Introduction and Overview

The consequences of drug and alcohol abuse in the United States are enormously costly. Although the costs can be evaluated in dollars, they are more readily understood in human terms: family discord, neglect of children, personal misery, financial straits, medical problems, fetal alcohol syndrome, HIV infection, legal problems, incarceration, automobile accidents, lower work productivity, and job lossÑand the list goes on. Combating and reducing the source of these problems have proven to be difficult indeed, but one of the most straightforward and noncontroversial ways is to provide effective treatment to drug abusers.

This book is about treatment. In particular, it is about the basic component of most treatment programsÑgroup and individual counseling. The intent of this book is to present information on various counseling approaches used in some of the best known and most respected treatment programs in the United States. Certainly all meritorious counseling models are not represented and, as a practical matter, could not be represented. However, chapters have been written by representatives of such well-known treatment programs as the Hazelden Foundation (chapter by Patricia Owen), the Betty Ford Center (by Fred Sipe), CENAPS® (by Terence T. Gorski), Living In Balance (by Jeffrey A. Hoffman), and the Washton Institute (by Arnold M. Washton). Other chapters were prepared by representatives of nationally known research centers on the treatment of drug abuse, including William R. Miller (University of New Mexico), Delinda Mercer (University of Pennsylvania), and Dennis C. Daley (Western Psychiatric Institute and Clinic). Two of the three treatments in Project Match, the monumental clinical trial sponsored by the National Institute on Alcohol Abuse and Alcoholism, are described in this volume. (See William R. MillerÕs Motivational Enhancement Therapy and Joseph NowinskiÕs Twelve-Step Facilitation.) Finally, chapters prepared by Elizabeth Driscoll Jorgensen and Richard Salwen and by Scott D. Miller illustrate innovative counseling strategies designed for special populations and settings. Each chapter was written by an authoritative spokesperson for the counseling model being described.

After surveying a number of chapters in a typical edited book on treatment models, the reader may have a difficult time comparing them, seeing how they are similar, seeing where they differ. Each author typically finds different topics important, emphasizes different issues, and writes a chapter whose coverage is unlike any other authorÕs. Furthermore, if the chapter focuses on the theoretical background, it may be hard to gain a practical understanding of the counseling interventions and what the counselor actually does with the client. In an effort to make the comparison of the various models less difficult and to clarify how the model is applied in practice, two of the editors (K.M.C. and L.S.O.) designed a comprehensive outline of topics that could be applied to almost any counseling approach. The topics ranged from theoretical rationale to specific counseling practices. The authors were asked to follow a specific format, and they did so, with only an occasional exception in a few chapters. The format is:

1. OVERVIEW, DESCRIPTION, AND RATIONALE
   1.1 General Description of Approach
   1.2 Goals and Objectives of Approach
   1.3 Theoretical Rationale/Mechanism of Action
   1.4 Agent of Change (e.g., patient, therapist, group affiliation)
   1.5 Conception of Drug Abuse/Addiction, Causative Factors
   
2. CONTRAST TO OTHER COUNSELING APPROACHES
   2.1 Most Similar Counseling Approaches
   2.2 Most Dissimilar Counseling Approaches
   
3. FORMAT
   3.1 Modalities of Treatment
   3.2 Ideal Treatment Setting (inpatient, outpatient, residential, other)
   3.3 Duration of Treatment (fixed or open ended; length and usual number of sessions)
   3.4 Compatibility With Other Treatments (e.g., pharmacotherapy, family therapy)
   3.5 Role of Self-Help Programs
   
4. COUNSELOR CHARACTERISTICS AND TRAINING
   4.1 Educational Requirements
   4.2 Training, Credentials, and Experience Required
   4.3 CounselorÕs Recovery Status (essential, helpful, irrelevant)
   4.4 Ideal Personal Characteristics of Counselor
   4.5 CounselorÕs Behaviors Prescribed
   4.6 CounselorÕs Behaviors Proscribed (techniques and interventions that are discouraged or contraindicated)
   4.7 Recommended Supervision (e.g., role, format, goals)
   
5. CLIENT-COUNSELOR RELATIONSHIP
   5.1 What Is the Counselor's Role? (teacher, collaborator, therapist, peer, adviser)
   5.2 Who Talks More?
   5.3 How Directive Is the Counselor?
   5.4 Therapeutic Alliance (the quality desired, strategies the counselor uses to build the alliance, strategies to address a poor alliance)
   

 

6. TARGET POPULATIONS
   6.1 Clients Best Suited for This Counseling Approach
   6.2 Clients Poorly Suited for This Counseling Approach
   

 

7. ASSESSMENT (before, during, or after treatment; major domains assessed; instruments typically used)
   

 

8. SESSION FORMAT AND CONTENT
   8.1 Format for a Typical Session (How does the session begin and end?)
   8.2 Several Typical Session Topics or Themes (Is the theme of the session determined by the patient or the counselor?)
   8.3 Session Structure
   8.4 Strategies for Dealing With Common Clinical Problems (lateness, missed sessions, patients who attend under the influence)
   8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation
   8.6 Strategies for Dealing With Crises
   8.7 Counselor's Response to Slips and Relapses
   

 

9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT (Are other family members involved and in what way?)

With all chapters following the format, the reader can not only compare the various counseling models on any selected characteristic but also have a better idea of what a counselor actually does while following a particular model.

The work for this book began in October 1993 when the Treatment Research Branch of the National Institute on Drug Abuse (NIDA) held a conference in Rockville, MD, on counseling models. Many of the authors represented in this volume attended this conference, described their counseling approaches, and exchanged views. Subsequently, chapters were prepared and then updated in the summer of 1996. The editors hope that the chapters will show how well-developed treatment programs counsel drug abusers and will serve as a resource to counselors, treatment providers, and interested readers who seek knowledge on counseling theory and practice.

John J. Boren, Ph.D. (retired)
Chevy Chase, MD