
think clearly?
Homing-in on the main motivator
Patients coming for treatment will generally present multiple reasons for seeking treatment. Almost always, however, there is a single, very specific event that has led them to finally seek help. It may be loss of a job, an ultimatum from a spouse, a legal problem, or having presented to an important family event intoxicated. Often, patients will be embarrassed or ashamed of what has finally brought them to treatment. They will tend to be vague and speak in generalities. It is important to spend a good deal of time and energy here, probing gently for specifics. A supportive and empathic approach is critical. Shame is a common feeling that is often very useful in motivating patients. However, it is important that the patient not feel shamed by the therapist. The idea is to use the power of a positive regard for the patient so that they can bear their own shame, and use this in the service of making change.
Internal vs. external motivation
Quite commonly, patients are nudged into treatment because of external forces: an ultimatum from their spouse or a court order. These are important and useful, particularly in getting a patient into treatment. External motivators are not always sufficient to keep the patient in treatment or to maintain change. This is often true in situations where conflict with a significant other has brought the patient to treatment. As soon as the conflict subsides, so does the patient’s motivation. If the relationship ends, so goes the patient’s motivation for treatment. Whenever possible with such patients, it is important to try to elicit internal motivation early on, and throughout the treatment process.
So I understand that your wife thinks it’s important that you change,
but I’m wondering do you have any concerns about your drinking?
So it sounds to me as if you are here because you’re other option is
prison, which is fine. I’m very glad that you’re here, and many of our patients
come here for exactly that reason. Now, from your point of view, what are some
of the problems you have noticed with your drug use over the years, besides
problems with the law?
Positive vs. negative motivation
So far we have focused on “negative motivators.” These are bad things that happen as a consequence of using substances that patients would like to avoid. Asking patients about positive motivators can be just as important. Positive motivators are good things that can be expected to happen as a result of not using substances. Patients with substance dependence, reflecting on the ruin of their lives, often have little hope for the future. Helping to identify the things they have to look forward to is important.
What do you think would improve in your life if you could give up
drugs?
Can you think of any good things that might come of staying sober?
Tell me about your dream life. What would your life look like if all
goes well, you are successful in treatment and recovery, and you are still
sober a year from now? Where would you be living? Would you be working? What
kind of job? How about your finances? What would your relationships with your
family be like? What kind of social life would you have? How about your
romantic life? How do you imagine you would you spend your free time?
This last line of questioning often provides ample opportunity for the patient to reflect on how many areas of their lives might be improved by making change.
Working with Ambivalence
|
Key Points
|
The good, the bad, and the ambivalent
In motivational interviewing, ambivalence is not a bad thing. On the contrary, ambivalence is a defining feature of the change process. It can be expected to be present through much of it, as illustrated in the Stages of Change Model in Figure One. Our goal is to acknowledge the patient’s ambivalence, explain that it is normal. We then seek to explore all the reasons for using substances and for not using substances, in the service of helping them to move forward along the change process.
We start by asking questions to identify and enhance existing motivation to change. Next, it is important to explore their motivation for not changing – that is, for continuing to use. In motivational interviewing, all patients are assumed to be ambivalent. To oversimplify a bit, if patients were not ambivalent, it wouldn’t be so hard for them to change. The reality is that patients have powerful reasons for continuing their current behavior. Here are some of the most common ones:
- Feels good
- Improves mood
- Escape problems
- Reduce stress
- Creates social life
- Enjoy sex and intimacy
- Relieves boredom
The patient before us is choosing to use a substance because it does something good for them. And presumably, if they are seeking treatment, they are considering the idea that it might have some negative consequences as well. This is the essential dilemma of the patient who ends up in our office: they want to change and at the same time they do not want to change.
The actual technique of exploring ambivalence is straightforward. Simply asking the question directly is the best place to start.
Tell me a little about your drug use. What
do you like most about the drugs you use? What's positive about these drugs for
you? And what's the other side? What are your worries about using drugs?
So what are some of the good things about
alcohol?
What does alcohol do for you?
What does it help with in your life?
What are some of the things you like about
drinking?
What would be the downsides to giving up alcohol?
What do you think would be hard about giving up alcohol?
What are some of the things you would miss?
What problems can you see that might come up if you stopped drinking?
Decisional balancing
By enumerating all the advantages and disadvantages of changing and not changing, we make the ambivalence explicit. This process is called “decisional balancing.” It can be helpful to do this in a two-column format, on a piece of paper or a marking board, which allows both sides of the “Decision to Change” to be displayed side-by-side. A sample is provided in Figure Two. Sometimes I draw a scale, with a fulcrum in the middle, to represent this process. I explain to patients that they are likely to change their behavior if they feel the positives of change outweigh the negatives of continued use. This keeps me out of the position of arguing one side or the other. The patient needs to argue BOTH sides.
We provide the patient a way to see all the information before them at the same time. In doing so, we take what is typically a behavior that is done out of habit, impulsiveness, and/or factors of which the patient is not aware, and make it possible for them to exercise conscious choice, through a careful consideration of the pros and cons, as seen from their own perspective.
Decisional balancing is a powerful technique. First, it communicates respect and can strengthen therapeutic alliance by acknowledging the patient’s reasons for using substances. Second, it creates tension and emotional arousal, and mobilizes energy for change. Third, it provides a cognitive structure through which the patient can process conflicting information. Fourth, it is useful for understanding forces driving and maintaining the behavior, and allows anticipation of strategies needed to change.
