"For Prof. Goodman"

Clinician attitudes significantly influence the acceptance and utilization of new or innovative therapeutic approaches (Levenson, Speed, & Budman, 1995). In addictions treatment, this is influenced in part by clinicians’ understanding of addiction in general (Ogborne, Wild, Braun, & Newton-Taylor, 1998; Shaffer & Robbins, 1991), alcoholism in particular (Miller & Hester, 2003), and the purpose and intended outcome of treatment (e.g., abstinence; Caplehorn, Lumley, & Irwig, 1998).

Using cluster and discriminant analyses, Thombs and Osborn (2001) identified three distinct groups or types of chemical dependency counselors in Ohio (N = 343), based on participants’ views of addiction and its treatment. “Uniform counselors” (56%) appeared to lend moderate support for moral and disease concepts of addiction, “multiform counselors” (29%) endorsed a broad range of beliefs about the nature of addiction and its treatment, and “client-directed counselors” (15%) were characterized as practitioners who recognized “heterogeneity among clients and consider[ed] counselor listening to be an essential aspect of treatment” (p. 454). Compared to the multiform counselors, client-centered counselors, among other characteristics, had greater confidence in their knowledge of Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV; American Psychiatric Association, 1994) criteria, were more likely to hold a higher academic degree, and were more likely to be licensed as mental health counselors. This and other studies (e.g., Caplehorn et al., 1998; Moyers & Miller, 1993; Ogborne et al., 1998) suggests that addiction ideology (e.g., medical, humanitarian or empathic, moralistic) does affect the selection of treatment strategies.

Advances in medical technology have paved the way for more sophisticated research initiatives in the areas of human genetics, neurobiology, and behavior. Coherent synopses of these findings are available for professionals (e.g., W. R. Miller & Carroll, 2006) and laypersons alike (e.g., Interlandi, 2008), and have the potential to challenge longstanding and entrenched views of addiction, and drastically change how chemical dependence is treated.

Although W. R. Miller, Sorensen, Selzer, and Brigham (2006) noted a shift in how addiction is understood in the United States today, movement away from the “widespread” endorsement of substance dependence as a disease (Ogborne et al., 1998) to an understanding of addiction as a complex phenomenon is likely to be slow. This is true in light of the disease model’s history as the “dominant” model of addiction in the United States (Morgenstern, Frey, McCrady, Labouvie, & Neighbors, 1996). Definitions of addiction as a disease do vary (see Thombs, 2006), but common elements include an acceptance of addiction (namely alcoholism) as a chronic, progressive, involuntary, irreversible, and potentially fatal illness, which has as its core criteria the loss of control over the intake of alcohol and physiological dependence. A single, standard, pre-determined form of treatment is often used, without regard for individual differences among clients. Lifetime abstinence is the unquestionable goal, and participation in Alcoholics Anonymous (AA) is strongly endorsed.

Many chemical dependency counselors may thus practice within the bounds of one model of addiction—likely the (ill-defined) disease model of addiction. Such a myopic perspective can have the effect of missing, ignoring, or even dismissing other, perhaps equally valid, explanations for a client’s addiction and of an inability to appreciate or apply alternative treatment methods. Indeed, Tracy (2007) concluded her brief historical review of the disease concept in the United States by stating that “It may be time to embrace a more holistic view of disease and disability, to appreciate the multiplicity of factors ... that affect what we consider ‘healthy’ and ‘diseased’” (p. 91).

This chapter is intended to offer practitioners an array or menu of treatment approaches in their efforts to assist a variety of clients struggling with substance use concerns. Just as there is no one “alcoholic” or “drug addict,” there is no one “tried and true” treatment approach. Miller and Hester’s (2003) “informed eclecticism” model guides the content of this chapter in that (a) there is no single superior approach to treatment for all individuals, (b) treatment programs and systems should be constructed with a variety of approaches that have been shown to be effective, and (c) different types of individuals respond best to different treatment approaches. In addition, W. R. Miller and Hester strongly emphasize tailoring or customizing treatment to the unique needs and strengths of each individual client, thereby increasing treatment effectiveness and efficiency. Implicit in this model is the need for all helping professionals in the addictions field to be familiar with a multiplicity of interventions so as to select from and offer the most appropriate type (or combination of types) and level of care to those needing and deserving quality services. Attention is given in this chapter to the application of research-supported counseling approaches. A list of useful Web sites addressing topics discussed in this chapter (namely, cognitive-behavioral interventions, brief interventions, solution-focused counseling, and harm reduction) is provided.

As can be seen from W. R. Miller et al.’s (2003) review of alcoholism treatment approaches, cognitive-behavioral (CB) interventions are well represented among the most effective treatments. These include behavioral self-control training, community reinforcement, contingency management and behavior contracting, social skills training, and behavioral couples/family counseling. Additional research suggests that these and other CB approaches are also effective for treating other drug dependence (e.g., cocaine and opioids). Two approaches (contingency management and behavior contracting, and community reinforcement) are briefly discussed in this section, highlighting their incorporation into substance abuse counseling.

Assumptions of Cognitive-Behavioral (CB) Substance Abuse Counseling

1. Substance abuse involves complex cognitive and behavioral processes

2. Substance abuse and associated CB processes are, to a large extent, learned

3. Substance abuse and associated CB processes can be modified, particularly by means of CB counseling

4. A major goal of CB counseling for substance abuse is to teach coping skills to resist substance use and to reduce problems associated with substance abuse and dependence

5. CB counseling requires comprehensive case conceptualization that serves as the basis for selecting specific CB techniques

6. To be effective, CB counseling must be provided in the context of a warm, supportive, collaborative counseling relationship

Source: Najavits, Liese, & Harned, 2005.

As noted in the previous sidebar, cognitive-behavioral (CB) theories of substance abuse and dependence typically operate according to six assumptions (Najavits, Liese, & Harned, 2005).

The six CB assumptions convey the importance of the substance abuse counselor intentionally integrating and implementing a variety of technical skills and personal qualities (e.g., empathy). For example, in order to help or teach a client in the early phase of recovery from cocaine use specific ways to manage cravings (e.g., “ride the craving wave”) and urges (e.g., “surf the urge”), the substance abuse counselor should not only have knowledge of the physiological effects of cocaine use and a comprehensive understanding of the client’s substance use history (by having completed a thorough case conceptualization) but should also have an appreciation for the first-hand experiences of the client struggling to stay clean. That is, by abstaining from something important to him or her (e.g., a behavior, beverage, or food item) and entering into an actual “abstinence contract” while practicing as a counselor, the substance abuse counselor (whether recovering or not from chemical addiction) can acquire greater empathy for the client’s subjective experiences. Graduate students (N = 120) enrolled in a substance abuse counseling course offered once per academic year (Osborn & Lewis, 2004) consistently reported that experiential assignments of trying to uphold an abstinence contract for the academic semester and attending 12-step self-help groups (e.g., AA) were valuable, possibly engendering greater empathy for persons struggling with substance use. As one student in the course noted,

“... we get so involved in the role of counselor that we sometimes forget the client inside us. It can become habit to separate ourselves from our clients with a sense of self-righteousness that we do not have the problems they do.” (p. 49).

