Chapter 8 Addictions

Just as there is no one "alcoholic" or "drug addict," there is no one

"tried and true" treatment approach.

problematic substance use

Due to the multiplicity of factors that contribute to problematic substance use, interventions can and are often implemented to address more than one type of trigger

"alternative paths" or "new roads"

Only by making connections between triggers and effects can "alternative paths" or "new roads" be constructed for achieving preferred outcomes (e.g., relaxation) without the use of substances.

BASICS program on campus

a two-session program intended to raise awareness of drinking behaviors and to encourage a consideration of behavior change by providing feedback in a nonjudgmental manner. The BASICS program has proven effective at decreasing alcohol use and its consequences at 6-month follow-up, especially for male students, at one large university

CB interventions

address coping skills and are grouped according to five factors or types of precursors (or triggers) to addictive behaviors.

Contingency management and behavior contracting]

are specific CB approaches that have demonstrated efficacy in treating alcohol and other drug dependence—namely, cocaine and opioid dependence—for adults and adolescents

Past exceptions

can be detected by inquiring about life before using or occasions when the negative consequences of one's use were not prominent or even existent.

Customer-type relationship (SFBT)

client and therapist jointly identify a problem and a solution to work toward

prize incentives

clients may be awarded with an increasing number of vouchers or opportunities to win a prize (e.g., from a raffle or drawing). This particular practice is known as prize incentives CM for substance abuse

CRA enlists

community reinforcers (e.g., family, recreation, employment) to support change in an individual's substance use

Solution Focused Therapy

conceived and developed by de Shazer and colleague sat the Brief Family Therapy Center (BFTC) in Milwaukee, Wisconsin, almost 45 years ago. It emerged as a form of brief or short-term psychotherapy. The emphases of SFC are pragmatism (i.e., what works) and mental health (rather than mental illness; Berg & Miller, 1992), which make SFC a radically simple approach. SFC has its roots in the work of hypnotherapist Milton Erickson and family systems theory

Behavioral assumptions

consider only observable behavior, including autonomic and other forms of physiological activity (e.g., craving), without necessarily considering the influence of cognitive activity.

functional analysis assessment

interactive and structured format of the antecedents (or triggers) and consequences (or effects) of substance use. a piece of paper to record responses (triggers in one column, effects in another

Physical interventions

involve activities intended to distract the person's attention away from triggers and the consequent cravings and urges to use. They also can include pharmacological intervention,

customer-type relationship

involves joint construction of a solution plan or path that the client is able and willing to participate in and even take the lead on.

Community Reinforcement Approach

is a comprehensive biopsychosocial approach to the treatment of substance use disorders based on the premise that one's environment or community plays a critical role in reinforcing one's recovery efforts.

Functional Analysis occurs

is conducted at the beginning of counseling and follows an interactive and structured format, preferably using a piece of paper to record responses (triggers in one column, effects in another).

Recent and recurrent exceptions

may not be in the client's awareness and so require the counselor's curiosity skills about recent events or experiences that can be interpreted as glimmers of a possible solution in the making. Reframing also may be necessary.

Incentives for upholding the contract

might include meeting with the counselor outside, on the grounds of the agency; having access to the agency's basketball court following a counseling session; an extended (by 5 minutes) smoke break during group counseling; and securing from the counselor a letter of reference for a job application. Privileges" for upholding one's contract might include telephone access to family members, being able to receive visitors on "Family Day," and being able to skip meal preparation and cleanup or other household chores for one day.

multifaceted and complex phenomenon

movement away from the "widespread" endorsement of substance dependence as a disease (Ogborne et al., 1998) to an understanding of addiction as a

Notice The Difference

must also assist their clients (and the client's family members, too) to notice when these problem irregularities occur.

CB assumptions

pertain to humans only, focusing on internal, self-appraisal, and other cognitive functions that influence behavior.

Solution Focused Brief Therapy

post-structural/post-modern, constructivist, or social constructionistic ideology: Positive change is not only regarded as possible, but inevitable (Berg & Miller, 1992), characterizing SFC as the "counseling of hope"

clinician attitudes

significantly influence the acceptance and implementation of new or innovative therapeutic approaches

behavioral economics

that posits behavior is chosen because of the immediate and tangible reward(s) it provides, including monetary reward.

