Substance Abuse And The New Road To Recovery

A Practitioner's Guide

Glenn D. Walters

• Publisher: Taylor & Francis
• Year: 2014
• Print ISBN: 9781560324287
• eBook ISBN: 9781317822615
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Substance misuse is one of the more common, yet baffling, problems confronting the practising mental health professional today. The issues involved in the misuse of substances can be so complex that some practitioners are inclined to avoid working with clients who have been diagnosed with a drug abuse problem.; This new guidebook is designed to assist clinicians with the task of conceptualizing, understanding and intervening with persons who abuse substances. It accomplishes this by offering practical suggestions, assessment procedures, and change strategies directed at the thoughts, feelings and behaviours believed to support a drug lifestyle. Although the approach described in this book utilizes a number of cognitive-behavioural techniques, the approach is unique in the sense that it also deals with the fear of change that frequently interferes with a client's ability to benefit from therapy. It also considers change strategies used by people who have escaped from a drug lifestyle without any type of treatment or formal intervention.; Momentarily arresting the lifestyle is the first step of intervention. This is followed by skill development in which the conditions, choices and cognitions associated with a drug lifestyle are targeted for intervention and change. In the final phase of this approach, the client is engaged in the resocialization process whereby he or she is encouraged to develop ways of thinking and behaving that are incompatible with continued misuse of psychoactive substances. The end result is a concise, yet comprehensive, examination of ways clinicans might facilitate change in persons previously committed to a drug lifestyle.

 

Chapter 1

Introduction: In Search of the Path Less Traveled

 

 

 

 

 

 

Before entertaining the applications for which this book was intended, it may be helpful to consider the applications for which it was not intended, in the knowledge that negative examples can sometimes be just as valuable as positive depictions in clarifying a subject. The absent or negative example is, in actuality, fundamental to human learning, development, and growth, whether reference is being made to a young child who forms an incipient sense of self by learning to differentiate him or herself from the surrounding environment, or an adult who settles on a career in marketing after discovering that accounting and finance do not coincide with his or her temperament and interests. Learning from the negative instance may be particularly helpful in defining the purpose of a published work, a task that may seem unnecessary and tedious to some, but which is actually vital to the success of any such work. Numerous books and manuals have been published on the topic of substance abuse treatment; some have failed because they have tried to be all things to all people. This could perhaps have been avoided had the authors taken the time to discuss their reasons for writing the book. With this in mind, I will attempt to elucidate my rationale for drafting the current text by contrasting the purposes for which this book was intended with those for which it was not intended, beginning with the former.

First and foremost, the reader should understand that this book was not meant to serve as a self-help manual. Lifestyle theory respects the fact that many people desist from problematic drug use without formal treatment. Accordingly, many of the incentives mentioned by people who have exited a drug lifestyle on their own (Biernacki, 1990; Ludwig, 1985; Tuchfeld, 1981; Vaillant & Milofsky, 1982; Walters, 1995b) have been integrated into the present program. However, the concepts, procedures, suggestions, and exercises outlined herein are subject to misinterpretation and misapplication in situations where the user lacks sufficient training or experience to appreciate the limits of the knowledge acquisition process. The fact that competent self-help programming is critical to continued desistance from drug use in no way relieves the clinician of the responsibility for supervising the therapeutic activities of his or her clients. Although lifestyle theory readily acknowledges that self-directed intervention is vital to program effectiveness, it insists that such interventions be overseen by trained professionals who appreciate the limitations inherent in any organized program of assessment and intervention. The respect lifestyle theory affords self-help programming is exemplified, in part, by Appendix 1: Participant Handbook.

A limitation that may be apparent only to trained professionals is the minimal reliability and validity data that is currently available for the assessment procedures reproduced in the appendixes, with the exception of the Drug Lifestyle Screening Interview (DLSI) and the Psychological Inventory of Drug-Based Thinking Styles (PIDTS). Although many of the assessment procedures do not conform to strict scientific standards, this is probably not a fatal flaw unless the supervising clinician fails to identify and discuss these limitations with his or her clients. These assessments are designed to serve only as general clinical aids, rather than as standardized psychometric instruments. Unfortunately, people unfamiliar with measurement theory tend to confuse publication, whether in a newspaper, magazine, or book, with validity. This is a dangerous assumption and one that violates the basic principles of lifestyle theory. It would therefore be hypocritical of me to profess greater confidence in these measures than is scientifically or methodologically warranted. These procedures should therefore be treated as working tools, potentially capable of defining certain change goals and issues, but limited by their simplicity and general absence of reliability and validity data. As such, they should be used only under the continuing supervision of a trained professional so as to avoid misinterpretation and misapplication.