Yet another student reflecting on the abstinence experience stated, “I don’t know how many times I have said and heard others say to smokers, ‘Just quit.’ Now I have a sense of why that doesn’t work” (p. 50). CB practices in substance abuse counseling, therefore, may not be confined to interventions used with clients; they might also include the substance abuse counselor’s own personal practices. Experiential learning, which incorporates CB assumptions and practices, might be considered an activity shared by both the client and counselor while engaged in counseling.

Najavits et al. (2005) described specific CB interventions that address coping skills and are grouped according to five factors or types of precursors (or triggers) to addictive behaviors. Due to the multiplicity of factors that contribute to problematic substance use, interventions can and often are implemented to address more than one type of trigger. Social interventions include certain lifestyle changes (e.g., exercise, meditation), enhancing one’s sober social support (e.g., attending AA/NA meetings), and refusal skills (i.e., practicing verbal and nonverbal communication to avoid and turn down offers to use). One client I worked with requested that the guided imagery exercises we had engaged in during our weekly sessions (I had tailored a script designed for this particular client and facilitated—verbalized—the exercise) be audio taped so that he could participate in guided imagery outside of our sessions. One day when I left the counseling facility, I could see this client sitting on a nearby park bench, eyes closed, and earphones on. I surmised he might be listening to my voice, guiding him through relaxation and a new awareness of sobriety.

Cognitive-Behavioral Interventions

· Social –lifestyle changes, social skills training, interpersonal conflict management

· Environmental–living/geographic changes, cue exposure

· Emotional–to regulate both positive and negative emotions (e.g., distress tolerance, reframing, self-soothing)

· Cognitive–to modify automatic thoughts

· Physical–to introduce distractions from triggers, urges, and cravings to use

Source: (Najavits, Liese, & Harned, 2005)

Environmental interventions include cue exposure whereby environmental triggers associated with substance use (e.g., photos or videos of drug paraphernalia or persons using substances) are repeatedly viewed while being monitored so that automatic responses (e.g., cravings, urges to use) are diminished or even extinguished. Clients can also be advised to thoroughly clean their living space, one area or one room at a time, so as to reinforce their sense of control over their own personal or local environment. This practice could also symbolize a cleansing or purging of the “toxic self.”

Emotional interventions are designed to regulate both positive and negative emotions so that neither serves as a trigger for relapse. Through cognitive strategies, clients may be taught to stay with the feeling while reviewing to themselves (preferably verbalizing out loud) the list of things they have already accomplished to stay sober (e.g., “Mark, you are reMARKable for having said, ‘Let’s take a time-out of 5 minutes to cool down before we talk about this some more’”). This practice is similar to the distress tolerance skills (e.g., self-soothing, one thing in the moment) taught in dialectical behavior therapy (Linehan, 1993a, 1993b). In self-soothing, clients are taught to focus on one of the five senses at a time, pausing to fully attend to, experience, or soak in the natural or non-substance-induced sensation (e.g., observing the contrast of green tree leaves against a bright blue sky) in order to withstand an urge or a craving to use. In addition, certain feelings can be reframed as positive protective devices, if not acted upon in destructive ways. For example, fear and anxiety can be understood as normal responses to a brand new reality or lifestyle, and regarded as the client’s attempts to protect what is now valuable (i.e., sobriety). One reframe that I often use with clients is, “the compulsivity of addiction is the persistence of recovery,” meaning that they didn’t necessarily have to discard all aspects of “bad behavior”; rather, they could channel or redirect their frenetic energy into a “no-holds-barred” or “pull out all the stops” approach to recovery (e.g., continuing to attend AA meetings until they found their “home” fellowship).

Cognitive interventions are specifically intended to modify automatic thoughts and drug-related beliefs, as well as conditional assumptions and core beliefs. Rather than automatically thinking that only marijuana can help them get to sleep, clients can be taught to catch themselves from lighting up (perhaps by telling themselves out loud, “Hold off!” or “Wait!”) and reviewing the written plan constructed with their counselor detailing alternative preparations for sleep (e.g., listening to relaxing music while depressing a stress ball). A list of cognitive comebacks to urges or cravings can be devised so that the client has an expanding toolbox of relapse prevention strategies. Such comebacks might resemble the externalization exercise (White & Epston, 1990) used in solution-focused counseling in which the client names the problem (e.g., “restless roamer,” as one heroin addict described his struggle in finding “peace” in his life), is able to regard the problem as an external entity (i.e., “I am not the problem ... ‘restless roamer’ is the problem”), and through conversation is able to keep the problem at a distance so as to diffuse its power over him. The client can be taught to confront the problem with comebacks such as, “You’ve led me astray!” and “I’m no longer following your twisted map!” and doing so out loud, with an amplified voice, while standing up. Using cognitive interventions, clients can also be taught to question the evidence regarding the seemingly infinite benefits of substance use, as well as the seemingly infinite detriments or negative assumptions about sobriety. Counselors can assist in stopping any circular reasoning by interjecting, “Okay, where’s the evidence that this is true?” and “How do you really know that for sure?”

Physical interventions involve activities intended to distract the person’s attention away from triggers and the consequent cravings and urges to use. Such activities include physical exercise (e.g., doing chores around the house, going for a walk), talking with someone (e.g., calling one’s AA sponsor), breaking out into song, or snapping a rubber band worn on the wrist. In addition, clients can be reminded of the “insanity” of their active using days, recalling the “seemingly irrelevant decisions” made (see Marlatt & Donovan, 2005) and the negative physical consequences of their using. One I worked with, a blue-collar machinist who found his employment fulfilling because “I’m able to work on things that last,” made the decision one morning to no longer drink. He said he was able to uphold this decision because “I was sick and tired of being sick and tired. I didn’t want to lose this job.” I recall commending this client on his decision and what I heard as his desire to work not only on large truck engines that would last, but on himself as well, so that he would last.

Specific CB approaches that have demonstrated efficacy in treating alcohol (Petry, Martin, Cooney, & Kranzler, 2000) and other drug dependence, namely cocaine and opioid dependence (Higgins & Silverman, 1999; Iguchi, Belding, Morral, Lamb, & Husband, 1997;Preston, Umbricht, Wong, & Epstein, 2001), have incorporated contingency management and behavior contracting (Higgins, Silverman, & Heil, 2008). These two approaches are based in part on the theory of behavioral economics, which posits that behavior is chosen because of the reward(s) it will provide, including monetary reward. Contingency management makes use of external incentives or tangible reinforcers (namely vouchers redeemable for goods and services, e.g., groceries, public transportation, movie theater tickets) contingent on the client meeting predetermined treatment goals, such as submitting drug-free urine specimens and arriving to counseling on time. Over time, clients may be awarded with an increasing number of vouchers or opportunities to win a prize (e.g., from a raffle or drawing) for not only submitting clean urine specimens, but also submitting documentation of having engaged in new and positive behaviors (e.g., going on a job interview, paying off court debts, bringing in a report card of improved school grades).