Behavior contracting

the intended behavior clearly described, the targeted date of task completion specified, and both the incentive and the consequence for not abiding by the contract clarified. In addition, the contract should be signed by both the counselor and client, dated, and a copy of the contract provided to the client.

exceptions in one or more of four areas

(a) the past, (b) recent nonproblem occurrences, (c) recurrent exceptions (i.e., instances that occur periodically, often without warning), and (d) occasions in the future when the client can imagine the problem no longer existing or being influential.

"informed eclecticism"

(a) there is no single superior approach to treatment for all individuals, (b) treatment programs and systems should be constructed with a variety of approaches that have been shown to be effective, and (c) different types of individuals respond best to different treatment approaches.

externalization exercise

used in solution-focused counseling in which the client names the problem (e.g., "restless roamer," as one heroin addict depicted his reasons and struggles in finding "peace" in his life), is able to regard the problem as an external entity (i.e., "I am not the problem . . . 'restless roamer' is the problem"), and through conversation is able to keep the problem at a distance so as to diffuse the problem's power over the client.

Language of Hope

words and language are thought to create reality and meaning. Given that the majority of clients in substance abuse treatment have not initiated services on their own (i.e., have been mandated by a court system or a social service agency and are thus considered "involuntary") and more than likely feel angry, demoralized, and fearful about being sent to counseling, skeptical about the need for treatment and its outcome, the specific words used by the counselor can have a significant effect on the client's amenability to and engagement in counseling. DONT use Alcoholic or addict

CM implementation was found to be cost-effective

$29.40 for each participant for nine sessions total) and to significantly improve attendance

CB approaches six assumptions

(a) substance abuse involves complex cognitive and behavioral processes; (b) substance abuse and associated cognitive-behavioral processes are, to a large extent, learned; (c) substance abuse and associated cognitive-behavioral processes can be modified, particularly by means of CB counseling; (d) a major goal of CB counseling for substance abuse is to teach coping skills to resist substance use and to reduce problems associated with substance abuse and dependence; (e) CB counseling requires comprehensive case conceptualization that serves as the basis for selecting specific CB techniques; and (f) to be effective, CB counseling must be provided in the context of a warm, supportive, collaborative counseling relationship.

CB interventions

(e.g., relapse prevention) are effective in treating drug dependence (e.g., cocaine and opioids).

18 modalities were determined to be efficacious

). Due to both the methodological rigor employed and the strength of treatment outcome: brief intervention, motivation enhancement, community reinforcement, self-change manual, behavioral self-control training, social skills training, behavioral marital therapy and family therapy, a variety of pharmacologic interventions (e.g., acamprosate, naltrexone), and cognitive therapy.

addiction ideology (e.g., medical, humanitarian or empathic, moralistic)

. Studies suggest that addiction ideology (e.g., medical, humanitarian or empathic, moralistic) affects the selection of specific treatment strategies as well as receptivity to evidence-based practices

(SAMHSA) National Registry of Evidence-based Programs and Practices

171 interventions for substance abuse prevention and treatment. Included are cocaine-specific coping skills training, relapse prevention therapy, motivational interviewing (MI), motivational enhancement therapy (an adaptation of MI), multisystemic therapy, contingency management, Seeking Safety (treatment for co-occurring substance abuse and trauma; seekingsafety.org), solution-focused group therapy, Twelve Step Facilitation Therapy, and several brief interventions

_____________ of alcoholics experience depression and anxiety, respectively, while approximately 25% of all suicides are committed by individuals with chronic alcohol use disorders.

25-30%

mindfulness exercises urges to smoke

7 days later: (a) they smoke significantly fewer cigarettes per day and (b) a significantly weaker connection between experiencing a negative affect (e.g., anxiety) and the urge to smoke (i.e., less reactivity).

overlap between behavioral and CB assumptions.

A core principle specific to addictions shared by behavioral and CB theories is that substances are powerful reinforcers of behavior

list of cognitive comebacks

A list of cognitive comebacks to urges or cravings to use can be devised so that the client has an expanding toolbox of relapse prevention strategies. Such comebacks might resemble the externalization exercise

Disease model

A single, standard, predetermined form of treatment is often used, without regard for individual differences among clients. Lifetime abstinence is the unquestionable goal and participation in Alcoholics Anonymous (AA) is strongly endorsed.

extension of CRA is Community Reinforcement and Family Training (CRAFT)

CRAFT is based on the principles of CRA but it is designed for and targets the friends and family members of the person with the substance use problem, specifically the person who refuses to enter treatment (Meyers et al., 2005). Rather than working directly with the person with substance use problems, CRAFT enlists the assistance of a concerned significant other (CSO), such as a parent or a spouse, by training the CSO to interact with his or her loved one in new and more constructive ways. These would include not speaking with the family member when he or she is intoxicated (e.g., saying in a calm and measured voice, "I'll wait and talk with you about this in the morning, once you're sober") and allowing the family member to realize the natural consequences of his or her substance use (e.g., not bailing the family member out of jail).

