Psychotherapy for
Substance Abuse:
A Busy Resident’s
Guide to
Motivational
Interviewing and
Relapse Prevention
Murat
Z. Akalin MD MPH
Alcohol and Drug Treatment Program
San Diego VA Medical Center
UCSD Combined Residency Training
Program in Family Medicine and Psychiatry
March 2006
This manual is dedicated to the millions of
human beings suffering from drug and alcohol addiction, and especially to the individuals
for whom I have had the honor of caring.
Acknowledgments
This manual is, above all, a product of great mentorship. Dr. Marc Schuckit took me on as Senior Resident on the inpatient unit of the Alcohol and Drug Treatment Program (ADTP) at the San Diego VA Medical Center. He gave me the opportunity to work with veterans with substance abuse disorders in an intensive treatment setting under his exacting tutelage. He provided me a framework for thinking critically about substance abuse disorders, and how to help people with them, something I will carry with me for life. He also offered invaluable feedback on how to get my message across more clearly, in this manual and in life. Dr. Stephen Groban, a master teacher and physician, allowed me the privilege of working with him, side-by-side on a day-to-day basis, as we shared an office on the inpatient unit, for a one-of-a-kind apprenticeship few psychiatry residents will ever have. Dr. Groban’s gentle confidence supported the development of my own voice and style as a therapist. He was also instrumental in helping me formulate the chapter on relapse prevention. Dr. Shannon Robinson gave me the latitude to work specifically on patient motivation during my “detox” clinic. Her energy, humanism and unrelenting confidence in my abilities motivated me to persevere through the (sometimes tedious) writing of this manual. Her detailed comments were invaluable. Dr. Andres Sciolla was incredibly encouraging in pursuing a project that would further psychotherapy training for residents, and provided feedback as well. John Sevcik, MSW, gave me the opportunity to work with him and Michael Wilcox, LCSW, as a co-therapist in the ADTP “brown group” – a group for the least-motivated (often court-mandated) patients. Roger Fishero and Brian Redden, addiction therapists working primarily on the inpatient unit, were my first teachers and co-therapists, back in my second year of training. Dr. Margaret McCahill, Founder and Director of the Combined Residency Training Program in Family Medicine and Psychiatry, is an ongoing inspiration in her dedication to provide services for the most seriously mentally ill, and especially to those with substance abuse disorders. Dr. David Folsom was a role model early on, in the compassionate care of homeless persons with chronic alcoholism. I am also grateful for Dr. Chris Searles, my close friend and colleague, whose natural inclination toward patient responsibility and freedom has provided a mirror for me to examine more carefully the results of my best efforts to “help.” Of all people, however, I give most thanks for my fiancé Dr. Nancy Thomas, talented woman and psychologist, who provided the feedback, encouragement, and support, to pull this project off. All this said, I take full responsibility for whatever errors and omissions are contained in this manual.
Foreword
For those of you who have never worked with substance abuse and dependence, I don’t think you could learn as much in one hour in any other activity as you can in the hour you spend reading this guide. For those of you, like myself, who have worked with this group of patients, I feel it is the best hour I spent educating and reminding myself about how to approach patients with substance dependence, all year.
Reading this guide will help you make the most out of every interaction with your patients. Like many of you, I can get diverted by a variety of patient problems and lose focus on the psychotherapeutic aspects of interacting with patients. I have read this manual twice now and plan to continue to read it and reread it to help myself focus on joining with the patient where they are. The least amount of resistance is obviously a goal most of us share, and this guide helps us in developing those skills of avoiding resistance. The second part of the guide allows us to work on relapse prevention and abstinence skills.
This guide, Psychotherapy for Substance Abuse, will only take you 60 to 90 minutes to read. I believe you will find this one of your best-spent hours of training.
Shannon Robinson, MD
Table of Contents
Chapter One: Motivational Interviewing
The
Motivational-Interviewing Style
Chapter Two: Relapse Prevention
The Cognitive-Behavioral
Model of Relapse
Chain Analysis of Events
Leading to Relapse
Identfying High Risk Situations
Dealing with Somatic
Complaints
Chapter Three: A Sample Course of Therapy
Session One: Building
Motivation
Session Two: Identifying
High Risk Situations
Session Three: Preventing
Relapse
Session Four: Maintaining
Abstinence
When your Patient has a
Relapse
Figure One: Ambivalence across the Stages of Change
Figure Two: Decisional Balancing
Figure Three: Cognitive-Behavioral Model of Relapse
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.
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.
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.
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.
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.
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Key Points
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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.
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.
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.
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.
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Key Points
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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?
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.
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?
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.
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Key Points
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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:
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?
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.
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.
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Key Points
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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.
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Key Points
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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.
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Key Points
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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.
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Key Points
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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