The patient who has no ambivalence
Many eager patients come into treatment with an air of having “seen the light.” They say things like “I’ll never use again.” When you inquire about the good things about alcohol, they say “What do you mean? There’s nothing good about alcohol.” Beware of this patient who appears to have no ambivalence. By avoiding a conversation about pros and cons, they avoid the difficulty (tension, emotional arousal) of having to consider the problem fully. Their motivation appears high, but it may be superficial rather than strong. They may be less likely to engage in the difficult work of recovery. By inviting even the apparently motivated patient to consider carefully their reasons for substance use as well as change, we can help strengthen their motivation for change.
Therapist: So what are some of the good things about drinking?
Patient: Good things? There aren’t any. It’s poison and it’s killing
me.
T: Really? You’ve been drinking a long time, and you seem like an
intelligent person. Surely there must
be some reasons that you continue to do it, some benefit that you get, at least
in the short-term.
P: Well, it takes away the stress of the day.
T: Yes. Anything else?
P: It gives me something to do. Hang out with other drunks.
T: So it helps you avoid boredom, and gives you some social contact.
And it helps you cope with stress.
P: Yeah, that’s right.
Providing Information
|
Key Points
|
Some people are under the mistaken impression that motivational interviewing means that all you do is ask questions and reflect back what the patient says to you. While it is true that motivational interviewing does involve more asking than telling, providing needed information is an essential part of the process.
A patient may present to treatment for health reasons, for example after a friend develops end stage liver disease. The patient is a new grandparent, and does not want to die prematurely of liver failure. This patient is likely to ask questions to fill in important gaps in their knowledge, such as “How do I know if my liver is already damaged?” and “If I stop drinking now, can I stop the process?” If a patient asks such questions of fact, provide the information requested. Be as factual as you can. Avoid ominous predictions; these may be perceived as confrontational and evoke resistance.
Given what you know about a patient’s motivation, you may notice obvious information deficits that you feel are important to address, even though the patient does not ask. Suppose the patient above seems to know about alcohol’s adverse effect on the liver only. This would suggest the need for further information. Ask permission. Again, we avoid resistance at all costs.
It’s clear that you love your family and want to be around for your
grandchildren. Since you are concerned about your health, would it be okay if I
told you about some of the other harmful effects of alcohol?
In each case, after you provide information, ask for the patient’s response. In doing so, you are seeking to elicit more self-motivational statements.
Developing Discrepancy
|
Key Points
|
A powerful motivational technique begins with clarifying how the patient sees him or herself – a loving parent, a good spouse, a hard worker, a reliable friend. Once we understand what it is that the patient values, we can check to see how this fits with the reality of their behavior.
Patient: My wife doesn’t like it when I drink. She says I’m not myself
when I’m drinking. And she says I’m a lousy example for the kids.
Therapist: Sounds like it’s important to you to be a good father to
your children.
P: Totally. I want to do for them what my father didn’t do for me.
T: So it’s clear that you love your children very much. You want to
spend time with them and be a good father to them, but there are times that you
find yourself drinking beer for much of the weekend. Is that right?
P: Yes, that’s right. It’s really not what I want at all.
The first step is picking up on values held by the patient. If the value is stated negatively, try to reframe it in a positive value. By restating the value, we are also checking to make sure we are accurate in our assessment. The second step is reflecting the patient’s actual behaviors in order to develop discrepancy between how the patient wants to be and how they actually are. Developing discrepancy is one of the most powerful ways of developing motivation that is internal. A tone of positive regard for the patient’s intentions here is critical.
Even with positive regard, emotional discomfort is normal, even essential. The emotional arousal generated when patients confront the discrepancy between their self-image and their actual behavior is central to the mechanism by which this technique works. Patients become upset by the discrepancy, and thereby are motivated to seek change. The reflection of the discrepancy to the patient must be done gently and specifically. Avoid additional judgment. Stay close to the patient’s own stated values and behaviors, checking for accuracy, and avoiding undue amplification. Above all, keep explicit your positive regard for the patient. In many cases, it will be this positive regard that will allow them to face the painful realization that they are not who they would like to be…. And that they would like to change.
The Poorly Motivated Patient
|
Key Points
|
If a patient does not think it is important to change (i.e., is not sufficiently motivated), it will be fruitless to move on to skills for behavior change and relapse prevention. There are patients who may end up in intensive treatment, for a variety of reasons, with limited motivation to change. They may be destitute, mandated for legal reasons, or coerced by family members. The focus of treatment with such patients must be intensive motivational interviewing. This point is seemingly obvious, but often ignored, particularly in intensive treatment settings where patients are presumed to be sufficiently motivated by their simple presence in the program.
Readiness to Change
|
Key Points
|
Assessing self-efficacy
Motivation is necessary for change, but it is not sufficient. A person must believe that they have the capacity to change a particular behavior. This is called self-efficacy. A simple formula expresses this idea:
motivation + self-efficacy = readiness to change
One easy way to assess readiness to change is to ask patient’s to rate their motivation and self-efficacy:
On a scale from zero to ten…
How important is it for you to change? (motivation)
How much confidence do you have that you could change if you decided
to? (self-efficacy)
You may then ask, for each:
What would it take to move you up on the scale, closer to 10?”