First step in a Functional Analysis

Clients are first asked about the situations in which they are most likely to use, including places, people, times of day, and feeling states.

Functional Analysis in action

Clients are first asked about the situations in which they are most likely to use, including places, people, times of day, and feeling states. Next, clients are asked what they like about using, what for them are the desired or anticipated consequences of using. Client responses are recorded in the right-hand "effects" column. Once there is a sufficient number of items recorded in each column (and counselors are encouraged to ask for elaboration after each client's response), clients are then asked to make connections between each of the entries in the triggers column with each of the entries in the effects column If the client acknowledges a connection between these two entries, the counselor then draws a line between them. The client is then encouraged to make as many connections as possible between the remaining entries in the triggers column with those in the effects column, drawing a line between them so that all entries are connected.

Community Reinforcement Approach

Encouraging a person to change environmental conditions to make them more reinforcing than drug use. Careful attention is given to the ongoing assessment of external and internal triggers for substance use. Not only are attempts made to regulate environmental stimuli; the counselor routinely inquires about the client's internal triggers (e.g., mood, beliefs, physical status). As a CB-oriented approach, the CRA is intended to equip the client with a variety of skills needed to not only effectively manage negative stimuli or triggers, but to also establish and maintain a lifestyle and an environment that support and allow one's recovery to thrive.

FRAMES

Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy to enhance a person's own resources for change by activating his or her own self-regulatory processes

myopic perspective

Many chemical dependency counselors may thus practice within the bounds of one model of addiction—likely the (ill-defined) disease model of addiction. Such a myopic perspective can have the effect of missing, ignoring, or even dismissing other and perhaps equally valid explanations for a client's addiction and that client not being able to appreciate or apply alternative treatment methods

second step of functional analysis

Once there is a sufficient number of items recorded in each column (and counselors are encouraged to ask for elaboration after each client's response), clients are then asked to make connections between each of the entries in the triggers column with each of the entries in the effects column. The counselor demonstrates by linking two entries. If the client acknowledges a connection between these two entries, the counselor then draws a line between them.

"top-down" methods

Other reasons for not adopting and then routinely implementing evidence-based treatments include administrative "top-down" methods used in some settings that do not consider frontline provider views and preferences, and the perceived and actual high costs of implementation, which include ongoing and quality provider training.

Pragmatism (Parsimony)

SBFT Simple SFC exemplifies a brief intervention in its focus on helping the client get unstuck by not dwelling on the intricacies of the problem

SOBER breathing space

SOBER refers to the five sequential tasks of Stopping or slowing down when experiencing a trigger to use, Observing what is happening in the moment, focusing on your Breathing, Expanding your awareness of other sensations (e.g., clammy hands, sweating), and Responding (versus reacting) with awareness in a healthy, self-compassionate way.

They found that five assessment instruments were seen both as most important to use and most often used by substance use disorders counselors.

Substance Abuse Subtle Screening Inventory (SASSI) (both the SASSI-3 and the SASSI Adolescent versions), the Beck Depression Inventory (BDI), the Minnesota Multiphasic Personality Inventory—2 (MMPI-2), the Addictions Severity Index (ASI), and the Michigan Alcoholism Screening Test (MAST). Interestingly, two of the five instruments, the BDI and the MMPI-2, are primarily used to detect mental and emotional disorders, not substance use disorders per se.

Collaboration Is Key

The emphasis on or commitment to client-counselor collaboration is evident in SFC's proposition of three types of therapeutic relationships as opposed to three types of clients visitor-type, complainant-type, customer-type relationship

behavioral and cognitive principles

The most effective treatments for substance use problems combine

"warm turkey"

This alternative includes sobriety sampling, whereby the client attempts to abstain for a period of time (e.g., over a weekend), on an experimental basis, is intentional about taking mental or even written inventory of the experience (e.g., completing a self-monitoring card of cravings/urges, "close calls," emotional states, and any relapses), and then reports to his or her counselor at the next session how the trial period went.

