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Questions for Therapists

To gauge potential receptiveness to MM

If the directory of MM-affirming therapists lists no one near us, these questions can help to identify professionals who are more likely to support moderation-based approaches.

The answers shown can be used as general guidelines, not black-and-white indicators. They offer suggestions that can lead us to the professional support we need.

Interviewing a potential therapist or counselor, ideally, should be a relaxed conversation in which we determine whether there is enough synergy between our needs and the expert's skills to build a productive, therapeutic relationship. We, as clients, are responsible for hiring the best person to do the job we need done.

When hiring an architect to build a house, the customer needs to find an expert whose skills and style are compatible with the type of house she or he wants. Connecting with the best therapist for our needs is similar to that.

Have you used Rational Emotive Behavioral Therapy (REBT) or Cognitive Behavioral Therapy (CBT) to help clients with substance abuse issues?
 
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Yes, for some clients it's been very effective.

Not specifically, but I've used REBT or CBT in other areas and would be open to using it to address your drinking problem.

No, I am not familiar with or well-versed in using REBT or CBT.

No (or Yes), but I generally find REBT and CBT to be incompatible with substance abuse issues.
Yes, REBT and CBT are helpful, but only to the extent that they help clients work their 12-step program.

Are you familiar with Prochaska and DiClemente's Stages of Change model? How does it affect your work with clients?

Yes, I'm familiar with it and find it helpful in guiding my clients toward change.

Yes. Some clients have found it very helpful to identify where they are in the change process; my job is to help them progress from one stage to the next.
Yes, their work has been most helpful for clients who are alcohol abusers, less so in my experience with the alcohol dependent.
The Transtheoretical Model? Yes, it has changed (for the better) how I work with clients.

No, I've never heard of it.

Sure, I'm familiar with it. In rare cases it explains how people work past their denial, but more often I've seen it become an enabler.
I haven't found it helpful; my approach, which follows the Minnesota Model pretty closely, generally involves helping my client break their illogical thinking about drinking. Ideally we do that gently together, but confrontation is sometimes in the client's best interest..

How do you differentiate your approach to clients with alcohol abuse versus alcohol dependence?

Abuse and dependence are quite distinct.

Clients who meet the criteria for alcohol abuse have a number of options for changing their behavior, including but certainly not limited to abstinence.

Clients who are alcohol dependent are likely to do best by persuing abstinence, but my job is to help them make that choice for themselves.

There are studies (like Shuckit, Smith, et. al in 2001) which suggest that abuse does not routinely lead to dependence.

Abuse and dependence, while distinct, are intertwined. Those who are dependent have progressed through an abuse phase first. People with alcohol abuse, particularly those seeking help, are at imminent risk for developing dependence.

Small numbers of alcohol abusers may be able to prevent becoming dependent for a time (sometimes years) while continuing to drink, but given the inherent risks, it would be irresponsible for me to support that.

For that reason, I support clients in moderating their drinking only if they do not meet the DSM-IV criteria for alcohol abuse, and I support abstinence only for the rest of my clients.

I've heard that "harm reduction" is a topic that is discussed in your field. What do you know about it?

A number of studies are pointing to the possibility that harm reduction empowers people on their way to change.

I help my clients understand all of their options in order that they might choose what works best for them.
Sometimes harm reduction is the most viable step my clients can take immediately, even though better long-term solutions are available. It's often a good starting point, though, which sets the stage for more permanent solutions later.

It sounds interesting, but there's no scientific evidence to support it yet.

I'm curious about it, but using it with my clients it would reinforce their denial.
I help my clients pursue abstinence, so talking with them about how they might continue drinking, but less harmfully, would be unethical.

Some people with drinking problems seem to be helped by medications like Naltrexone. What can you tell me about that?

I've had clients who have used it effectively. It isn't a miracle cure, but in some cases it seems to help.

I'm not able to prescribe it myself, but I can refer you to a physician who has prescribed it for others.
I don't have the expertise to make that choice, but I've got some helpful materials which you're welcome to take to your family doctor if you so choose.

I can't support or condone the use of medications. It's just too risky in the treatment of substance abuse of any kind, so I work with my clients on being entirely drug-free.

I support the use of Naltrexone, but only with a commitment to permanent abstinence.
I support Naltrexone and have had clients benefit from it, but I'll only prescribe it after at least 30 days of continuous sobriety.

I've heard about SMART Recovery, Secular Organizations for Sobriety, Women for Sobriety and other groups. What can you tell me about them?

I know that SMART runs support groups in the area, and the rest are available online.

Some of my clients have not found 12-step approaches to be workable, so we've explored these together. I'd be happy to do the same with you.
They're all good options for pursuing abstinence. I encourage my clients to find face-to-face support whenever possible, but sometimes they're able to meet that need through another REBT or CBT group that isn't specifically geared to substance abuse.

Huh?

My work has been confined to the Minnesota Model, which is based on 12-step recovery.
I've never had a client achieve recovery without using AA.
The 12-step approach is incredibly flexible and can be fitted to meet the needs of pretty much anyone. These other groups may have helped some folks, but frankly I don't see the need for them.
At its core, substance abuse has a spiritual component. Until we address that, and AA is an ideal way to do so, recovery is simply not stable. That's why I support my clients who participate in other groups in addition to, but not instead of, 12-step groups.

I've heard that Motivational Interviewing and Motivational Enhancement Therapy have been shown to be more effective than confrontational approaches. Your thoughts?

Yes, that seems to be true.

Client-focused therapy works better than directive or coercive therapy.

In the era in which Betty Ford first got treatment, it was assumed that people would only go for help with their drinking when given ultimatums. While it has obviously worked for some, other methods -- like MI/MET -- have proven to be more effective.

My approach is to help my clients uncover their own motivation to change instead of trying to force the change upon them. That's not to say that confrontation is never a part of the work I do, but it is generally not necessary or helpful with a self-motivated client.

The majority of my client base comes through the door because their families or employers are pushing them.

Unless I'm directive or confrontive at the appropriate times (like people were with me), they only get worse.

I won't sugar-coat it: Addiction is a tough issue. I'll be as gentle and understanding as I can be, but since I've been there myself, there are times that I have to play the bad guy with my clients. I only do it because it's in their best interest and because I know it works. Doing any less wouldn't be right.

The motivational techniques? Yeah, sometimes they help, but that's generally not my therapeutic style.

What about the suggestion from the developers of Motivational Interviewing that people do best when they have treatment options to choose from -- do some of your clients choose something other than permanent abstinence?

Yes, I'm serious about supporting my clients in making their own choices.

The only caveat is that some options may trigger consequences. If a client has put his/her family at risk by driving under the influence several times, it's my job to help them understand the risks they face. Whatever their choice, they take responsibility for it.

The value of the motivational techniques lies in helping people work through their ambivalence about abstaining.

That's the basis on which I use it -- my conversations with my clients are open and vigorous, and they're free to disagree with me, but for a person with any history of alcohol abuse, overcoming the resistance to abstinence is the ultimate goal.

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Revised 07.26.2003 mm@moderation.org