This information will provide clues on where to focus therapeutic attention. Using scales periodically in therapy, you can track the patient’s position in the change process.
Note that patients will not always openly express low self-efficacy. Moreover, signs of low self-efficacy are not always obvious. They may actually appear as resistance or narcissistic defenses. Such defenses are a predictable response to low self-efficacy. If one has little hope that things can change, there is little reason to face the problem.
Increasing self-efficacy
We begin supporting self-efficacy from the beginning, through our style, which communicates unconditional positive regard for the patient. Specifically, we liberally share our optimism that the patient has the ability to make change if they desire.
When self-efficacy seems low, we work hard to make the task of change manageable. Steps toward change should be broken down into small pieces. Exercises between sessions should be tailored to the patient’s level of functioning, so that they are achievable and provide serial experiences of mastery.
When self-efficacy is very low, we might ask the patient directly. Often times there are cognitions here that need to be challenged.
Therapist: What part of making this change seems most impossible?
Patient: I just don’t think
I’ll be able to stay sober for that long.
The patient here is looking into the future, expanding the task beyond what they are being asked to do. This patient might be encouraged to hear that they need to stay sober only for today.
P: I’ll just relapse again. I’ve never been sober.
This patient is predicting and expanding. There may be evidence for prior relapse, but there is almost always evidence for some prior periods of sobriety:
T: Would it be okay if we examined that statement a bit more closely?
P: Sure. It’s just that I’ve always relapsed. Every time I get sober, I
just mess up.
T: So you’ve had many relapses before, I understand…. I’m concerned
that when you say “I’ve never been sober,” you might be looking at only part of
the picture. What if we were to add up all your sober periods, ever since you
first started trying to get sober?
P: I had nine months in 2002. And then a few months here, a few months
there. It probably makes about a year and a half.
T: So one and a half years in the last 4 years or so. Is that right?
P: Yeah, I just wish it would stick.
T: So you have been successful in getting it to stick for significant
periods of time. Sounds like about 1/3rd of the last four years. How did you do
it?
The therapist would then proceed to explore strategies that have been successful, and seek to activate a sense of self-efficacy. Some brief education here -- that relapses are common and provide opportunities for further learning (more on this in Chapter 2) – can be used to re-orient the patient’s goals. The idea is to shift the patient’s perspective away from the all-or-none thinking which is not conducive to change.
T: I hear you saying you really would like to be sober for the rest of
your life. But you know, most of the patients I see do have relapses. Can I
tell you a little about what happens to them?
P: Sure.
T: Well, if they stay in treatment, they get to learn from each
relapse. What I’ve found is that over time, people who stay in treatment end up
staying sober for longer and longer… which is really the goal of therapy, to
maximize the amount of time you spend sober. If it’s forever, that’s great, and
that’s definitely what I would recommend we shoot for. But if you could be
sober for most of the rest of your life, how would you feel about that?
P: Well that would be an improvement over being the drunk I am these
days.
Low self-esteem, and anxiety in social situations are often expressed in the following way:
P: I can’t talk to people without being high.
This is an untested assumption that is open to testing, if the patient is willing. There is also likely an underlying belief about how they are perceived by others in social settings.
T: I’m sure there’s some truth to that statement, but would you be open
to looking at that a bit more closely?
P: Okay.
T: So what happens to you when you are in social situations when you
are not high?
P: I just feel nervous and like, I’m not fitting in. I don’t know, just
wound-up. Not good. Sometimes I think people don’t even want me around. But
when I’m high, everything’s better. I laugh, and talk more, and tell jokes. I
can even talk to girls.
T: Do you talk at all when you are not high?
P: Yeah, I guess. Just not that much. I feel like a dork.
T: So then, the statement “I can’t talk to people without being high”
is not completely accurate? Would you be willing to try to make it more
accurate?
P: Sure. What do you mean?
T: Well, instead of saying “I can’t talk to people without being high,”
what would be more accurate? Try
starting with “When I am not high…”
P: When I am not high…It’s hard for me to talk, because I feel like
people don’t like me.
T: Does that sound right to you?
P: Yes, that’s right.
This would be a starting point for engaging the patient in behavioral experiments such as engaging in small talk after 12-step meetings. Collecting real data about the responses of others allows the patient to test the underlying belief that they are not likable.
Note that with thought-challenging interventions such as these, it is important to obtain the patient’s permission. Unlike a patient entering cognitive behavioral therapy for treatment of depression, the patient with substance-dependence has not “signed-up for” having their thoughts challenged in this manner. We need to get consent, so as to avoid raising resistance.
Exploring past hardships and achievements is another technique that can activate feelings of self-efficacy from the past, as well as provide strengths to build upon in the therapy:
What’s the hardest thing you’ve ever had to go through?
What aspects of your personality got you through?
Chapter Two: Relapse Prevention
The Cognitive-Behavioral Model of Relapse
|
Key Points
|
Once a patient has decided to change undesired behaviors, the next challenge is even greater: to maintain that change. Many substance-dependent persons find it relatively easy to stop using temporarily, but maintaining abstinence for longer periods of time is more difficult.
Relapses are the norm rather than the exception, especially within the first 90 days of abstinence. A “lapse” (or “slip”) is a brief return to substance use after a person has made a commitment to abstinence. A relapse implies full-scale return to use of the substance, with associated problem behaviors.