"New Roads"

This process of functional analysis follows the "New Roads" exercise developed by W. R. Miller and Pechacek (1987) and used in Project COMBINE. The intended outcome is enhanced understanding—for the counselor and for the client—about the role of alcohol and other substances in the client's life.

Commendations

Throughout the process of counseling, solution-focused counselors are on the lookout for and notice positive differences—exceptions—in their clients. When sincere efforts or accomplishments are evident (e.g., attending one's first AA meeting), the counselor brings those to the client's attention in the form of commendations or what are referred to in motivational interviewing as "affirmations." Commendations or affirmations are not to be confused with well-intentioned, although less than substantive, "cheers" that may be regarded by the client as disingenuous. commendations should highlight the client's hard work.

social learning theory of Albert Bandura

Unlike behavior theories, however, CB theories include cognitive principles of learning, chief among them the

question the evidence

Using cognitive interventions, clients can also be taught to question the evidence regarding the seemingly infinite benefits of substance use, as well as the seemingly infinite detriments or negative assumptions about sobriety. Counselors can assist in stopping any circular reasoning by interjecting "Okay, where's the evidence that this is true?" and "How do you really know that for sure?"

tailoring or customizing treatment

W. R. Miller and Hester strongly emphasize tailoring or customizing treatment to the unique needs and strengths of each individual client, thereby increasing treatment effectiveness and efficiency

Definitions of addiction as a disease

a chronic, progressive, involuntary, irreversible, and potentially fatal illness, which has as its core criteria the loss of control over the intake of alcohol and physiological dependence.

Brief Intervention FRAMES

a) Feedback of personal risk or impairment, delivered in a matter-of-fact and nonjudgmental manner; (b) emphasis on personal Responsibility for change, intended to be empowering for the client; (c) clear Advice to change, delivered as a recommendation and, consistent with motivational interviewing, only with client permission (see Miller & Rollnick, 2013); (d) a Menu of alternative change options; (e) therapist Empathy; and (f) facilitation of client Self-efficacy or a sense of optimism and competence.

MBRP

aftercare program intended to promote increased awareness of triggers for substance use, habitual patterns of using, and "automatic" reactions that seem to control a person's daily living.It takes place in 2-hour weekly group sessions over an 8-week period. Each session offers instruction on mindfulness skills, and time is allotted for practicing these skills when urges, cravings, and other triggers to use arise.

CRAFT

also is designed to help CSOs take better care of themselves and to realize a sense contentment on their own. CRAFT has been described as "a rigorous treatment package" (Roozen, de Waart, & van der Kroft, 2010, p. 1730) and its results are impressive. A review of CRAFT studies conducted over 25 years indicates that 55%-86% of treatment-refusing family members enter treatment as a result of their CSO participating in CRAFT

Berg and Miller (1992)

are credited with being the first to apply SFC to substance abuse treatment, specifically treatment for alcohol-related problems. Since then, many others have contributed to the conversation of integrating SFC into substance abuse treatment

Emotional interventions

are designed to regulate both positive and negative emotions so that neither serves as a trigger for relapse. Through cognitive strategies, clients may be taught to stay with the feeling while reviewing to themselves (preferably verbalizing out loud) the list of things they have already accomplished to stay sober (e.g., "Mark, you are reMARKable for having said, 'Let's take a time-out of 5 minutes to cool down before we talk about this some more'"). This practice is similar to the distress tolerance skills (e.g., self-soothing) taught in dialectical behavior therapy

Cognitive interventions

are specifically intended to modify automatic thoughts and drug-related beliefs, as well as to modify conditional assumptions and core beliefs. Rather than automatically thinking that only marijuana can help them get to sleep, clients can be taught to catch themselves from lighting up (perhaps by telling themselves out loud, "Hold off!" or "Wait!") and reviewing the written plan constructed with their counselor detailing alternative preparations for sleep (e.g., listening to relaxing music while depressing a stress ball).