This manual is not a cookbook. Helping someone with a substance abuse problem is not like changing a tire. Substituting one lifestyle for another is not the goal of lifestyle intervention. Rather, the purpose is to provide the client with information, skills, and support as a way of stimulating a change in attitude and behavior. Unlike a drug lifestyle, change does not follow a script or blueprint, but is a path unique to itself. The Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1940) is an instrument for which various cookbooks have been constructed and successfully applied. In devising an MMPI cookbook, the researcher examines the behavioral correlates of a defined set of varying MMPI scale patterns, called high-point codes, and generates interpretative statements from these correlates. Some of the more popular MMPI cookbooks include those by Gilberstadt and Duker (1965) and Marks, Seeman, and Haller (1974). Whereas such an approach may be helpful in interpreting the results of a standardized personality inventory, there are at least two reasons why a cookbook will likely never be successfully assembled for intervention. First, the unique thoughts, feelings, and experiences of the individual client cannot be properly covered by a cookbook. Change is not typically realized in a blueprint or well-worn path, but in a path less traveled. One way to conceive of lifestyle intervention, then, is as an attempt by clinicians to assist clients in their search for a life path that takes their unique life circumstances and abilities into account, rather than forcing them onto the well-worn path of a drug or other lifestyle. Second, the working relationship that forms between a therapist and client defies simplistic cookbook reductionism. Procedures, suggestions, and guidelines are possible; but they must be flexibly applied in order to facilitate, rather than inhibit, the therapist-client relationship.

Lifestyle theory also rejects the mechanistic theorems of the medical, disease, and conditioning models in favor of a more existential, teleological conceptualization of human deportment. The medical model assumes that drug use symptomatology is an expression of some underlying, often emotion-based, problem. Like a mechanic who checks the carburetor when the engine won’t start, practitioners of the medical model search for childhood traumas and emotional disturbances to explain the current drug use difficulties of their clients. This approach has spawned the self-medication hypothesis, but not all, or even most, of the drug-seeking behavior of substance abusers is driven by self-medicating motives, particularly during the early stages of drug involvement (see Walters, 1994c). The disease model assumes that substance abusers suffer from a progressive and potentially fatal disease that can be arrested only by providing the client with a counter-dependency. In many cases the prescribed treatment for the “disease” of alcoholism or drug abuse is regular attendance at 12-step meetings (e.g., Alcoholics Anonymous, Narcotics Anonymous). The conditioning model rejects the disease concept of addiction, but holds that environmental conditions are fully responsible for substance abuse difficulties. As such, supporters of the conditioning approach consider modification of external conditions to be the primary vehicle by which a person terminates his or her relationship with drugs. Lifestyle theory repudiates the passivity and pessimism of all three models by holding the individual accountable for his or her actions, discouraging dependency on outside influences and standards, and encouraging increased commitment to personal goals, values, and expectancies.

The reader also needs to understand that this manual is not a panacea or cure-all, but rather, an alternative to traditional views on drug-seeking behavior. It is well recognized that the lifestyle model does not apply to all drug-involved clients any more than Alcoholics Anonymous benefits all persons who have ever abused ethyl alcohol. If the reader harbors any skepticism about the need for alternative methods of intervention, research documenting the efficacy of client-treatment matching (Hester & Miller, 1988) should fairly well convince him or her that when it comes to substance abuse programming, one size clearly does not fit all. Further advances in the substance abuse field will depend on the field’s ability to entertain many more perspectives than currently exist. Although some clients may profit from the traditional disease concept of addiction, there will be others who resist the model, not because they are denying their problem, but because the approach is irrelevant to their current life situation. The lifestyle model is viewed by its proponents as one alternative to the traditional disease, medical, and social work models that have dominated the substance abuse field for decades, mindful of the fact that not everyone will respond favorably to any one approach. Consequently, a change in mindset needs to occur wherein the question, “Which approach works best with substance abusers?” is replaced by the query, “Which approach works best with which type of clients under which specific sets of circumstances?”

With the purposes for which this book is not intended clearly delineated, it is now time to turn our attention to the purposes for which this book was originally designed. Throughout this introductory chapter, I have asserted that the lifestyle model is an alternative to traditional conceptualizations of substance abuse and substance abuse treatment. The overriding purpose of this book, then, is to introduce the reader to a perspective on substance abuse and substance abuse intervention that is novel, user friendly, and sufficiently inclusive to serve as the basis for a comprehensive program of assisted change. This purpose is supported by three subpurposes: (a) to demonstrate the feasibility of a skill-based approach to intervention, (b) to illustrate precisely how affirming respect for human dignity and choice can facilitate change in drug-involved individuals, and (c) to describe the manner in which adaptability promotes change and prevents relapse.