Contingency Management and Behavior Contracting

· Based on theory of behavior economics and operant conditioning

· Designed to shape and reinforce non-using behavior

· Clients and counselors agree (or contract) to participate in the systematic application of behavioral consequences

· Use of external incentives or tangible reinforcers (e.g., bus passes, vouchers redeemable for groceries or personal hygiene products), contingent upon changes in drug use and other therapeutic goals (e.g., attendance)

Source: Higgins, Silverman, & Heil, 2008.

Despite beneficial effects in research trials, it appears that contingency management practices have not been adopted by many practitioners due in part to the cost-prohibitive nature of the program. Counselors and agencies intent on offering helpful services, however, would be encouraged to pursue creative partnerships with local business representatives. These might include time-limited free access for agency clients on the local bus in exchange for free advertisement of the bus service on agency publications. In addition, as was done in Petry et al.’s (2000) study, local businesses could be approached to donate items (e.g., department store gift certificates) that would then be raffled off to clients who had upheld their contract.

Behavior contracting itself (apart from the use of vouchers) can be implemented with minimal or no cost to the counselor or agency. This practice might resemble treatment planning, but is typically not as comprehensive or expansive (i.e., the contract can focus on a specific task to accomplish in the next week) and can be done on a periodic basis. It is advised that the contracts be written (maybe even at times on a scrap piece of paper), the intended behavior clearly described, the targeted date of task completion specified, and both the incentive and the consequence for not abiding by the contract clarified. In addition, it should be signed by both the counselor and client, dated, and a copy provided to the client. Incentives for upholding the contract might include meeting with the counselor outside, on the grounds of the agency; having access to the agency’s basketball court following a counseling session; an extended (by 5 minutes) smoke break during group counseling; and securing from the counselor a letter of reference for a job application. Particularly in residential treatment settings, behavior contracts are routinely used to encourage greater participation and cooperation among clients. Privileges for upholding one’s contract might include telephone access to family members, being able to receive visitors on “Family Day,” and being able to skip meal preparation and clean-up or other household chores for one day.

The community reinforcement approach (CRA) is a comprehensive biopsychosocial approach to the treatment of substance use disorders based on the premise that one’s environment or community plays a critical role in reinforcing recovery efforts. CRA enlists community reinforcers (e.g., family, recreation, employment) to support change in an individual’s substance use (Meyers, Villanueva, & Smith, 2005). Two reviews (Roozen et al., 2004; Smith, Meyers, & Miller, 2001) of studies conducted with the CRA in treating problematic alcohol and other drug use attest to its efficacy, particularly when combined with contingency management (e.g., use of vouchers as incentives).

Meyers et al. (2005) identified eight components of CRA, and although they conceded that each component is not necessarily used with every client, two are standard applications: functional analysis and treatment planning. After completing a functional analysis or thorough substance use assessment, including taking inventory of the client’s external and internal motivations for substance use and its treatment, the focus of the CRA is to determine how environmental stimuli can be rearranged so that sobriety is supported and substance use is no longer tolerated or rewarded. Goals typically reflect the presence of something positive (e.g., maintaining employment, graduating from high school) rather than the absence of something negative (e.g., not drinking or drugging). Specific areas in the client’s life considered in both assessment and treatment include social and recreational activities, employment, and family dynamics. Whenever possible, a significant other (e.g., life partner or spouse, girlfriend/boyfriend) is involved in treatment and regarded as an important ally in the construction and maintenance of a non-using and healthy lifestyle.

The CRA can be understood as a “package”; that is, “it contains a number of procedures that may or may not be used, depending on [the] client’s specific needs” (Smith, Meyers, & Milford, 2003, p. 238). Indeed, the counselor can sift through many of the CB interventions already described in this chapter and then select those strategies that are most relevant for the client’s current situation. These may include job skills training, social skills training, and couples counseling to address strains in communication. Careful attention is given to the ongoing assessment of external and internal triggers for substance use. Not only are attempts made to regulate environmental stimuli, but the counselor routinely inquires about the client’s internal triggers (e.g., mood, beliefs, physical status). As a CB-oriented approach, the CRA is intended to equip the client with a variety of skills needed to not only effectively manage negative stimuli or triggers, but to also establish and maintain a lifestyle and environment that support and allow one’s recovery to thrive.

A new version of CRA, Community Reinforcement and Family Training (CRAFT), is based on the principles of CRA but focuses on the environment (i.e., family members) of those persons with substance use problems who refuse to enter treatment (Meyers et al., 2005). Rather than working directly with the person with substance use problems, CRAFT enlists the assistance of a concerned significant other (CSO), such as a parent or a spouse, by training the CSO to interact with his or her loved one in new and more constructive ways. These would include not speaking with the family member when he or she is intoxicated (e.g., saying in a calm and measured voice, “I’m going to wait and talk with you about this in the morning, once you’re sober”) and allowing the family member to realize the natural consequences of his or her substance use (e.g., not bailing the family member out of jail). Although the goal of CRAFT is for the family member to enter treatment, it is designed to help CSOs take better care of themselves and to realize a sense of contentment on their own.

Brief interventions for problematic drinking are not a homogeneous entity; rather, they are regarded as “a family of interventions varying in length, structure, targets of intervention, [and] personnel responsible for their delivery” (Heather, 1995, p. 287). However, W. R. Miller and Sanchez (1994) maintained that all brief interventions should include six elements, known by the mnemonic FRAMES. These shared elements are intended to fulfill the purposes of brief interventions, which Zweben and Fleming (1999) stated are to (a) increase one’s awareness of the costs and consequences of substance use, (b) strengthen beliefs about one’s ability to change (i.e., enhancing self-efficacy), (c) utilize natural helping systems to support positive change, (d) encourage the person to accept responsibility for change, and (e) promote a commitment to positive change.

Frames = Six Elements of Brief Interventions

· FEEDBACK of personal risk or impairment, delivered in nonjudgmental manner

· Emphasis on personal RESPONSIBILITY for change

· Providing clear ADVICE to change

· Offering MENU of alternative change options

· Therapist EMPATHY

· Facilitating client SELF-EFFICACY or optimism

Source: W. R. Miller & Sanchez, 1994.