Behavioral Techniques

aversion therapy and cue exposure treatments wherein a conditioned behavior (e.g., opiate addiction) is targeted for extinction by introducing an aversive stimulus (e.g., medication that produces negative side effects) or presenting a series of drug-related cues (e.g., images or smells associated with drug use) and preventing the conditioned response (i.e., drug use).

effective behavioral and cognitive-behavioral (CB) interventions

behavioral self-control training, community reinforcement, contingency management and behavior contracting, social skills training, and behavioral couples/family counseling.

(involving 75,000 clients) up through the year 2000, W. R. Miller, Wilbourne, and Hettema (2003) acknowledged little overlap between modalities with strong research support and "those components often employed in U.S. alcoholism treatment programs" today (p. 41). Due to both the methodological rigor employed and the strength of treatment outcome, 18 modalities were determined to be efficacious. These included

brief intervention, motivation enhancement, community reinforcement, self-change manual, behavioral self-control training, social skills training, behavioral marital therapy and family therapy, a variety of pharmacologic interventions (e.g., acamprosate, naltrexone), and cognitive therapy.

reframe feelings

certain feelings can be reframed as positive protective devices, if not acted upon in destructive ways. For example, fear and anxiety can be understood as normal responses to a brand new reality or lifestyle, and both feelings can be regarded as the client's attempts to protect what is now valuable (i.e., sobriety).

"irregularit[ies]"

characterized exceptions as problem "irregularit[ies]" (p. 2), further illustrating the notion that exceptions are changes or alterations to what the client may have resigned him- or herself as being the "same old, same old" problem pattern. In order to help the client get unstuck from a "problem-saturated story"

self-soothing

clients are taught to focus on one of the five senses at a time, pausing to fully attend to, experience, or soak in the natural or nonsubstance-induced sensation (e.g., observing the contrast of green tree leaves against a bright blue sky) in order to withstand an urge or a craving to use

CB approaches

consider the role of cognitive processes such as self-efficacy, expectancies, and values in the initiation and maintenance of problematic substance use, as well as in its recovery.

"The compulsivity of addiction is the persistence of recovery."

convey that when persons with substance use problems begin and maintain recovery, they do not have to discard all behaviors associated with their addiction. Rather, they can (and perhaps need to) "channel" or redirect their frenetic energy into a "no-holds-barred" or "pull-out-all-the-stops" approach to recovery

fourth step of functional analysis or start of treatment planning

creating a third column, entitled "alternatives," and having the client identify possible substance-free behaviors that can be linked to each entry in the "effects" column. formulating possible interventions.

Mindfulness-Based Relapse Prevention

deliberate practice of noticing, accepting, describing, and not judging one's immediate perceptual experience (Hayes, Follette, & Linehan, 2004). Essentially, it is an openness to and an attentional focus on what is taking place in the present moment, using as many senses as possible (e.g., sight, sound, smell), including attending to visceral functioning (e.g., breathing). This type of centering can serve as an antidote to impulsive behaviors, including substance use behaviors. The very act of intentional awareness of the present moment (externally and within) without responding to or acting on what is observed can delay or suspend, diminish, or erase urges to act (e.g., using a substance). reducing substance use and craving during and up to 4 months after participating in an 8-week program (

visitor-type relationship

describes the interaction that may ensue when the client believes there is not a problem and the counselor agrees, validates, or "goes along with" this perception, while at the same time offering to help the client in ways the client may be able to determine.

last assumption of CB approaches

dictates a practice fundamental to CB counseling: conducting a functional analysis at the start of care

physical activity and expression include

engaging in physical exercise (e.g., doing chores around the house, going for a walk), talking with someone (e.g., calling one's AA sponsor), breaking out into song, or snapping a rubber band worn on the wrist. In addition, clients can be reminded of the "insanity" of their active using days, recalling "seemingly irrelevant decisions" made (see Marlatt & Donovan, 2005) and the negative physical consequences of their using

Slow adoption and routine implementation of Evidenced practices

estimate that only 25% of providers in addictions treatment offer evidence-based treatments. As mentioned earlier, this is due in part to the persistence of one ideology of addiction (i.e., disease) associated with certain interventions that continue to be used despite evidence that they are ineffective

Exceptions Facilitate Change

focus on exceptions to the problem rather than on the problem itself. Exceptions refer to occasions when the problem is not a problem or times when the problem could have happened (e.g., relapse) but did not.