Skill development and education are both features and goals of lifestyle intervention. In fact, lifestyle theory conceives of the drug lifestyle as a form of acquired developmental disability characterized by arrested emotional development and reduced opportunities for adaptive learning. In addressing these issues, lifestyle therapists search for solutions, rather than becoming preoccupied with problems. It is important to understand that although problems are not ignored by lifestyle therapists, they are clearly deemphasized in favor of potential solutions and the component skills of each solution. For this reason, the model begins by identifying relevant core and ancillary skills, follows up with an evaluation of each skill, and concludes with an organized plan of action. This three-step procedure is summarized by the acronym SAP (Skill-Assessment-Plan). Although an awareness of problems may activate the treatment process by highlighting the need for change, the identification of skills is the point at which intervention formally begins. Within this framework, lifestyle therapists attempt to define the spectrum of relevant skills, gradually breaking them down into their component subskills so that treatment can be optimally effective for clients, each of whom displays a unique pattern of skill strengths and weaknesses. In brief, a comprehensive evaluation of skills is implemented, rather than an assessment based simply on the presenting problem.

Skills come in a multitude of shapes, sizes, and forms. Some of the major categories of skill addressed by lifestyle therapists include educational skills, occupational skills, intellectual/learning skills, social skills, coping skills, communication skills, and thinking skills. The identification of skills and their component subskills is the initial step in the change process; the next step is to assess these skills. The assessment procedures outlined in the appendixes of this book are designed to assist clinicians with the assessment process. However, assessment procedures for all skills and subskills potentially relevant to clinical work with substance abusing clients would require a book many times the size of the present one. For this reason, the majority of assessment devices found in this book provide only a general overview of a skill area that will need to be modified or delineated further when addressing an individual client’s unique issues. Clinicians, however, must take pains to avoid getting so “bogged down” in assessment that they have little time left for intervention. It is imperative, then, that the purpose for which assessment is intended be kept firmly in mind: Assessment is designed to identify strengths, weaknesses, and targets for future intervention and to document any changes that occur in these skills as a consequence of intervention. Assessments are enacted, not for their own sake, but for the sake of intervention or, in some cases, prediction. The degree to which the feedback loop from assessment to intervention assists with the planning and modification of specific therapeutic interactions is an estimate of the value of that assessment.

The development of a skill-based change plan follows from the identification and assessment of skills. The plan may involve remediation of a previously learned skill, acquisition of a previously unlearned skill, or transfer of a skill strength to cover an area of weakness. Stress management training may therefore be helpful to clients who no longer remember how to relax without drugs, and negotiation skills training may potentially benefit an individual who has never learned the fine an of interpersonal persuasion and compromise. In some cases, however, the client may already possess the skill being assessed. Although remediation or skill development is unnecessary under these circumstances, such skills may still work their way into a client’s change plan. A person holding an advanced degree in accounting, for instance, can probably forgo the academic enrichment portion of a change program, whereas a client with strong imagery skills probably does not require additional training in imagery enhancement. Nevertheless, the well-developed academic and intellectual skills of the first individual could be employed as part of an intervention aimed at irrational thinking by assigning articles on rational restructuring for the client to read; the second individual’s strong imagery skills might be used to improve social isolation through implementation of an imagery-enhanced rehearsal technique designed to improve his or her communication skills. It is also essential that the change plan adapt as new information is brought to bear on a subject. Consequently, the second (assessment) and third (plan) stages of lifestyle intervention overlap extensively.

Traditional substance abuse treatment may encourage dependency on a treatment philosophy, program, or group. The lifestyle model rejects this approach, arguing that dependency is one of the building blocks of a drug lifestyle with the strength to reactivate drug-related thinking and behavioral patterns in currently abstaining individuals. Shifting the dependency from one source to another may assist some clients, but will leave many others vulnerable to relapse. Perhaps this explains, in part, the disappointing outcomes attained by persons graduating from traditional inpatient substance abuse programs (Hunt, Barnett, & Branch, 1971). In contrast to dependency-fostering models such as Alcoholics Anonymous, the lifestyle approach strives to promote independence by focusing on issues such as responsibility, choice, and the ongoing evaluation of consequences. Instead of imposing preconceived notions and ideas on clients, the lifestyle approach teaches its consumers to think for themselves in the belief that a lack of self-confidence and an overreliance on externalized standards of success and happiness may have been what encouraged development of a drug lifestyle in the first place. Accordingly, the lifestyle model honors the dignity of the individual client by encouraging independence and the formation of personal skills designed to enhance the client’s decision-making competence. The focus of lifestyle intervention, then, is on teaching clients how to more effectively manage their lives through choice, responsibility, and autonomy. Demonstrating exactly how this might be accomplished is the second subpurpose of this book.

