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Alcohol and Other Drugs
Prevention and Intervention
• Most efforts directed at young people
• Rates of alcohol and tobacco use are very
high in this group
• National “Drug-free” policies don’t include
alcohol and tobacco, widely considered
gateway drugs
• Related to politics not best practice
• Harm Reduction: when it is assumed that
SA cannot be eliminated
• Types:
Needle exchange
Sobriety check points
Designated drivers
Tobacco Stings
Supply Vs. Demand
1.7 Billion for war on drugs in 87’
1.2 was for supply reduction
1990 committee revealed little evidence that
supply reduction worked
• 1997 67% for supply reduction, 33%
divided between prevention,Tx, research
• Legalization
– Extremely controversial
– Which drugs, how much, for who, where?
– Legalization vs. decriminalization
• Some drugs are legal (ETOH, Nicotine, RX
• Making drugs legal and unrestricted as
opposed to removing penalties for certain
drug related offenses
• Public Health Model (PHM)
• Focus on epidemiology
– SA is conceptualized as an interaction between
host (the substance abuser), the agent ( the
substance used), and the environment
– Prevention activities are conceptualized as
primary, secondary and tertiary
• Primary Prevention
– Attempts to dissuade individuals from initiating
• Secondary Prevention
– Early intervention, designed to halt progression
in individuals identified as users
• Tertiary Prevention
– Treatment aimed at substance abusers and
substance dependent
• Prevention Efforts
– Universal
• Directed at entire population (national media
– Selected
• targeted at risk groups (ACOAs)
– Indicated
• Similar to secondary prevention
• Prevention Strategies
Information dissemination
Problem identification and referral
Community based processes
Environmental approaches
• Few of these prevention strategies have
been proven to impact SA
• Environmental approaches (deterrence laws,
sobriety checkpoints, bartender training)
have proven effectiveness. Usually rely on
community coalitions to implement these
• Education works up to three years
• Why is intervening with SA so challenging?
• Denial- a psychological defense, response
to assault on ego integrity
• Fear- of abandoning a relationship that,
while harmful, is at least familiar. The
addict may be immobilized by fear of life
without drugs
• Intervention (according to Anderson) is the
process of stopping someone who is
experiencing the harmful effects of AOD
• Johnson Intervention- Based on the disease
model asserts that forcefulness is needed to
counter the “almost impenetrable defenses
of the victims…which are organized into
highly efficient denial systems.”
• Johnson Intervention
– “It is a myth that alcoholics have some spontaneous
insight and then seek treatment. Victims of this
disease do not submit to treatment out of
spontaneous insight-typically, in our experience
they come to their recognition...through a buildup
of crises that crash through their almost
impenetrable defense systems. They are forced to
seek help; and when they don’t, they perish
• Johnson Intervention
– Raise the bottom
– Serves to precipitate a crisis that is not life
threatening or seriously damaging
– Presents “reality” in opposition to “denial”
– Objective, unequivocal and caring
– Attacks defenses, not the victim
• Johnson Intervention Process
2 or more people
Sometimes not the closest people
Be prepared for client refusal
Get professional help
Have options arranged!!!
Emotionally charged!!!
• Effectiveness of Coercive Treatment
– Has a higher cure rate (Matuschka,85’)
– 97% of the time successful (Royce,
– 50% of the time successful (authors)
• Motivational Interviewing (William Miller
and Stephen Rollinick)
– “is a process for assessing a client’s readiness to
change and it uses procedures based on this
readiness to enhance the probability of change.
In Motivational Interviewing it is
acknowledged that the client may not be ready
to benefit from a direct attack on his or her use
of AOD.”
• Motivational Interviewing (MI)
– Confrontational strategies are not supported by
outcome studies. No persuasive evidence that
aggressive tactics are even helpful let alone
– Understandable and predictable reactions and
resistance to change cause many counselors to
jump to the conclusion that clients are in denial.
This stance elicits further resistance and denial.
• Stages of Change (Prochaska and
• Stage 1 or 2-contraindicated for use of aggressive
interventions as clients may react with increased
• Stage 3 or 4-appropriate for aggressive
intervention as client is in a position to react
• Stage 5 or 6- MHP focus on creating an
environment where client can safely discuss
difficulties with behavior change
• MHP should recognize that the stages of
change exist on a continuum and that clients
may cycle through them several times
• Working through ambivalenceCreate an environment of empathy,
respect, warmth, concreteness, congruence,
genuineness, and authenticity
• Traps to Avoid
• Confrontation- can result in a “yes you are no I’m not”
• Question answer trap- avoid closed ended questions
• Expert trap- MHP takes role of expert, client avoids
having to make choices
• Labeling- client may resist diagnosis
• Premature focus- focus on AOD before client is ready
• Blaming-client feels blamed by MHP
• Strategies for Resolving Ambivalence
– Open ended questions
– reflective listening
– affirming
– supportive statements
– summarization
• The elicitation of self-motivational
statements is the “guiding strategy to help
clients resolve their ambivalence. In MI it
is the client who presents argument for
change. It is the counselor’s task to
facilitate the client’s expression of these
self-motivational statements.
• Self-motivational Statements
Client describes the pros and cons of SA
Asking client “what worries you about SA”
“How has SA been a problem for you?”
Paradoxical Techniques
• MHP argues for continued use while client
argues against
• Rolling with Resistance
– Ambivalence does not disappear but diminishes
– Assumption is that client resistance is a
therapist problem
– Change in resistance is significantly impacted
by therapist attitudes
– Categories of resistance
• Arguing, interrupting, denying, ignoring
• Rolling with Resistance
– Techniques for reducing resistance
• Amplified or double sided reflections
• Shifting the focus (redirection)
• Emphasize personal control and choice
– Have client explain the consequences of his or her
continued SA
• Re-framing
– Assist the client in viewing the problem from a different
• Transition From Resistance to Change
– MHP will be aware of transition when client
Reduces questions about the problem
Seems more calm and settled
Makes more self-motivational statements
Asks more questions about change
Talks about life after change
Experiments with change
• If the client progresses to the action stage
the emphasis should be on
Setting goals
considering options to achieve goals
deciding on a plan
staying aware of issues that indicate a return to
an earlier stage of change