In a cognitive-behavioral model of therapy, lapses and near-lapses are considered opportunities for further learning, and invited into the therapy as “grist for the mill.” An important message to patients is that lapses are common, and that a major goal in treatment is to learn from whatever setbacks occur in their goals to achieve abstinence for the long-term. Each setback is thus seen as a key ingredient for further abstinence.
The goals of relapse prevention are:
1. To reduce the risk of lapses.
2. To reduce the likelihood that brief lapses will become full-scale
relapses.
The cognitive-behavioral model of relapse is presented in schematic form in Figure Three.
Chain Analysis of Events Leading to Relapse
|
Key Points
|
The starting point for relapse-prevention therapy is a detailed exploration of the chain of events that have led the patient to relapse in the past. It is critical to be VERY SPECIFIC in detailing the chain of events. Patients may be resistant to doing this work for many reasons. It takes determination and skill on the part of the therapist to press for the thoroughness and detail required. Avoid working in the abstract; help the patient analyze in detail a specific situation in which they went back to using drugs. Focusing on the most recent relapse experience makes this easier. You may choose to use the diagram of the cognitive-behavioral model with your patients to help specify the chain of events that lead to relapse for them.
Identifying High Risk Situations
|
Key Points
|
Teaching patients how to identify the circumstances that increase the risk of relapse is the foundation of effective cognitive therapy for relapse prevention. It is an essential skill for all patients. High-risk situations are highly individual. They may be external (people, places, events, or things) or internal (feeling states such as anger, loneliness, depression, boredom). For one patient it may be the jobsite, if the workplace is one in which drinking takes place. For another it may be unemployment. For many being alone is a high-risk situation; for some, socializing in group settings also poses risk. For some it may be hearing a particular kind of music that brings back memories of using substances. For others, it may be particular activities, such as playing or watching sports. Even seemingly positive interests can have associations with substance use for the individual. For example, I recently met a patient who is an artist. It was his custom to use stimulants and alcohol while painting. Now, in early recovery, sketching brings up positive memories of being high and urges to use. This otherwise healthy hobby represents a high-risk situation for this patient.
External high-risk situations are identified most easily by asking the patient to inventory all the people, places, and events around which they use the substance. Internal high-risk situations can be elicited by asking directly: “Do you find yourself more likely to use if you are feeling a certain way? Sad? Angry? Lonely?” Often, however, the patients are relatively unaware of emotional states. In these cases, a careful, guided analysis of the circumstances preceding a recent relapse can help the patient to identify internal high-risk situations.
Another way of identifying high-risk situations is to ask the patient to keep a daily record of cravings when they occur, noting the time, place, situation, and feeling state. The intensity of cravings may also be noted.
All through treatment, increasing awareness to high-risk situations is to be encouraged. Patients, particularly eager patients in early treatment, may be tempted to believe they can avoid all high risk situations. This misperception should be corrected. High-risk situations are a fact of life; it is impossible to avoid them all of the time. They need to be identified and watched for continually.
Skills then need to be developed to deal with high-risk situations when they arise. There is a wide array of such skills. Many will be important for all patients. Others will be relevant only to some patients. Based on the chain analysis, you will determine where to focus the patient’s attention to get the most “bang” for your therapeutic “buck.” The skills can be broken down into intra-personal skills and inter-personal skills.
Intrapersonal Skills
|
Key Points
|
Coping with anger
Distraction techniques, deep breathing, time-outs, counting to ten (or one-hundred!), or taking a walk are all simple and important strategies to teach patients for whom anger is a high risk situation. These all provide a “delay” period, aiming to reduce the chance the person will act impulsively and relapse. They also give time for the patient to think through options. Calling a trusted friend or sponsor to share angry feelings may be a useful skill to develop. Finally, problem solving skills, and developing ways to resolve recurring conflicts can be important.
Coping with negative thoughts
Standard CBT techniques of thought-stopping, thought-challenging, and positive self-talk are useful here.
Problem-solving skills
Stress resulting from life-problems constitutes a high risk situation for patients with substance dependence. The patient’s ability to solve problems is often limited, which goes hand-in-hand with a history of maladaptive coping through substance use. Thus, the relapse prevention phase of therapy often involves helping patients develop basic problem solving skills. This would entail teaching patients how to think through a problem, generate options, gather needed information, evaluate options, make a plan, and carry out the plan. This work is similar to that of supportive psychotherapy, with a clear emphasis on building skills to solve problems and reduce risk of relapse.
Building pleasant activities
People with substance dependence have come to a place in which the substance has supplanted many normal life activities. Social skills and the ability to entertain oneself may be underdeveloped. When they stop using, most patients will experience a sudden void in their lives. In addition to having extra time on their hands, the void may be accompanied by feelings of emptiness, loneliness, anxiety, or boredom; in other words, a high risk situation. Helping patients to develop or rediscover activities which occupy their time and bring them pleasure and satisfaction is an important part of relapse prevention.
Coping with urges and cravings
Some of the most important skills to teach are simple delay tactics. Cravings, like all feelings, come and go. Most patients know this from experience; having patients keep a daily log of their cravings will bring the point home. The simple intervention of helping patients appreciate that cravings are transient can be an important first step in gaining control over previously automatic behaviors.
Any distracting technique that the patient finds easy to use, like those described for coping with anger, can be useful in managing cravings. Practicing skills such as leaving the situation, or seeking support from others can be useful too.