Lifestyle intervention is guided not only by skill-based training and respect for client autonomy, but also by a pursuit of adaptive goals. In actuality, the manner in which autonomy and skill development are attained centers on fortification of a person’s adaptive resources. Whereas a lifestyle furnishes people with the rules, roles, rituals, and relationships that allow them to function within the rigid boundaries of an established lifestyle, adaptation supplies people with skills they can use to modify their behavior and learn from their environment. Survival, in fact, depends on our ability to adapt to certain physical and psychological demands. Unfortunately, as people grow accustomed to depending on lifestyles to cope with the pressures, disappointments, and hassles of everyday living, they experience a corresponding atrophy in their ability to think for themselves. Lifestyle therapists attempt to remedy this situation by assisting clients in identifying, rediscovering, and developing their adaptive resources by teaching and reinforcing basic skills. As a client begins to clarify and expand his or her repertoire of adaptive responses he or she becomes less dependent on the drug lifestyle to meet life’s challenges and moves further down the path less traveled. This illustrates the interactive nature of the relationship that forms among the three subpurposes of this book (skill development, facilitation of independence, and increased adaptability) in the evolution of an alternative program of substance abuse intervention. The tools designed to assist with the implementation of a lifestyle-based program of change will be explored in Chapters 3 through 8, but first Chapter 2 will provide a review of the underlying tenets of the lifestyle model.

Chapter 2

An Overview of Lifestyle Theory

The differences and interrelationships between the structural and functional divisions of lifestyle theory can perhaps be best explained using the analogy of an automobile engine. A car’s engine is made up of rods and pistons, plugs and points, belts and hoses, a battery, a carburetor, and a wide assortment of gears and wires. In this analogy, these automobile parts represent the structural division of lifestyle theory. The functional division, on the other hand, is represented by processes that place the battery in interaction with the points and plugs in order to create chemical and mechanical reactions that then start the engine. This insinuates that the structural elements of a car engine or lifestyle must be clarified before the functional features can be understood. Conversely, examining the structural components of a car’s engine or lifestyle, without simultaneously considering the dynamic interrelationships that exist between these individual components, is equally unwise. This overview of lifestyle theory is organized around these two major divisions—structural and functional—with the first part of the chapter devoted to a review of the primary structural elements of a drug lifestyle and the second part exploring the functional features of this lifestyle.

STRUCTURAL COMPONENTS OF THE DRUG LIFESTYLE

The structural division of lifestyle theory follows along the Lines of the so-called three Cs: conditions, choice, and cognition.

Conditions

Conditions are internal (e.g., heredity, anger) or external (e.g., socioeconomic status, drug-related cues) variables that increase or decrease a person’s propensity to engage in drug use. These conditions may be either historical-developmental or current-contextual in nature. Historical-developmental conditions are past events (e.g., family relationships) and innate characterist...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Chapter 1 Introduction: In Search of the Path Less Traveled
• Chapter 2 An Overview of Lifestyle Theory
• Chapter 3 Arresting the Lifestyle
• Chapter 4 Skill Development: Condition-Based Strategies
• Chapter 5 Skill Development: Choice-Based Strategies
• Chapter 6 Skill Development: Cognition-Based Strategies
• Chapter 7 Resocialization and Effective Aftercare
• Chapter 8 Practice, Application, and Usage
• References
• Appendix 1: Participant Handbook
• Appendix 2: Drug Lifestyle Screening Interview (DLSI)
• Appendix 3: Administration and Scoring Key for DLSI
• Appendix 4: Inventory of Negative Consequences
• Appendix 5: LOCUS Test
• Appendix 6: Change Thermometer
• Appendix 7: Estimated Self-Efficacy in Avoiding Drugs
• Appendix 8: Imagery Exercise Questionnaire
• Appendix 9: Self-Monitoring of Drug-Related Thoughts and Behaviors
• Appendix 10: Sample Behavioral Contract
• Appendix 11: Lifestyle Stress Test
• Appendix 12: Drug-Related Cues Checklist
• Appendix 13: Access to Drug Use
• Appendix 14: Interpersonal Influence Scale
• Appendix 15: Suggested Role Plays for Social Perspective Taking
• Appendix 16: Multiple Options Analysis
• Appendix 17: Social-Communication Skills Checklist
• Appendix 18: Role Play Rating Scale
• Appendix 19: Suggested Social-Communication Role Plays
• Appendix 20: Index of Life Skills
• Appendix 21: Review of Academic and Occupational Skills
• Appendix 22: Values Inventory
• Appendix 23: Expectancies Grid
• Appendix 24: Self-Monitoring of Constructional Errors
• Appendix 25: Lapse Versus Relapse
• Appendix 26A: Psychological Inventory of Drug-Based Thinking Styles (PIDTS)
• Appendix 26B: PIDTS Scoring Key
• Appendix 26C: PIDTS T-Score Conversions
• Appendix 27: Fear Checklist
• Appendix 28: What Will Be Missed From a Drug Lifestyle
• Appendix 29: Schedule of Family and Community Support
• Appendix 30: Bipolar Identity Survey
• Index