The temporal nature of this service delivery certainly implies a shorter length of stay in treatment than what might be considered standard substance abuse counseling (i.e., detoxification followed by intensive outpatient individual and group counseling). “Brief” or “minimal” counseling can refer to one or two one-hour individual sessions, or structured and direct feedback provided in 5 to 30 minutes. Brief interventions are typically developed by specialists to be delivered by other professionals, and service settings vary from primary health care centers (e.g., hospital emergency rooms) to college campuses. Brief interventions conducted specifically with college students have included (a) an hour-long individual face-to-face motivational intervention with high-risk/binge drinkers (Borsari & Carey, 2000; Larimer et al., 2001; Marlatt et al., 1998; Murphy et al., 2001); (b) small group (e.g., fraternity house) review of assessment results (Larimer et al., 2001); (c) personalized mailed feedback of the student’s reported substance use patterns (Collins, Carey, & Sliwinski, 2002; Walters, 2000; Walters, Bennett, & Miller, 2000); (d) computerized individual assessment and computer-generated feedback (Dimeff & McNeely, 2000; Neighbors, Larimer, & Lewis, 2004); and (e) combinations of these interventions.

Although believed to be underutilized by chemical dependency treatment professionals because they are thought to be reserved for those with less severe forms of substance use disorders, brief interventions should be delivered based on the recipient’s stage of change (Vik, Culbertson, & Sellers, 2000) and targeted specifically to those who are relatively low on the readiness-to-change continuum (Maisto et al., 2001). Vik et al. (2000), however, noted that “Students contemplating change were the heaviest and most problematic drinkers” (p. 679). As a result, brief interventions for substance use problems should always be an option regardless of a client’s level of substance dependence (Sanchez-Craig, 1990), and may be used to help prepare or cultivate one’s readiness for more intensive or extensive services (W. R. Miller, 1992). Brief interventions for the substance dependent client can be ethically justified, therefore, particularly if the client would otherwise receive no help at all (Heather, 1995), including homeless adolescent substance users (Baer, Peterson, & Wells, 2004).

Studies report reduction in drinking as a result of participation in brief intervention, but no commensurate and significant reduction inconsequences of drinking, such as missing college classes or engaging in risky sexual behaviors (Borsari & Carey, 2000; Collins et al., 2002; Murphy et al., 2001; Walters et al., 2000). Interventions should be devised, therefore, that will reduce drinking consequences, as well as consumption amounts and frequency. This may depend, among other things, on the counselor’s ability to engage the student or client in a consideration of the potentially extensive and hazardous effects of one’s substance use. Focused conversation on the person’s use history, his or her current status and use patterns, comparisons with others in his or her peer group (e.g., age, gender, race/ethnicity), and the counselor’s own informed perspective (from research findings and clinical wisdom) may at least help the client to think twice about the extent of future use.

Solution-focused counseling (SFC) was conceived and developed by de Shazer and colleagues (de Shazer, 1985, 1988; de Shazer et al., 1986; Molnar & de Shazer, 1987; O’Hanlon & Weiner-Davis, 1989) at the Brief Family Therapy Center (BFTC) in Milwaukee, Wisconsin, almost 40 years ago. It emerged as a form of brief or short-term psychotherapy with an emphasis on pragmatism (i.e., what works) and on mental health (rather than mental illness; Berg & S. D. Miller, 1992), thus representing an alternative to the problem-focused approaches that continue to prevail in both mental health practice and substance abuse treatment. SFC has its roots in the work of hypnotherapist Milton Erickson and family systems theory, and during its later years of development, in post-structural/post-modern or constructivist ideology (de Shazer & Berg, 1992).

The essence of SFC is its focus on the accomplishments, strengths, resources, and abilities of the client. That is, rather than prioritizing the problems and deficits that typically accompany a referral to counseling, the solution-focused practitioner solicits (from clients, family members, referral source, other treatment staff) and attends to those things in the client’s life that have gone well and continue to go well. Indeed, SF counselors assume that clients want to change and that the solution, or at least part of it, is probably already taking place (Gingerich & Wabeke, 2001). This is not to say that presenting concerns are dismissed; rather, “exceptions” (de Shazer, 1988) to problem occurrence are given prominence so as to formulate with the client a solution or series of solutions so that formal treatment is no longer necessary. Such a focus exemplifies the clinician’s confidence in the client’s ability to make positive changes in his or her own life by accessing and utilizing strengths and resources. Positive change is not only regarded as possible, but inevitable (Berg & S. D. Miller, 1992), characterizing SFC as the “counseling of hope” (Nunnally, 1993).

Berg and S. D. Miller (1992) are credited with being the first to apply SFC to substance abuse treatment, specifically treatment for alcohol-related problems. Since then, many others have contributed to the conversation of integrating SFC within substance abuse treatment (Berg & Reuss, 1998; Chandler & Mason, 1995; de Shazer & Isebaert, 2003; Juhnke & Coker, 1997; Linton, 2005; Mason, Chandler, & Grasso, 1995; Osborn, 1997; Taleff, 1997). Additional contributions to the literature are needed to further support what S. D. Miller, Hubble, and Duncan (1996) described as SFC’s suitability with a range of client concerns in a variety of treatment settings. Although SFC lacks a solid empirical research base (see reviews by Corcoran & Pillai, 2009; Gingerich & Eisengart, 2000; Kim, 2008), it remains a popular approach among mental health and substance abuse treatment providers. Indeed, Herbeck et al.’s (2008) survey of program administrators and staff members in California revealed that SFC was considered one of the more effective treatment approaches and used in more than half of participating sites despite the lack of compelling research findings. Herbeck et al. surmised SFC may be intuitively appealing to treatment providers because its “techniques and tools ... fit particularly well with the complex needs of substance-abusing populations” (p. 708). Linton (2005) also noted that SFC can be integrated well with other interventions.

Although not a study explicitly utilizing SF approaches, Iguchi et al.’s (1997) “shaping strategy” with 103 opioid dependent clients (63% male, 85% White) bears resemblance to several essential aspects of SFC and offers encouraging results for the use of SFC in substance abuse treatment. Clients were randomly assigned to one of three treatment groups: (a) standard treatment (ST; individual counseling with for take-home medication eligibility), (b) urinalysis-based reinforcement (UA; standard treatment plus opportunity to earn vouchers for each urine specimen testing free of unauthorized substances), and (c) treatment-plan-based reinforcement (TP). Vouchers were described to clients as “treatment assistance coupons” which could be redeemed only for expenses tied to a specific treatment plan goal, such as clothing appropriate for a job interview and transportation to counseling sessions.