“Surfing the urge” is a mindfulness-based technique in which the patient learns to observe the cravings, developing the skill of witnessing their comings and goings. The urge is found to behave like a wave, rising, coming to a crest, and then falling off suddenly. In therapy, patients are taught to note the quality and intensity of the urge, and associated bodily sensations. When observed in this fashion, urges usually take from 5 to 20 minutes, from beginning to cresting.
While craving, patients are apt to overestimate the positive effects of using, and underestimate the negative. “Reminder” techniques -- in which the patient can review their motivations for quitting when cravings arise -- are useful. For example, you may help a patient make a card, which lists these motivations, to be carried in their wallet and referred to when needed. Another option is to list perceived positive effects on one side, and then the negative effects which outweigh each positive effect on the reverse side.
Planning for emergencies
It is inevitable that patients will end up in high risk situations in which they become overwhelmed or the above skills are ineffective. You should work with your patients to develop a specific plan for such emergencies. It should include the signs to activate the plan (e.g., finding oneself taking steps to obtain the substance; overt pressure from friends to use), as well as specific steps the patient will take. Usually emergency plans will include people to call, such as a sponsor or other sober support, health care provider, or a crisis hotline. It may specify going to an Alano club or other sober meeting place. It may include reading specific positive affirmations, or a safe activity that is reliably calming for the patient. Almost always it should involve the patient contacting someone in some way, and not being alone. Because the plan will be activated in a high-stress situation, it should be reviewed and rehearsed in therapy. It should also be written down, and carried in a wallet or pocketbook.
Dealing with relapse
From a cognitive model, an initial lapse often becomes a full-blown relapse as a result of underlying all-or-none thinking.
I’ve blown my whole sobriety; I’ve lost everything!
I’m right back to zero. It’s always the same.
I’ve failed. I can’t do this recovery thing.
This type of thinking justifies and gives permission for full-blown relapse. A preferable response would be to continue without interruption in treatment and conduct a careful review of the circumstances that led to the lapse, strengthening skills for abstinence in the future.
Relapse is a special category of emergency. As described above, there should be a specific written plan of who to call and what to do. This should be reviewed in therapy and carried on the person.
Patients may prefer not to face the possibility of relapse, saying “That’s not going to happen to me. It’s just not an option.” The reality that many (and depending on the population, sometimes most) patients do relapse should be shared with the patient. By sharing the rationale for planning ahead, as described above, you may engage the patient in this important part of relapse prevention.
Interpersonal Skills
|
Key Points
|
The skill of saying no
The ability to refuse an offer of drugs or alcohol may be the single most important interpersonal skill in relapse prevention. The skill should be practiced through role plays in therapy, imagining a variety of different situations. Through role plays, it should be demonstrated that vague or apologetic answers leave the door open for more insistent offers. Here are two common examples:
Therapist: Hey Bob, how about a beer?
Patient: Sorry, not tonight. I’m not feeling well.
Therapist: Oh, come on, it’ll do you good. Don’t make me drink alone.
Therapist: Hey Bob, I’ve got some really good weed. Looking for some?
Patient: No, I don’t have any money.
Therapist: That’s alright. I’ll give you a sample on credit. I know
you’re good for it.
The statement should be clear and assertive. Most important is that the statement begin with the word “No.” For example:
No thank you. I don’t drink.
No, I’ve given up using, thanks.
Expanding social support
Loneliness is a negative feeling that may activate thoughts about using and lead to relapse. Substances are often used in social settings which temporarily provide patients with company to relieve loneliness. In these two ways, the development of a substance-free social support network can be expected to reduce the chance of relapse. Twelve-step and other recovery programs are an obvious starting place. Friends and family who do not use substances are another. Reestablishing contact with friends and family can be difficult for patients, when there is shame or fear of rejection. Support and facilitation of social connections are important not only to combat loneliness and boredom, but also to provide an environment supportive of abstinence and relationships that will inspire continued abstinence.
Social skills training
Patients seeking treatment for substance dependence as a rule suffer from feelings of shame or inadequacy. They may have tendencies toward social isolation.
The may also have poorly developed social skills, for which they are used to compensating by using substances. Training in basic social skills is often needed to facilitate the development of a social support network. This may include things as basic as how to strike up a conversation and how to make plans to socialize as well as cognitive and behavioral techniques for coping with social anxiety and avoidant behaviors.
Relationship problems
Nearly half of relapses are related to interpersonal conflict. Teaching patients skills to handle difficult situations, especially with significant others, can be a key element in relapse prevention. Communication skills, being assertive without being aggressive or defensive, using “I statements”, and knowing when to take some distance, are all important basic skills to work on. Patients may be referred for specific couples counseling as well.
Handling criticism
For many patients, negative feedback from others results in anger, which can trigger relapse. These patients may benefit from learning how to receive feedback about behaviors, how to avoid personalizing feedback, and how to evaluate feedback, taking what is useful and discarding the rest. Similarly, giving feedback to others can also cause problems. Feedback, poorly given, is likely to provoke negative responses from others, and then anger in the patient in return. Teaching how to give feedback (the feedback sandwich, describing behaviors rather than attributing blame, using “I statements”, etc) is useful.
