Chapter 7 - Treatment Initiation

Patients often enter treatment with ambivalence about giving up their drug use. Counseling begins with helping the addict decide to participate in treatment and accept abstinence as a goal. The counselor can help the patient recognize and understand the damaging effects of addiction, address his or her denial of the problem, and show motivation toward recovery. In this progressive treatment model, the patient's ambivalence is discussed specifically in the first 2 weeks of treatment, although motivation and commitment to recovery may be issues that are returned to throughout treatment.

The first two sessions of counseling should be devoted to introducing the treatment program to the patient, obtaining a drug usage and treatment history, and developing the treatment plan with the patient. Because of their specific purpose in establishing the overall framework for the provision of treatment, these sessions are described in some detail. Counselors should follow the session agenda described. In addition to the setting up of the framework for the treatment, the first two sessions are important in fostering the patient's motivation to become sober. Ambivalence and denial are likely to be relevant concerns in the early phase of treatment. Because they are so fundamental to the recovery process, the counselor should discuss them here or at any future point in the individual patient's treatment.

1. Introduce the patient to the counseling program and its expectations. If the counseling will be time limited, point that out.
2. Obtain the patient's history. Develop a treatment plan.
3. Help the patient to realize that he or she suffers from the disease of addiction.
4. Help the patient to decide to break the addictive cycle.
5. Help the patient to see the benefits of a drug-free lifestyle.

1. Denial
2. Ambivalence

Denial

Denial is defined as refusing to believe the reality about one's life circumstances. It may be refusing to believe that one is addicted or refusing to acknowledge that the losses one has suffered as a result of the addiction are significant.

Patients often enter treatment with some denial about their addiction, so this behavior should be pointed out and explored early in counseling. In spite of evidence to the contrary, addicts may believe they still can control their chemical use. They often do not believe that they have the disease of addiction, and they frequently are ambivalent about giving up their drugs.

A patient experiencing denial may exhibit some of the following erroneous beliefs:

1. Refuse to believe that he or she is an addict.
2. Think that he or she can solve the problem by "cutting down" on cocaine use, rather than eliminating it totally. Patients may also say that they want to get their cocaine use back "under control."
3. Refuse to believe that a secondary drug (alcohol, for example) is a problem, as well as their primary drug of choice (cocaine, for example).
4. Refuse to believe that Alcoholics Anonymous or Narcotics Anonymous will be helpful, because he or she is "not like the people there," ostensibly because their drug problems are so severe.
5. Insist on continuing to spend time with "friends" who enable the patient's use by agreeing that drugs are not a problem.

When the counselor recognizes that denial is interfering with the patient's ability to successfully deal with the addiction, the counselor should endeavor to get the patient to realize that he or she is not seeing the truth about the addiction. Finally seeing the truth will foster motivation and promote a desire to change. The counselor may use confrontation, pointing out what the addiction has cost the patient, and encourage the patient to abstain from drugs temporarily if he or she truly is not addicted.

Ambivalence

Patients usually enter treatment with some ambivalence about staying sober or making a commitment to treatment. The patient's motivation should be examined early in the counseling sessions.

Feelings of ambivalence often are present for the following reasons:

1. The patient associates drug use with some positive emotional change.
2. Drug use may have been employed as a coping strategy for solving problems, and the patient does not yet know of a better coping strategy.
3. The patient may feel too weak or helpless to break the powerful cycle of addiction.

A patient's feelings of ambivalence should be explored so the counselor can assist the patient to recognize the ambivalence and identify the underlying reasons. Understanding the patient's reasons also will help the counselor to direct discussion regarding motivation appropriately.

Motivation refers to how much the patient is impelled to act on the desire to become sober. A patient may enter treatment already somewhat motivated because he or she recently "hit bottom" in some way. Such a "bottom" may be losing one's job or one's spouse, draining one's bank account, or getting arrested. Although these consequential life events may help to motivate the patient, they may not be sufficient. Additionally, the counselor should encourage and support the patient's desire to become sober.

The counselor should discuss the patient's ambivalence and motivation to quit using and commit to recovery. Encouraging the patient to discuss the pros and cons of using and focusing on the patient's reported negative consequences of using may help to cement, or at least strengthen, the patient's desire to become abstinent. Having the patient identify the personal benefits of a drug-free lifestyle, and particularly what he or she really wants in life, helps to highlight the advantages of becoming sober. Identifying patients' individual goals for their life and talking about how such goals can be attained can be empowering and lead patients to feel more able to be proactive in making positive changes.

Session 1

In the first session, the counselor's goals are to establish rapport, review the ground rules for participating in treatment, and begin to know the patient. The patient needs to understand the expectations of the program and agree that they are important for successful treatment. Next, the counselor should begin to take a detailed drug usage and treatment history to allow the counselor to focus on the patient's own addiction related concerns. The counselor also will want to find out recovery-related activities in which the patient is involved (NA, religious program, etc.) and what supports he or she has (supportive partner or family, etc.).

Session 2

The counselor should finish obtaining a thorough drug usage and treatment history that will culminate in the treatment plan, basically a contract established by the counselor and patient collaboratively. The plan should identify the problems to be addressed in treatment and the desired goals. The primary problem identified always should be the addiction; other problems should be addiction related. In IDC, the drug-use goal always should be total abstinence, not just abstinence from cocaine. The initial treatment plan is basic. Its purpose is to clarify the mutually agreed upon goals of the patient and counselor, with the patient making a commitment to work toward recovery.

The counselor should inquire about the patient's experience with 12-step groups and ask whether the patient already attends meetings, or has previously but no longer attends, or has never heard of them. If unfamiliar with the 12-step approach, the patient should be introduced briefly to the 12-step approach and meetings in the area. (The counselor can provide lists of the local meetings.) All patients should be encouraged to attend meetings at least 3 to 4 times a week as part of his or her plan for recovery. If agreed to, participation in self-help groups should be listed on the treatment plan.

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