In the TP group, counselors met weekly with clients to establish the following week’s behavioral tasks and “were generally free to tailor tasks to suit the needs of individual participants” (p. 423); hence, the “shaping strategy” of TP. As opposed to the UA group, TP members earned vouchers for demonstrating their engagement in new and positive behaviors (e.g., contacting local computer training program), rather than their non-activity in or elimination of substance use (i.e., providing a “clean” urine specimen). That is, desirable behaviors were reinforced. In addition, if the client failed to earn vouchers for these tasks (e.g., not appearing for a scheduled counseling session), the counselor would be urged to establish an easier task (e.g., participating with the counselor in an abbreviated telephone conversation). When clients succeeded in earning vouchers, counselors were directed to gradually increase the difficulty of subsequent tasks, with the aim of achieving long-term treatment plan goals.

Primary results of Iguchi et al.’s (1997) study were that over the four 6-week evaluation periods, only TP clients demonstrated significant improvement in abstinence rates over time, and TP clients attended significantly more counseling sessions than clients in either of the other two groups. The authors interpreted these results to suggest that “the reinforcement of clearly defined behavioral tasks targeted toward long-term goals increases involvement in behaviors inconsistent with drug use among methadone maintenance patients” (p. 426). Overall, the TP program’s encouraging outcomes indicate that a strengths-based, non-punitive, and collaborative form of treatment—an approach consistent with SFC—is appropriate and perhaps preferable to an approach where all clients receive the same type of care, are required to achieve abstinence, and are rewarded only for what they are not doing (i.e., using). Results such as these bode well for the continued integration of SFC in substance abuse treatment. Indeed, the design and implementation of the TP program appears to fulfill all seven of Berg and S. D. Miller’s (1992) criteria of “well-formed” treatment goals: (a) saliency to the client; (b) small; (c) concrete, specific, and behavioral; (d) the presence rather than the absence of something; (e) a beginning rather than an end; (f) realistic and achievable within the context of the client’s life; and (g) perceived as involving “hard work.”

Related to personalized goal formulation, de Shazer and Isebaert (2003) studied nurse therapists and their patients who participated in a chemical dependency treatment program in Belgium that subscribed to an SF approach. The focus of treatment was on identifying exceptions to the presenting problem and honoring clients’ preferences for therapy—that is, what patients wanted from treatment. Patients were allowed to choose a treatment goal of controlled drinking or abstinence, provided in an individual, couple, or family format. Approximately 10% of the clients who initially chose controlled drinking changed their goal to abstinence.

At 4-year follow-up (former patients contacted by telephone), 50% (n = 36) of the former patients reported being abstinent and 32% reported success at controlled drinking. de Shazer and Isabaert (2003) reported that only 19 of the 36 former clients who claimed abstinence had originally chosen abstinence as their goal; controlled drinking had been the choice of only 12.5% (n = 9) of those who were now claiming abstinence at follow-up. The authors stated that this result “... strongly suggests that having a choice of goals and the ability to change goals makes a big difference in patients’ treatment success” (p. 49). In addition, such findings support the work of client-counselor collaboration in formulating treatment goals. Indeed, de Shazer and Isabaert noted that “... areas of choice allow the patients to cooperate with the treatment program” (p. 50). Rather than the counselor prescribing a goal (e.g., “Client will abstain from all mood- and mind-altering drugs”), SF counselors are encouraged to elicit from the client his or her preferred outcome and honor that choice as much as possible. This study suggests that clients may actually benefit in the long run by being active participants in counseling, empowered by having had their choices heard and respected. The authors concluded that:

... at least some optimism is warranted. The situation is entirely changed once a second possible remedy to the alcohol problem is introduced. With two ways to approach the goal, failure at one only means that patients should try the other approach.... There is a big difference between choosing to drink and believing that you have no choice but to drink.11 (p. 51)

SFC has been used in combination with other counseling approaches, namely Adlerian therapy (Watts & Pietrzak, 2000), motivational interviewing (Lewis & Osborn, 2004); person-centered therapy (Cepeda & Davenport, 2006); existential therapy (Fernando, 2007); CB therapy and motivational interviewing (Corcoran, 2005); and creative arts therapy (Matto, Corcoran, & Fassler, 2003; Tyson & Baffour, 2004). A separate chapter of this book is devoted to motivational interviewing, and the specific practices of an integrated SFC and creative arts therapy approach appear to be particularly conducive for substance abuse counseling. Therefore, this latter combination is briefly highlighted.

Tyson and Baffour (2004) studied 108 adolescents ranging in age from 11 to 18 years (mean age of 15.29 years; 92.6% Caucasian, 67.5% female), who participated in an SF and strengths-based group treatment program on a child and adolescent unit of an acute-care psychiatric hospital (typical length of stay was 4 to 7 days). Just over 10% of the participants had a primary diagnosis of substance abuse (the 4th highest among 9 primary diagnoses assigned) and 24.1% had a secondary diagnosis of substance abuse (most frequent secondary diagnosis assigned, almost twice that of any other secondary diagnosis assigned). The focus of the study was on soliciting from the young patients their positive strengths for managing stress, with the assumption being that these internal resources would be useful in accentuating exceptions to the problem. That is, patients were asked to identify possible future crisis situations that would not require hospitalization as a result of their implementation of positive strengths (namely some type of expressive art that they alone identified).

Of those youth with a primary diagnosis of substance abuse, half identified “playing a musical instrument” as their arts-based strength (a statistically significant difference from those with a primary substance abuse diagnosis who did not identify with playing a musical instrument) that would be used to “stop the problem from pushing me around.” None of the youth who reported that they initially “write poetry, journals, stories” as a means of dealing with their problems had a primary diagnosis of substance abuse. Tyson and Baffour (2004) concluded that youth with a primary diagnosis of substance abuse were more likely to play a musical instrument or sing in order to deal with an impending crisis. In terms of treatment, they stated, “For these youth, it might be appropriate and personally relevant to use some form of music (e.g., play musical instrument) in the context of treatment” (p. 223).

For both adolescents and adults struggling with substance use problems, the integration of SFC and art therapy may prove helpful. Matto et al. (2003) described the process of having clients draw a picture of their primary problem as a form of externalization or detachment from the problem. They stated that such an activity “introduces fluidity to problems ... [so that] the oppressive nature of the problem is lifted...” (p. 266). In addition, depending on the skill of the counselor, solutions can be constructed in the very act of drawing. That is, clients can be encouraged to modify aspects of their art work (e.g., using another color, outlining some aspect of the drawing, erasing or removing something from the art work); this in itself conveys that solutions are constructed over time, in stages or increments (i.e., not necessarily one giant leap), and under the client’s control. During this process, clients can be commended on changes made and can then be asked to draw their strengths, with the effect of making the strengths “more concrete and tangible [because of the] physical and emotional investment in the creative process” (p. 270).

Several solution-focused (SF) assumptions guide the practice of SFC. Although clearly not exhaustive, the SF assumptions and practices presented in this section were selected in light of their feasibility to substance abuse counseling.