Dealing with Trauma and Grief
|
Key Points
|
Many of our patients come to treatment bearing tragic childhood histories of physical and sexual abuse, abandonment and neglect. Others have significant grief over loved ones lost. Difficult feelings about these events are often part of the patient’s understanding of why they use substances. Patients feel an urgency to “deal with” these issues, yet we know that activating strong negative emotions creates a high risk for relapse. We may be tempted to redirect our patient, and tell them “it is better not to get into that now.” A more helpful way to approach this issue would be to acknowledge the negative feelings, and validate that it is, indeed, essential to deal with them in treatment. We can then proceed to explore how such negative feelings lead to relapse, and then help the patient develop practical skills for dealing with these feelings.
Dealing with Somatic Complaints
|
Key Points
|
Many patients in early abstinence will have an increase in symptoms of physical discomfort. Back pain, neck pain, and insomnia are some of the most common. These symptoms can make more difficult the already hard work of recovery. Appropriate responses to such complaints include physical therapy and exercise, sleep hygiene, non-narcotic analgesics, education, reassurance, and specific diagnostic work-up if indicated.
Many of these problems will be chronic, recurrent, and/or slow to resolve to treatment. Paying too much attention to these issues can take the focus off of recovery. At the same time, ignoring the complaints can damage therapeutic alliance and usually just does not work. Telling the patient to “grin and bear it” or “tough it out” can be similarly invalidating and ineffective.
One way of handling this dilemma is, paradoxically, to focus attention on the physical complaint, and to use it therapeutically. A central problem for most people with substance dependence is a deficit in the ability to tolerate discomfort. Drugs and alcohol work to take away discomfort, such that other coping skills are atrophied or undeveloped. Developing coping skills for tolerating discomfort is thus key to maintaining abstinence over time. By explaining this to patients, you can turn discomfort into an opportunity for developing new coping skills. Experiencing physical pain, insomnia, and other discomfort without returning to substance use are thus reframed as progress. You can actually talk about the physical complaint in the therapy, as you elicit from the patient what they do or could do to cope with the discomfort. The idea is that such coping skills are generalizable to other forms of discomfort. This idea should be shared explicitly with the patient.
Being Flexible and Creative
|
Key Points
|
Keep in mind that the techniques described above are general suggestions. Relapse-prevention therapy, like motivational interviewing, is focused and directive. We keep the attention on identifying the factors that increase risk of relapse, and developing skills to reduce that risk. Within these parameters, however, it is important to be flexible and creative. The choice of interventions must be tailored to the individual patient. The shape of each intervention, also, will depend on the high risk situations, thoughts and behaviors of the individual patient. No two persons with substance dependence are alike. Just as your patients develop new skills, you too will develop new skills as you practice doing this work.
Chapter Three: A Sample Course of
Therapy
Below I present an outline, session by session, of how a course of therapy might be structured over 4 sessions of about 45 minutes each. This is a guide, a menu of the basic elements of a course of therapy that will be relevant for all patients. The techniques are grouped in an order that will make sense for most patients. It is not intended to be used in cookbook fashion or as a structured manual. It is “the bare essentials.”
If you find the patient is poorly motivated, you will spend more sessions on motivational interviewing and less on relapse prevention. If a patient has skills deficits in areas that put them at high risk for relapse, such as relationship conflict, you would be sure to address those skills, in addition to the basic content areas below.
Every session should begin with a brief review of patient motivation, since this is the driving force for change. It is also a dynamic entity, subject to fluctuations over time. Motivation needs ongoing monitoring and reinforcement.
Beginning with Session 2, every session should review the list of identified high risk situations, and seek to identify new ones to add to the list. Written exercises between sessions can be given.
Session One: Building Motivation
|
Key Techniques Elicit Motivational Statements Pros and Cons Exercise Develop Discrepancy Assess Information Gaps Assess Readiness to Change |
Overall, the first session should establish the general tone of the work. Remember the key components of the MI style: Empathic Listening, Affirming the Patient, Avoiding Argumentation, and Communicating Free Choice.
But do not forget that MI is direct and active. After welcoming the patient and commending them for coming, start out by asking what concerns the patient has about their use of alcohol or drugs. Elicit as many issues as possible. Invite the patient to offer specific examples whenever possible. Ask for “Anything else?” when things seem to be stalling out.
The Pros and Cons Exercise should be a staple of the first session. Doing the Pros and Cons exercise together, on a piece of paper or white board, is a good way of showing the patient that they have both the responsibility and the freedom to choose to change.
See also if you can develop an understanding of what is important to the patient, and begin to develop discrepancy between what they value and how they actually behave. Note any areas where the patient could benefit from more information. Ask permission to provide some information in that area the next session (then do your homework to prepare!). Ask the patient to rate how important it is for them to change, how confident they are in their ability to make change, and what would it take to move these higher?
Before the end of the first session, a schedule of meetings should be agreed upon.
|
Suggested Home Exercise:
Ask patient to list Pros and Cons for Changing and Not Changing. If
this was started in session, ask patient to elaborate further, with more Pros
and Cons, or with specific examples. |
Session Two: Identifying High Risk Situations
|
Key Techniques Identify internal high risk situations Identify external high risk situations Cognitive-Behavioral model of relapse prevention |
First, motivation should be briefly reviewed and summarized. Information gaps identified in the first session can be addressed. To avoid argumentation, it is important to ask the patient’s permission.
Last time you told me you were worried about the effects of alcohol on
your liver. Would it be okay if I shared some information with you on the other
effects of alcohol on the body?
