Counseling Strategies Paper
Research indicates that the majority of individuals drinks less frequently and consume less alcohol when they do drink following alcoholism counseling, although short-term outcomes (e. g. 3 months) are more favorable than those from studies with at least a year follow-up. Positive outcomes yield benefits for alcoholics and their families, as well as leading to savings to society in terms of decreased costs for medical, social and criminal justice services.
Reviews of counseling outcome for alcohol problems have developed from early efforts to summarize findings, to reports which derived outcome statistics, to more recent publications examining efficacy in controlled studies with data on cost effectiveness. Clearly, the literature suggests that a variety of approaches can be effective, some more than others because of the nature of the counseling and treatment and the intensity of the approach.
The community reinforcement approach (CRA) attempts to increase clients’ access to positive activities and makes involvement in these activities contingent on abstinence. This approach combines many of the components of other behavioral approaches, including monitored disulfiram, behavior contracting, behavioral marital therapy, social skills training, motivational counseling and mood management. Some of the largest counseling effects in the literature have been associated with the community reinforcement approach (Miller et al. , 1995).
Compared to more traditional treatment approaches, the CRA has been shown to be more successful in helping inpatient or outpatient alcoholics remain sober and employed. Although community reinforcement is a more intense treatment approach, it is consistent with the basic philosophy of several other effective approaches. The ability to establish rewarding relationships, to focus on changing the social environment so that positive reinforcement is available, and to reduce reinforcement for drinking are emphasized with the community reinforcement and other approaches.
The key appears to be helping the client to find and become involved in activities that are more rewarding than drinking. To the degree that stress causes unpleasant physical sensations and associated dysphoric moods, it is a high-risk situation for excessive alcohol use. An important coping skill for clients to learn is how to use the physical and emotional signs of stress as cues to “stop, look and listen” and to try something to cope besides heavy drinking. Relaxation training is a fundamental coping skill in the repertoire of a person trying to avoid excessive drinking.
It can help clients to reduce their anxiety and tension when facing stressful situations and minimize their typical levels of motor and psychological tension. Relaxation training can also assist a person to remain calm and to think clearly in circumstances that require effective problem solving and fast action. Many individuals believe in the tension-reducing properties of alcohol, whether or not they are true, and, without an alternative means to relax, excessive drinking may be a person’s only means of coping with painful sensations and unpleasant emotions.
Relaxation training fosters general stress-reduction and can be taught to clients using various techniques that either reduce muscle tension, develop deep breathing skills or focus on the use of pleasant imagery (Monti et al. , 1989). In addition to relaxation training, both meditation and exercise have been shown to have similar stress reducing properties. Contingency management procedures assist clients to re-structure their environment to decrease the rewards associated with alcohol use and increase the costs of excessive drinking.
The principles of contingency management are based on operant or instrumental learning approaches to human behavior. Contingency management techniques include providing incentives for compliance with alcohol treatment and positive reinforcement from spouses or friends for sobriety. This approach is combined with punishment, in the form of withdrawal of attention and approval contingent on the resumption of excessive drinking, and provisions for social support, recreational activities and vocational counseling.
In recent years there has been a growing recognition of the importance of providing treatment for alcoholism that is tailored to patients’ level of insight and motivation to work on their substance misuse. Rather than emphasizing direct confrontation of patients who deny problems related to their substance misuse, social pressure to acknowledge the evils of alcohol abuse and immediate endorsement of abstinence as a treatment priority, motivational approaches initially focus on relationship formation and harm reduction.
While motivational strategies have gained some ascendance in the treatment of primary substance misuse, their importance has been even more rapidly accepted in work with individuals with comorbid disorders, whose psychiatric disorders are often inextricably tied to their use of alcohol and drugs. A useful overarching heuristic in work with all comorbid disorders is provided by the concept of stage wise counseling.
The stages of counseling are based on the observation that people with an alcohol misuse problem who change their behavior over the course of treatment typically progress through a series of stages, and that each stage is characterized by different attitudes, behaviors and goals. By understanding a patient’s current stage of counseling, counselor can optimize treatment so that it matches his/her current level of motivation, and avoid driving the person away from treatment by attempting interventions that are mismatched to his/her motivation.
Four stages of counseling have been identified: engagement, persuasion, active treatment and relapse prevention (Mueser et al. , 2003). Efforts to change another person’s behavior are doomed to failure if a therapeutic alliance has not first been established. Therefore, at the engagement stage the primary goal of counseling is to establish a working alliance (or therapeutic relationship) between the patient and counselor. A working alliance can be operationally defined as regular contact (e. g. weekly) between the patient and counselor (McHugo et al. , 1995).
Until this relationship is established, no efforts are directed at changing the substance misuse. A wide range of strategies exist for engaging the patient in treatment, including assertive outreach, resolving a crisis, attending to basic needs (e. g. medical, housing), and legal constraints (e. g. outpatient commitment). At the persuasion stage, the counselor has a working alliance with the patient, but the focus of the relationship is not on addressing the patient’s substance misuse. Therefore, at this stage the patient is still actively misusing substances, or has only recently begun to cut down on substance use.
The goal of this stage is to convince the patient that his/her substance misuse is an important problem, and to marshal motivation to begin working on that problem. Motivational interviewing (Miller & Rollnick, 2002) is one useful strategy for helping patients understand the negative impact of their substance use on their own personal goals. Persuasion groups (Mueser et al. , 2003), in which patients are provided with an opportunity to share their experiences with substance use with a minimum of direct confrontation or social censure, can help patients develop motivation to address their substance misuse.
Commitment to work on substance misuse can be operationally defined as an actual reduction in substance misuse (McHugo et al. , 1995), or another change in behavior that is associated with a reduction in risk (e. g. ceasing intravenous administration of a drug). In many cases, the duration of these attempts may at first be inhibited by the self-control skills the patient can marshal: in these instances, re-engagement occurs in close conjunction with training in skills to deal with situations in which previous lapses occurred.
Miller & Rollnick (2002) emphasize that commitment to change is a function of both motivation and self-efficacy or confidence in being able to change. As previously researchers like Bandura noted, past achievements are much more powerful influences on self-efficacy than verbal persuasion that is unrelated to past performance. The attention of patients is drawn to successful aspects of past control attempts, rather than to their ultimate failure to deal with the substance-related problems up to now.
While a sense of self-efficacy tends to have limited generalization across performance domains, commitment to change may sometimes be aided by success in another domain, such as work-related skills that open up options for a viable substance-free life-style. Once the patient has begun to reduce his/her substance use, the motivation to work on substance misuse is harnessed, and the goal of treatment shifts to further reduction of substance use or the maintenance of abstinence. Many of the strategies developed for people with a primary substance use disorder can be used with dually diagnosed patients once they reach the active treatment stage.
Examples of interventions at this stage of counseling include cognitive-behavioral counseling to address “high-risk” situations, self-help groups, and social skills training to address substance use situations. Structured activities, such as work preparation or leisure pursuits that decrease opportunities for using substances and divert attention from substance use, can assist in development of substance control. In relapse prevention, the patient has achieved substance control for a substantial period (e. g. at least 6 months).
The goals are to both guard against a relapse of substance misuse and to extend the gains made to other areas of functioning, such as social relationships, work and housing. Awareness of vulnerability to relapse can be achieved through continued participation in self-help groups, or individual or group work with substance misuse as a focus. The focus in the relapse prevention stage on other areas of functioning, such as relationships, leisure activities and work, reflects the belief that the better a patient’s life is, the less vulnerable he/she will be to a relapse of substance misuse.
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