Assumptions of Solution-Focused Counseling

· Pragmatism and Parsimony

· Client-Counselor Collaboration

· Language of Hope

· Exceptions Facilitate Change

. Past Exceptions

. Recent and Recurrent Exceptions

. Future Exceptions (e.g., Miracle Question)

· Notice the Difference

· Commendations

Consistent with its origins as a brief or short-term therapy, SFC is known for its pragmatism and, as Berg and S. D. Miller (1992) highlight, its parsimony. Perhaps in conducting intentional counseling that addresses directly the client’s presenting concerns and preferences (i.e., it is pragmatic), one is by default keeping the work simple or parsimonious. Conversely, simplicity may engender pragmatism. Regardless of the sequence, SFC resembles a brief intervention in its focus on helping the client get unstuck by not dwelling on the intricacies of the problem (e.g., the “reason” for the client’s substance use). In many ways this is a respectful approach that avoids wasting the client’s time gathering extensive historical data and prioritizes relief from pressing symptoms and concerns.

Solution-focused counseling (SFC) has been regarded as a means to further individualize care and to improve therapeutic partnerships with clients (Mason et al., 1995). The emphasis on or commitment to client-counselor collaboration is evident in SFC’s proposition of three types of therapeutic relationships as opposed to three types of clients (Berg & S. D. Miller, 1992; Berg & Reuss, 1998). The visitor-type relationship describes the interaction that may ensue when the client believes there is not a problem and the counselor agrees, validates, or “goes along with” this perception, while at the same time offering to help the client in ways the client may be able to determine. The complainant-type therapeutic relationship typifies problem recognition and a shared understanding of the nature of the problem (e.g., on probation with the county municipal court for a repeated driving under the influence [DUI] charge), with the focus being on how the client can transition to seeing him-or herself as part of the solution (as opposed to looking to others for resolution, e.g., “Get my probation officer off my back”). Finally, the customer-type relationship involves joint construction of a solution plan or path that the client is able and willing to participate in and even take the lead on.

Careful attention to the type of language and words used by clients is essential in the practice of counseling, as is counselor intentionality in the selection of words used with clients. This is particularly true for an SFC approach wherein words and language are thought to create reality and meaning. Given that the majority of clients in substance abuse treatment have not initiated services on their own (i.e., have been mandated by a court system or a social service agency and are thus considered “involuntary”) and more than likely feel angry, demoralized, and fearful about being sent to counseling, skeptical about the need for treatment and its outcome, the specific words used by the counselor can have a significant effect on the client’s amenability to and engagement in counseling. For example, use of the word “alcoholic” or “addict” to describe the counselor’s assessment of the client may not initially engender cooperation and may actually further aggravate the client’s frustration and reluctance to be in counseling. Gingerich and Wabeke (2001) articulated a SFC perspective on diagnostic labels by stating,

... SFBT therapists eschew talk of diagnosis, disability, and pathology. Such talk, in spite of good intentions, frequently serves to confirm the client’s view of himself or herself as someone who is disabled. Thus, unless there is reason to believe that diagnosing would lead to a needed medical intervention, the therapist steers conversation toward the client’s desired scenario and what he or she can do to make that happen. (p. 35)

When conveying assessment results and the preliminary diagnosis from an SFC perspective, it is advisable for the counselor to refer to the substance use disorder as a condition, something the client has, rather than someone the client is. A focus on the condition rather than an insinuation of the person’s worth (i.e., “you are the problem”) can be viewed as an effort to externalize the problem, thus empowering the client to exert control over it rather than allowing it to continue to consume the client. Such externalization, however, may not be regarded as compatible with the disease concept of addiction.

Other examples of language usage in SFC that may be interpreted by the client as hopeful rather than disempowering or judgmental include the words “setbacks” rather than “relapses” (Berg & S. D. Miller, 1992), and “multiple episodes of sobriety” (Mason et al., 1995) rather than a sole or primary consideration of “multiple relapses” or referring to a client as “a chronic relapser.” In addition, Berg and Reuss (1998) have made use of a “recovery checklist” (rather than a diagnostic or problem checklist) comprised of targeted positive behaviors for the client to engage in as part of his or her recovery. What may be regarded as a confrontational counseling style can be reframed as an “invitation for clarification,” with the counselor beginning with, “Help me understand” (i.e., requesting clarification of two discrepant reports or stories, e.g., “I don’t have a drinking problem” and a history of 3 DUIs). Although not originating from SFC, the “care map” (Chen et al., 2004) has been described as “a kind of algorithm outlining assessments and related treatment” (p. 857) specifically for children with asthma, and is developed by an interdisciplinary team in consultation with the child and his or her family. Although Chen et al. do not provide a specific example of such a “care map,” the name itself suggests a positive, beneficent, and salutary approach that may have greater appeal for clients and providers alike than what is commonly referred to as a “treatment plan” (see Osborn, West, Kindsvatter, & Paez, 2008).

An example of expeditious practice in SFC is the focus on exceptions to the problem rather than on the problem itself. Exceptions refer to occasions when the problem is not a problem or times when it could have happened (e.g., relapse) but did not. S. D. Miller (1992) characterized exceptions as problem “irregularit[ies]” (p. 2), further illustrating the notion that exceptions are changes or alterations to what the client may perceive as the “same old, same old” problem pattern. In order to help the client get unstuck from a “problem saturated story” (White & Epston, 1990), the counselor can inquire about exceptions in one or more of four areas (Nunnally, 1993): (a) the past, (b) recent nonproblem occurrences, (c) recurrent exceptions (i.e., instances that occur periodically, often without warning), and (d) occasions in the future when the client can imagine the problem no longer existing or being influential.

Past exceptions can be detected by inquiring about life before using or occasions when the negative consequences of one’s use were not prominent or even existent. “Tell me about a time before cocaine came into the picture when you felt good about something you had done, even proud of yourself” is a means of shifting the client’s perspective to a nonproblem time in the past when the client experienced positive emotions that were not drug-induced. If the client responds with “I don’t know,” the counselor should pursue with the follow-up, “Oh, take a moment to think back, maybe a time when you were in school, maybe when someone else pointed out something you had done well. Give it a shot.” If the client is still not able to generate a past success story, the counselor can encourage the client to consider a hypothetical scenario such as, “If there had been a time when you felt good, even proud, of something you had done, when might that have been? What would you have hoped you would have been able to accomplish back then?”

Recent and recurrent exceptions, as with past exceptions, may not be in the client’s awareness and so require the counselor’s curiosity skills about recent events or experiences that can be interpreted as glimmers of a possible solution in the making. Reframing may also be necessary. For example, “Anton” was a young and quiet African American male who faithfully attended his counseling sessions but said he was only coming in because he “had to.” “Okay, so you have to,” his counselor acknowledged. “But you’re here every week and on time, which is a miracle in itself compared to many other clients who come here. Tell me one thing that you’ve gotten out of our last few sessions that has brought you back for more.” After a long pause and a brief sigh, with eyes downcast, Anton softly said, “I don’t know, I guess I feel okay here, you know, like I’m not being hassled. You listen.” Rather than wanting to take full credit for Anton’s positive experience in counseling, his counselor followed up with: “Well, what’s made it possible for you to trust this place, trust me, a White woman, and talk in here?” The intent of this question was to identify what may have been a new or recurrent exception to Anton’s problem story (e.g., a change in thinking), an exception for which he could claim responsibility and credit, such as “I guess I need to lay off the weed so I can get through school this year. My auntie’s been on me for months, but now I need to do something.”