Share this information in as matter-of-fact way as possible. Sometimes reading aloud from a medical text or website, with an air of curiosity, can be useful. Be sure to ask for the patient’s response to the information provided, in your attempt to elicit more self-motivational statements.
The concept of the high risk situation, or “trigger” should be introduced (I prefer the phrase high risk situation, because it is easier to talk about varying levels of risk, and hence reducing risk). You may choose to introduce the Cognitive Model of Relapse diagram to frame the discussion at this point. Ask the patient to think of high risk situations. Be sure to cover both internal (feeling states) and external (people, places, things, events). Invite the patient to begin a list. Emphasize that this is a “work in progress,” the goal being to identify as many high risk situations as possible. Indeed for many who are successful in maintaining abstinence, it is a life’s work.
|
Suggested Home Exercise: Create or expand list of
high risk situations. The patient should keep an eye out for these as they go
through each day. A reasonable goal would be to identify at least one new
high risk situation and add it to the list each day. |
Session Three: Preventing Relapse
|
Key Techniques Skills to manage urges/cravings How to Say No Build Social Support |
Begin with a brief review of motivation.
So, John, remind me again - Why are you interested in giving up cocaine
at this point?
Then review the list of high risk situations.
Let me see if I got that… office parties, holidays, football, your
brother’s place, downtown. Anger at your girlfriend. Feeling criticized by your
parents. Boredom. Wow. That’s a lot of them. Seems like potential triggers are
just about everywhere.
Reemphasize that it is a good sign for this list to be growing. Ask specifically about any high risk situations that occurred since the last session. Enquire into what happened, and how they dealt with it.
Introduce the subject of urges or cravings to use. Many patients, especially those who are highly motivated, will deny they have urges to use. Emphasize that these urges are normal, and moreover, being able to identify them when they occur is vital for success. You may refer to the Cognitive-Behavioral Model of Relapse Prevention here. Point out how urges and cravings are a predictable consequence of high risk situations. Ask the patient what strategies they can come up with to deal with these urges. Identify delaying and distracting techniques. Emphasize the time-limited nature of urges. Introduce the idea of “surfing the urge.” Ask the patient to create a Reminder Card that they can keep in their wallet, to refer to when they get the urge to use.
Ask the patient to role play a situation in which they are likely to be offered substances. If they give vague or avoidant responses, be persistent, making further offers. The patient should gain practice in asserting him or herself in a way that is likely be effective in social situations.
Ask the patient about the development of their social support network. It is not enough to simply ascertain that they are going to 12-step meetings. Enquire into how they are enjoying them. Are they making connections with others? What are the barriers to establishing new relationships? (You may need to do a “Pros and Cons Exercise” on making new relationships here.) Be prepared to problem-solve and teach simple social skills. Also enquire into relationships with friends and family who do not have substance problems. These can be very important, but watch for relationships that are highly emotionally-charged, and also for relationships in which people drink or use substances in a “casual” way. Both of these constitute high risk situations that need to be approached with careful thought.
|
Suggested Home Exercise:
Ask the patient to take a specific step toward expanding social
support. For example “Go to that new 12-step meeting.” “Introduce myself to
someone at tomorrow’s meeting.” “Call that person who gave me their number at
last meeting.” This should be specific. Asking the patient to write it down
can be helpful. Ask the patient in the session to anticipate things that
might prevent them from completing the exercise. |
Session Four: Maintaining Abstinence
|
Key Techniques Emergency Plan Dealing with Relapse Pleasant activities |
First, review motivation and high risk situations. Review high risk situations experienced since the last session. Go over progress in expanding social support; do brief trouble-shooting. Ask your patient to come up with an emergency plan: a list of several specific things they commit to doing in case they are about to lapse or have lapsed. Remember, the emergency plan is not simply a list of coping strategies (e.g., doing deep breathing exercises, taking a walk, listening to music, or reading the AA Big Book). It is a plan to be used in an EMERGENCY. Therefore it should involve calling for HELP. Specifically, it should enlist the help of others in preventing a lapse from becoming a relapse. The plan should be written on a card and carried with the patient. All phone numbers should be written directly on the card. An emergency plan might look like this:
|
If I drink
or use (or if I am in imminent danger of doing so), I will: 1. Call my
sponsor and ask to meet. 723-6554 2. Call my
doctor and leave a message. 564-8700 3. Call Joe
and Mary ask to stay with them for a night. 567-9080 4. Go to
Alano Club and tell John what’s going on. 5. Go to a
meeting today. |
Creating this kind of plan with a patient communicates that a lapse is not equivalent to absolute failure, and more importantly, it is not a reason to relapse entirely.
If there is time, you might touch on a few pleasant activities that the patient will now build (or re-build) into their life. “Now that you’ve given up drugs, you’re going to have a lot of time on your hands. What are some of the things you’d like to get back to doing?” Make sure these activities are reasonable and immediately available. Remember the goal is to re-institute regular activities that provide some sense of satisfaction (that is, to make up for the satisfaction lost by giving up the substance). Goals of going back to school or finding a job are positive and should be supported. However more readily available activities, such as playing basketball, going fishing, or meeting a friend for coffee or a movie, are the things that patients can build into their lives today. Explain the rationale behind this seemingly inconsequential intervention. Then invite the patient to describe specifically their plans for these activities, gently asking for When? Where? How? How often? And with whom?
