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Patients have come to us for our expertise.
In substance abuse settings, the person is
using and wants to stop using for good
There is an implicit understanding that, since
the patient has come to us for our expertise,
he/she is now ready to engage in whatever
behaviors we prescribe for them
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The person in front of you is experiencing
negative consequences
The person would prefer to remove the
negative consequences with minimum effort,
and with a minimum change to their lifestyle
The person wonders if you can assist in
removing those consequences so they can get
back to business as usual
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The person may not any causal link between
their behavior and the consequences
(example: Patient court-ordered to treatment
after a DUI)
The person may have little desire to change
the behaviors that lead to those
consequences (a smoker wants treatment for
cancer, but may have no desire to quit
smoking)
No awareness of link of substance use and life
problems:
 I got a DUI because of random check points.
 I’m here because my parents are making me
do it.
 I’m in this program because I have to be in a
program to get housing/voc rehab/DSS/to
apply to disability
 I have to go to treatment as part of my
probation
Some awareness of a link:
 I’m drinking too much and I need to cut
down. OR I know I need to quit for now
(but when I can I start again?)
 I know smoking’s bad, but I already have to
give up sweets, fatty foods, and now I need
to exercise – smoking is the last pleasure I
have left
 AMBIVALENCE: the coexistence within an
individual of positive and negative feelings
toward the same person, object, or action,
simultaneously drawing him or her in
Clear awareness of a link
 I know I can never drink or use drugs. Not
even a little.
 I know what will happen if I start to drink
again – I might end up in jail – or worse, I
might end up dead
 I need to be totally abstinent
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While it’s pretty safe to assume a patient
wants to rid him/herself of some negative
consequences, you don’t know where the
client stands with respects to his/her
understanding of what’s happening or
his/her desire to make changes
Summary: You can’t assume they’re ready to
embrace your agenda
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People who use alcohol and pills are using legal, socially
sanctioned substances. Although marijuana is illegal, there is
a strong movement to support its benefits, and it is actually
legal for medicinal purposes in many states.
In my experience, these people seem more vulnerable to
failing to link use of these substances to their problems.
These people will often state ‘moderation’ as a goal.
Crack and heroin users know these drugs are illegal, they
know there is a stigma. It is therefore harder to make the
argument that these substances are not linked to problems.
They don’t argue for moderation, though they would secretly
prefer to be able to continue to use without negative
consequences.
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Usual purpose of interview: OBTAIN
DIAGNOSTIC INFORMATION, SEVERITY
Through a series of structured, close-ended
questions, we attempt to identify/quantify
substance abuse problem by asking direct
questions related to substance abuse
How’s a person in ‘Pre-contemplation’ going
to react to this?
Maybe they’ll get defensive, argumentative,
or shut down
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Although we feel pressured to get
information, resist this urge, and try the
following:
Ask the patient open-ended questions like:
“Why are you here? What brought you here?”
Follow up with further open-ended prompts:
“Tell me more about that.”
Clarify with: “What do you hope that our
working/talking together will accomplish?”
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Persons who are in Preparation/Action generally
acknowledge alcohol/drugs are a problem and can
probably better tolerate direct questions about
drug/alcohol use and negative consequences
Persons in Precontemplation/Contemplation might
get very defensive if you do rapid-fire substance
abuse questions
Work your way up to it gradually as part of the
psychosocial history.
Pay close attention to things in the history that may
be indicative of substance abuse problems
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Severity can affect how you approach
treatment
Someone with a long and severe history of
use will probably not benefit from harm
reduction/moderation, and might be more
willing to embrace total abstinence
Someone with a shorter, less severe history,
may only be willing to entertain moderation
at the present time. Arguing for total
abstinence will probably shut down treatment
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Starting use prior to 21 years of age (biologically
increases risk of developing addiction)
Use for 5-10 years (about the time it takes to
develop alcohol dependence)
Family history = more possibility of genetic
predisposition (did anyone die of liver problems?)
NOTE: You don’t have to know all the signs of
substance abuse – if you are taking a good
history, you should be able to present it to
someone with the background, and they can help
you recognize these signs
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“Tell me about any legal issues you have…” (DUI,
open container, posession)
“Tell me about your work history…” (Unstable
employment pattern, conflicts at work, tardiness)
Recreational activities (lots of things that involve
drinking)
Relationship patterns (divorces, loss of friends)
Physical symptoms – sweaty hands, shakes, sleep
problems (alcohol), lots of complaints pain
(opiates/pain killers)
“When did you first try x or y?”
“Tell me about your family, parents, their health”
(looking for drug-related problems)
Desire to change
 Ability to change
 Reasons for change
 Need for change
 Commitment to change
 Actions
 Taking Steps
NOTE: Using open-ended questions might give
you more access to this information than
would a closed yes/no kind of question
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As you gather data that the client gives you,
you are actually compiling a list for reasons
for that person to change
Later on, as you negotiate what you do in
treatment, you can reflect these data back to
the patient in the form of feedback (e.g. a
written summary or report)
Feedback can be a compelling motivator to
faciltate the desire to change – the data come
from the patient and not from you
They provide their OWN reasons to change
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Use reflective empathy statements (e.g. “that
must have been difficult”)
◦ Builds rapport
◦ Allows for clarification
◦ Gives the patient a feeling of being heard
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Reflective summary statements also build
rapport, show the patient you are listening,
and allows for clarification
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Patient unaware of problems related to drug use
are probably going to give more information that
points to those problems
Patients who are aware of problems might report
fewer problems, as there is a universal tendency
to present oneself in a favorable
Patients who are aware they are being evaluated
for drug/alcohol problems are going to be
motivated to under-report their use
Remember, self-report is but one source of
information that, in the case of addiction
especially, requires corroboration
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Corroborate information with significant
others, family members
Corroborate using drug screens,
breathalyzers, lab values
Feel uncomfortable about doing the above?
Work it into your consent to treat and be right
up front from the beginning
Preventing underreporting and increases
accountability is a highly effective
intervention in its own right!