Working with Resistant Drug Abusers

By Barber, James G. | Social Work, January 1995 | Go to article overview

Working with Resistant Drug Abusers


Barber, James G., Social Work


In recent years, the psychological treatment of addiction has come to be dominated by the so-called transtheoretical model of change developed by Prochaska and DiClemente (1984, 1986; Prochaska, 1982). Under the model, drug users pass through five stages of change involving 10 processes that receive differential application during the five stages. The five stages of change are (1) precontemplation (denying the problem and resisting change), (2) contemplation (thinking about changing), (3) decision making (becoming determined to change), (4) action (actively modifying the behavior and environment), and (5) maintenance (maintaining new behaviors).

Despite the demonstrated heuristic power of the model overall, one stage--precontemplation--has been largely ignored by drug researchers and clinicians alike. Although the literature is replete with information about treatment and relapse prevention methods, much less is known about how to bring resistant clients to a point where they will seriously contemplate treatment, let alone pursue it. For example, a recent and influential book on the treatment of addictions (Miller & Heather, 1986), based entirely on Prochaska and DiClemente's (1986) change model, contained not one chapter on working with precontemplators. It is true that Miller's (1983, 1989; Miller & Rollnick, 1991) innovative work on motivational interviewing incorporated strategies for increasing the attractiveness of treatment, but even his ideas assumed that the drug user has some degree of ambivalence that can be exploited by the drug counselor.

This gap in the literature is not as surprising as it might first appear. After all, treatment methods are developed by drug specialists for use with their clients, and by definition precontemplators fall outside this purview. Although specialist drug counselors may have no other option than to exclude precontemplators, the opposite is true of nonspecialist welfare agencies that must deal with the social consequences of drug abuse. Social workers frequently encounter drug abuse in the context of another, often more pressing social problem such as domestic violence, homelessness, or child maltreatment, and in these circumstances many of the individuals concerned will either deny that a drug problem exists or reject any suggestion that their level of consumption should change. In a recent survey of West Australian prisoners, for example, Indermaur (1990) found that although approximately 65 percent of the sample had consumed more than 10 drinks before committing an offense, only 27 percent expressed any concern about their use of alcohol.

In one of the very few attempts to develop guidelines for practitioners working with precontemplators, Tober (1991) adopted what she referred to as a "damage limitation" stance. Tober rejected the proposition that heavy drinkers must be made to suffer to motivate them to change. Her own preference is to minimize the harm done by drinking and wait for maturational or environmental factors to drive the client into treatment. Tober is right to reject punitiveness as a motivational device. Not only does the crude psychology on which it is based lack empirical support, it ignores the evidence that drug abusers are just as likely to change for positive as for negative reasons (for example, Vaillant & Milofsky, 1982). Despite this failure, if one accepts Tober's approach in its entirety one is left with no semblance of a strategy for change. Tober sought to minimize harm, not to advance the client toward later stages of the change process. In addition, although it may be appropriate to provide drug abusers with all of the regular services offered by the agency, it is highly inappropriate to protect them from the consequences of their own decisions. To do so would be a contradiction of the fundamental premise on which all forms of drug treatment must be based--that addicts are responsible for their own behavior.

This article considers some of the empirically validated options for social workers who deal with drug abusers who deny any need for change or even that a problem exists. …

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