|
Suggested Home Exercise:
Ask patient to share their Emergency Plan with the people who are
involved, even showing them the card. This can be expected to increase the
likelihood that the patient will use the Emergency Plan when needed. |
When your Patient has a Relapse
|
Key Techniques Positive regard Empathic listening Chain analysis of events leading to relapse Increase level of support |
If you work with patients who are trying to stop using substances, relapses are an expected part of the process. When this happens, it is important to invite them back into see you as soon as possible. This communicates that relapse is not a reason to fall out of treatment, but rather, a reason to come back in and redouble their efforts. Positive regard will help the patient cope with feelings of failure or shame. Feelings of hopelessness should be heard and validated, but the patient should be prompted to explore and challenge the cognitive distortions that usually follow (“I’ll never get sober.” “I can’t go back to my 12-step group after I’ve done this.”). You may provide information or share stories of other patients that will help normalize the patient’s experience (after asking permission, as always). Describe how people who have success in maintaining abstinence over the long term actually use relapses to make their recovery even stronger.
Ask the patient if they would be interested in analyzing the factors that led to the relapse. If they have returned to your office, they will answer this question in the affirmative, and they will have successfully re-engaged in therapy without you pushing them. Have the patient describe in detail the chain of events leading up to the moment of their return to use of the substance. Be sure to identify internal thoughts and feelings as well as external people, places and things. You may use the cognitive-behavioral model as a framework, and actually create a diagram of the steps leading up to the patient’s relapse. This will set the stage for helping the patient to identify and develop skills that will reduce the risk of relapse in the future.
When a patient has a relapse, it is a sign that their relapse prevention skills are not sufficient to maintain abstinence in their current environment. The patient is likely to benefit from a higher level of treatment. For some this could mean attending 12-step meetings, or increasing their frequency. For others, enrolling in a structured outpatient treatment program may be recommended. If there continue to be relapses with outpatient treatment, a residential or inpatient program should be recommended.
Patients are frequently resistant to enrolling in group treatment. One way of approaching this is to introduce the idea of step-wise increases in intensity of treatment, as follows:
Therapist: Okay, so I understand that you would rather not attend
meetings at this point, and that AA is particularly out of the question for
you. As always, I am here to help you figure out what is best for you.
What would you think about coming up with a plan of how you might respond in
the future if another relapse happens?
Patient: I guess that would be a good idea, at this point, since it’s
already happened once.
Therapist: Okay. One next step might be checking out some recovery
groups that are not AA-based. Then if it turns out that’s not enough, you might
think about an outpatient treatment program, where you would go for classes and
groups several times a week.
Patient: What’s after that?
Therapist: Well, again, it’s really up to you if there’s anything after
that. Generally, though, when people are unable to maintain sobriety, it means
that they need a higher level of care, until they develop the skills to manage
sobriety more independently.
Patient: Makes sense. I wonder if I should look into those meetings
now.
Figure One: Ambivalence across the Stages of Change
Figure Two: Decisional Balancing Example
|
Changing |
Not
Changing |
|
Pros 1. More
control over my life 2. Support
from family and friends 3.
Decreased job problems 4.
Financial gain 5. Improved
health |
Pros 1. More
relaxed 2. More fun
at parties 3. Don't
have to think about my problems |
|
Cons 1.
Increased stress/anxiety 2. Feel
more depressed 3.
Increased boredom 4. Sleeping
problems |
Cons 1.
Disapproval from friends and family 2. Money
problems 3. Could
lose my job 4. Damage
to close relationships 5.
Increased health risks |
Decisional Balancing
Exercise
|
Changing |
Not
Changing |
|
Pros |
Pros |
|
Cons |
Cons |
Figure Three: Cognitive-Behavioral Model of Relapse
1. Examples of high risk situations: Internal: Anger, Depression, Loneliness, Boredom. External: People, Places, Events, Things.
2. Examples: “Drugs are problems for some people, but they won’t be for me.” “Without drugs life would be boring.” “As long as I’m careful, drugs won’t hurt me.” “People who are against drugs don’t really understand them.” “When I have problems, drugs relieve my pain.”
3. Examples: “I need a drink!” “Time to get high!” ”I’m going to party!”
4. “I can use just one more time.” “Nobody has to find out.” “It’ll be okay to use again. I’ll keep it limited.”
5. These are the actual behaviors involved in seeking, acquiring, and using substances, (e.g. looking to see if the drug dealer is there, going to the ATM to get money, buying alcohol).
(Adapted from Beck, 1993)
References
Beck, A.T., Wright, F.D., Newman, C.F., Liese, B.S. (1993). Relapse Prevention in the Cognitive Therapy of Substance Abuse in Cognitive Therapy of Substance Abuse. New York: Guilford Press.
Miller, W.R. (1995). Motivation Enhancement Therapy with Drug Abusers. Therapist Manual for Project MATCH MET. Center on Alcoholism, Substance Abuse, and Addiction, University of New Mexico.
Miller, W.R. (1999) Enhancing Motivation for Change in Substance Abuse
Treatment
Treatment Improvement Protocol (TIP) Series 35. U.S. Department Of Health And
Human Services. Rockville, MD. DHHS Publication No. (SMA) 99-3354.
Miller, W.R., Rollnick, S. (2002). Motivational Interviewing. New York: The Guilford Press.
Schuckit, M., & Smith, T. Group Therapy for Relapse Prevention. Therapist training manual, Alcohol and Drug Treatment Program, San Diego VAMC. (Unpublished.)