Perhaps the best known example for constructing future exceptions in SFC is the use of the “miracle question.” de Shazer (1985) is credited with designing this creative question to encourage clients to visualize, and potentially make real, a future nonproblem period. By imagining and projecting themselves into a future situation in which the problem is no longer present, clients can view themselves as functioning satisfactorily (Molnar & de Shazer, 1987). The “script” for the miracle question might be worded as:

“Suppose that tonight, while you are asleep, there is a miracle and the problem that brought you to counseling was solved. However, because you’re asleep, you don’t know that the miracle already happened. So, when you wake up tomorrow morning, what will be different that will tell you that this miracle has really taken place?”

Being the “Curious Columbos” (Selekman, 1993) and skillful inquirers that they are, SF counselors will ask the client for details of their miracle day—specific behaviors they will be engaging in, things other people will notice in them, things they will be thinking about, and feelings that will be prominent to them.

“Susan,” a divorced Native American in her mid-30s, struggled with visualizing her non-problem day. Not only had she been using alcohol problematically for the past 10–15 years, she also presented with symptoms of social phobia, and had been physically and sexually abused by her ex-husband. She was currently estranged from her immediate family members, including her teenage son, who had decided to live with Susan’s father several hours away. Rather than continuing to press her for a description of her miracle morning, I contacted, with Susan’s permission, her father and her son by mail, requesting that they complete a questionnaire I had devised containing specific questions that might elicit some “ingredients” to help Susan imagine and eventually make real at least one day that minimized or even was free of her problem.

The counseling session in which the returned and completed family questionnaires were shared with Susan remains vivid. Her father wrote that he was proud of his daughter’s courage to finally leave her abusive husband and her son wrote that he was grateful for the love and protection his mother had shown him since he was little. Her son said he was doing well in school so that she would be proud of him. Susan was tearful throughout this counseling session as she heard the “testimony” of family members dear to her, testimonials to Susan’s personal strengths and qualities (exceptions!) that she had not been able to recognize in herself for a long time. Following that session, Susan was able to use what she heard from her father and son to begin formulating her “miracle morning,” in which she awakened with courage not to consume her usual alcohol “eye opener” and to talk to her neighbor instead, doing so without experiencing panic symptoms. She said this would be her way of continuing to love her son and to make both her son and father proud of her. Rehearsing this miracle morning was something that we did over the next few sessions, knowing that miracle construction would not take place in a day, but over time, in pieces or ripples, and with practice, feedback, support, and encouragement.

It is critical that SF counselors are not only on the lookout for positive differences in or exceptions to client behaviors, but assist their clients (and the client’s family members) to notice when these problem irregularities occur. One Appalachian client I had the privilege to work with over several months demonstrated the importance of this. “Ricky” was in his mid-30s, married and a father of two elementary school age daughters. He acknowledged being illiterate, experiencing discord in his marriage, consuming alcohol on a daily basis, and still grieving over the loss of his father (his “drinking buddy”) 3 years earlier. Unemployed due to a physical disability, Ricky spent his time working in the garage on automobiles and motorcycles and secluding himself in a TV room he had fashioned for himself.

In one session, Ricky reported having maintained sobriety from alcohol for 4 consecutive days in the past week, a monumental effort given his long history of excessive alcohol use. After attempting to explore with Ricky how he was able to remain sober for 4 consecutive days (using SF coping questions), I asked about his return to drinking after 4 days: “What happened?” His response is still haunting and tugs at my empathic heart: “No one noticed.” Without his genuine efforts to initiate sobriety being recognized by those most important to him, Ricky essentially gave up, perhaps asking himself, “What’s the use?” Although he may have been able to identify for himself some benefits of his 4-day sobriety, at this very early stage of his recovery, Ricky needed the positive reinforcement of others (i.e., external motivators), particularly with the co-occurrence of depressive symptoms.

If I had this client case to work with again, I would have been more intentional about including Ricky’s wife periodically in counseling (consistent with outcome research indicating the efficacy of behavioral marital therapy) or at least asking her on the telephone, “What have you noticed in Ricky this past week that’s changed for the better?” (a question that presupposes positive change). I might have also challenged Ricky to engage in new and more positive behaviors that would be evident to his wife and daughters, things said or actions taken that would convince them he was making strides in attaining and maintaining abstinence. A target behavior could be reviewed and even practiced in counseling (e.g., “So when the girls get home from school, what will you do instead of working in the garage?” and “What will you say differently when your wife complains about you watching too much TV? Let’s practice having you say it out loud.”) and an assignment given such as, “When you spend time with the girls this next week, and when you say something different to your wife, notice how they respond. Be on the lookout for changes you see and hear in them. We’ll talk about this next week.”

Throughout the process of counseling, SF counselors look out for and notice positive differences—exceptions—in their clients. When sincere efforts or accomplishments are evident (e.g., attending one’s first AA meeting), the counselor brings these to the client’s attention through commendations or what are referred to in motivational interviewing as affirmations. Commendations or affirmations are not to be confused with well-intentioned, although less than substantive “cheers” that may be regarded by the client as disingenuous. In addition, accolades that do not specify a positive behavior the client has recently implemented (e.g., “You’re doing a great job!”) may fail to reinforce the specific positive behavior targeted as a client goal. Consistent with the hard work criterion of well-formed treatment goals in SFC, commendations should highlight the client’s hard work. For example, “Ricky” would be commended for his 4 consecutive days of sobriety (“Despite really wanting to go out to the garage and drink, you didn’t. You stayed inside and watched TV with the girls. I know this took a lot of effort on your part.”), and “Susan” would be commended for not drinking in the morning before talking with her neighbor (“How did you manage to do that? How were you able to use your courage to actually go outside, knock on her door, and start a conversation with her? I am amazed and very proud of your hard work, Susan!”).

Marlatt (1998), the most prominent voice of harm reduction in the addictions, has described this particular ideology and its practices according to five principles, assumptions, and values. Harm reduction can first be understood as a public health alternative to moral/criminal and disease models of drug use and addiction that, second, recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm. This second principle implies that “prevention” is an approach intended to prevent, or at least reduce, the harmful effects of use, not use itself (Marlatt & Witkiewitz, 2002). The third principle or assumption of harm reduction is that it has emerged primarily at a local level and represents a “grass roots” approach based on addict advocacy, rather than originating as a federal “top-down” mandate. Fourth, harm reduction promotes low-threshold access to services (i.e., meeting the individual where he or she is, respecting the individual’s initial goal as a means of engaging the person in services) as an alternative to traditional, “high-threshold” approaches (e.g., requiring abstinence as the initial treatment goal). Finally, harm reduction is based on the tenets of compassionate pragmatism (i.e., focusing on managing one’s daily functioning) versus moralistic idealism.