Brief Interventions

for problematic alcohol use have been practiced and studied for over 50 years (McCambridge, 2011). They now are part of a public health initiative known as Screening, Brief Intervention, and Referral for Treatment, or SBIRT, intended in part to integrate substance use services within primary care (McCance-Katz & Satterfield, 2012). Brief interventions are considered "a family of interventions varying in length, structure, targets of intervention, [and] personnel responsible for their delivery"

"informed eclecticism"model

guides the content of this chapter in that (a) there is no single superior approach to treatment for all individuals, (b) treatment programs and systems should be constructed with a variety of approaches that have been shown to be effective, and (c) different types of individuals respond best to different treatment approaches In addition, W. R. Miller and Hester strongly emphasize tailoring or customizing treatment to the unique needs and strengths of each individual client, thereby increasing treatment effectiveness and efficiency.

CM practices

have yet to be widely adopted by practitioners due in part to the belief that substance abuse clients should not be awarded with prizes or vouchers for abstinence (Ducharme et al., 2010) and the perceived and actual costs of the program

third step of functional analysis

he client is then encouraged to make as many connections as possible between the remaining entries in the triggers column with those in the effects column, drawing a line between them so that all entries are connected.

disease model's

history as the "dominant" model of addiction in the United States

future exceptions

in SFC is the use of the "miracle question." de Shazer (1985) is credited with designing this creative question to encourage clients to visualize, and potentially make real, a future nonproblem period. By imagining and projecting themselves into a future situation (namely, tomorrow) in which the problem is no longer present, clients can view themselves as functioning satisfactorily

Social interventions

include certain lifestyle changes (e.g., exercise, meditation), enhancing one's sober social support (e.g., attending Alcoholics Anonymous/Narcotics Anonymous [AA/NA] meetings), learning and practicing effective interpersonal communication skills (e.g., differentiating between aggressive and assertive communication), and refusal skills (i.e., practicing verbal and nonverbal communication to avoid and turn down offers to use). Group/individual/family member

Environmental interventions

include cue exposure treatment mentioned earlier. Clients also can be advised to thoroughly clean their living space, one area or one room at a time, to reinforce their sense of control over their own personal or local environment. This practice could also symbolize a cleansing or purging of the "toxic self." Avoiding certain places (e.g., neighborhood where crack or meth house located, certain bus stops) by frequenting other, nonhigh-risk locations (e.g., community center, local museum, AA/NA meetings)

urges to smoke

instructed students to pay attention to their thoughts, sensations, or urges to smoke without trying to change or avoid them when presented with cigarette cues. The urge-surfing exercise (Marlatt & Gordon, 1985) was described, and students were encouraged to visualize their urge as a wave and to imagine riding the wave as it naturally crested and then subsided, rather than fighting the urge or giving in to it (because urges, like waves, do gradually decrease in intensity as time goes by).

Contingency management (CM)

makes use of external incentives or tangible reinforcers (namely, vouchers redeemable for goods and services, e.g., groceries, public transportation, movie theater tickets) that are contingent on the client meeting predetermined treatment goals (or target behaviors), such as submitting drug-free urine specimens and arriving to counseling on time.

Functional analysis

means understanding the function or purpose of substance use behaviors for a specific individual.

Functional Analysis

means understanding the function or purpose of substance use behaviors for a specific individual. It constitutes an assessment of the antecedents (or triggers) and consequences (or effects) of substance use.

combined behavioral intervention (CBI) condition

provided a 20% advantage over the other two conditions (pharmacotherapy and a behavioral medical management program) at 1-year follow-up on at least two alcohol outcomes (Donovan et al., 2008). The CBI integrated certain cognitive-behavioral interventions (e.g., coping skills training) with other interventions, such as motivational interviewing, encouraging persons to sample and participate in 12-step and other support groups, and exploring client strengths and resources (see W. R. Miller, 2004).

complainant-type relationship

typifies problem recognition and a shared understanding of the nature of the problem (e.g., on probation with the county municipal court for a repeated driving under the influence [DUI] charge), with the focus being on how the client can transition to seeing him- or herself as part of the solution

complainant-type therapeutic relationship

typifies problem recognition and a shared understanding of the nature of the problem (e.g., on probation with the county municipal court for a repeated driving under the influence [DUI] charge), with the focus being on how the client can transition to seeing him- or herself as part of the solution (as opposed to looking to others for resolution, e.g., "Get my probation officer off my back").

pharmacological intervention

uch as the prescribed use of methadone or naltrexone to curb drug craving.