From this preliminary description, it may be evident that harm reduction reflects cognitive-behavioral (CB) principles, embraces the FRAMES perspective of brief interventions, and bears resemblance to solution-focused (SF) counseling. Indeed, as a “low-threshold” entry into addiction services, harm reduction “... [accepts] the client’s definition of the problem as the legitimate starting point for intervention ... [so as] to join with that which motivates the client to seek help, meet the client’s needs, and, around this motivation, facilitate a positive treatment alliance” (Tatarsky, 2003, p. 251). In addition, “Harm reduction approaches the participant as the expert of their story, respecting their solutions and pace” (Majoor & Rivera, 2003, p. 257), which echoes Walter and Peller’s (2000) admonition that clinicians listen for and honor client preferences.

Consistent with one of the assumptions of SF counseling, harm reduction is a pragmatic approach to alcohol and drug use and related problems, which Kellogg (2003) described as having three purposes: staying alive, maintaining health, and/or getting better. Marlatt and Witkiewitz (2002) expanded on these in their listing of three core objectives of harm reduction: (a) reduce harmful consequences (to user, society) associated with alcohol/drug use; (b) provide alternatives to zero-tolerance approaches by incorporating using goals (abstinence or moderation) compatible with the needs of the individual; and (c) promote access to services by offering low-threshold alternatives to traditional substance use prevention and treatment. Thus, harm reduction counseling does not require abstinence as an initial treatment goal because, as W. R. Miller and Page (1991) argued, “abrupt attainment and maintenance of total abstention is the exception rather than the rule” (p. 231). In addition, as SF practitioners de Shazer and Isabaert (2003) noted,

When a problem is believed to have only one remedy, failure in an attempt at that remedy is viewed as the individual’s fault. Each subsequent failure demands that the individual increase his or her efforts at applying the remedy, that is, doing more of something that is not working. (p. 50)

Other routes to abstinence are therefore often considered in harm reduction, including Miller and Page’s (1991) “warm turkey” approach. This alternative includes sobriety sampling, where the client attempts to abstain for a period of time (e.g., over a weekend), on an experimental basis, is intentional about taking mental or even written inventory of the experience (e.g., completing a self-monitoring card of cravings/urges, “close calls,” emotional states, and any relapses), and then reports to his or her counselor at the next session how the trial period went. Another alternative to abstinence is tapering down (also described as “gradualism” and “abstinence eventually”; Kellogg, 2003), where the amount and frequency of consumption is gradually decreased, perhaps using a weekly or monthly calendar. This practice was used with a young adult male client whose marijuana use reportedly reduced and calmed his tactile hallucinations (i.e., sensation of bugs crawling over his body). Rather than require this client to abruptly abstain from the only “home-grown treatment” that so far had helped his co-occurring psychotic symptoms, we agreed that he would gradually reduce the number of marijuana joints he was smoking daily each week for the next month. A calendar was created on which the client was to mark the number of joints smoked each day and bring to each counseling session. This plan and practice was in place while we waited for his initial appointment with the psychiatrist for an evaluation. Similar in some ways to gradualism, a third alternative to abstinence is that oftrial moderation which refers to a negotiated period of time when the client is allowed to try limiting his or her intake. Usually, however, this trial is commenced after a period of sobriety.

Despite the pragmatic and humanistic philosophy of harm reduction, many addiction counselors may not eagerly embrace its practices because they seemingly contradict long-held beliefs about addiction and its treatment (e.g., abstinence the only goal for the disease of addiction). Rosenberg and Phillips (2003) found that a majority of representatives (primarily clinical directors and program administrators) of drug and alcohol treatment agencies in the United States were receptive to implementing certain harm reduction strategies. Ten of 13 interventions listed were rated by a majority of respondents to the postal mail survey (51% return rate) as somewhat or completely acceptable, including education (63%), needle exchange (61%), and alternative therapies (e.g., acupuncture; 81%), as well as pharmacological interventions such as agents used in opiate detoxification (80%), postdetoxification (e.g., Naltrexone; 74%), and drug replacement (i.e., short-term use of methadone; 67%). Despite the rather high acceptability rates of these strategies, a majority of respondents indicated that the 13 harm reduction interventions listed were not available at their agency, primarily due to an incompatibility with agency philosophy and, to a lesser extent, lack of funding and staff resources. The use of nonabstinence as an intermediate treatment goal was reported by approximately a third of respondents as available at their agencies, whereas its use as a final goal for treatment was less available. Overall findings suggest that further education of staff about the legitimate benefits of harm reduction strategies (i.e., to promote a change in attitude or philosophy) would assist in the greater implementation of such interventions, along with parallel attitude changes in funding sources (e.g., federal government).

Similar to concerns raised with implementing brief interventions in alcohol and drug treatment, harm reduction may not be deemed appropriate by some practitioners because of what might be considered its “enabling” characteristics (i.e., viewed as encouragement to continue using). However, given that the vast majority of persons in the United States today with substance use problems do not receive treatment services (Substance Abuse and Mental Health Services Administration, SAMHSA, 2008), both brief interventions and a harm reduction approach appear well suited for reaching persons who may never obtain such services. Indeed, of the four most frequent reasons given for not pursuing services even when a need was recognized and an initial attempt made, two would be well-served by brief interventions and harm reduction: not ready to stop using (26.6%); and negative opinion from community/neighbors and negative effect on job (combined 15.9%). The remaining two reasons included cost or insurance barriers (35.9%) and other access barriers (e.g., transportation; 10.5%).

Pragmatic and humanistic counseling practices that respect the client’s initial goal for treatment, emphasize client-counselor collaboration, and address harm reduction rather than substance use elimination only may very well benefit the 20.8 million persons in 2007 reported by SAMHSA (2008) who needed but did not receive treatment for a substance use problem. At the very least, these practices could “gently persuade” and engage persons in needed services and in so doing, might serve as “stepping stones” to more intensive services. As Tatarsky (2003) noted,

Harm reduction practices are one way to begin an ambitious process of change, the endpoint of which cannot be foreseen at the outset. The goal is to support the client in going as far as [he or she] possibly can toward the harm reduction ideals of optimal health, self-sufficiency, self-actualization and satisfaction in the world of relationships. (pp. 250–251)

Chapter 8: Psychotherapeutic Approaches

ISBN: 9780137057788 Authors: David Capuzzi, Mark D. Stauffer

Copyright © Pearson Education (2012)