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Behavioral Therapy for Rural Substance Abusers

Behavioral Therapy for Rural Substance Abusers

Carl Leukefeld
Theodore Godlaski
James Clark
Cynthia Brown
Lon Hays
Copyright Date: 2000
Pages: 224
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  • Book Info
    Behavioral Therapy for Rural Substance Abusers
    Book Description:

    The problems and needs of rural substance abusers vary from those of abusers in urban areas. Accordingly, the means of treatment must acknowledge and address these differences. Despite this call for specialized care, no theoretically grounded therapy has yet been made available to rural patients.

    Behavioral Therapy for Rural Substance Abusers, developed and piloted over three years by University of Kentucky faculty and staff and substance abuse counselors in rural eastern Kentucky, provides a model for effective treatment for this segment of the population. A two-phase outpatient treatment, this approach combines group and individual sessions in an environment that is both comfortable and useful for the client.

    The success of this method lies in its regional approach to therapy. Rather than using role-playing techniques to examine old behaviors, therapy is designed around storytelling activities. Rural patients respond more positively to such time-honored traditions and thus become active participants in their own treatment.

    This manual offers a clear and well-constructed guide through the strategies of Structured Behavioral Outpatient Rural Therapy (SBORT). Supplemented with illustrations, sample exercises, and case studies,Behavioral Therapy for Rural Substance Abusersis a vital tool in meeting the treatment needs of an otherwise ignored rural population.

    eISBN: 978-0-8131-5785-6
    Subjects: Psychology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-ix)
  3. Acknowledgments
    (pp. x-x)
  4. Introduction
    (pp. 1-5)

    Rural communities, like urban communities, have drug-and alcohol-related problems (Edward, 1992). Based on information from urban centers, it is evident that therapies cannot be used in rural areas without modification. The characteristics of the substance abuser, drug(s) of choice, and the community where the client lives are important issues to be considered when selecting a therapy. However, there is little information about the changes required for therapies designed for urban populations to make them useful for rural residents (Leukefeld et al., 1992), and only a few studies focus specifically on rural drug treatment (Government Accounting Office, 1990). This manual-driven therapy,...

  5. Motivational Interviewing
    (pp. 6-24)

    Motivational interviewing is the approach used throughout SBORT to engage clients. It is based on the logic that any change in human behavior, including the changes that lead from substance abuse and dependency to recovery, is based on a process of change described by Prochaska and DiClemente (1982). The process involves distinct stages that therapists can use as a framework to assess clients’ status and to help clients move forward in the change process. This theory of change was modified by Miller and Rollnick (1991) to include relapse as part of the change process and is represented by the figure...

  6. Pretreatment and Assessment
    (pp. 25-38)

    A client assessment that incorporates motivational interviewing, (Miller & Rollnick, 1991), is an important part of therapy. With this approach, a therapist obtains both objective and subjective client information. In addition, the client obtains a clearer understanding of the need for change and can make a more solid commitment to a specific plan of change.

    In most clinical settings there is a need to obtain demographic and screening information so that an appropriate disposition can be made to open each case. The therapist’s attitude about assessment is related to the client’s responsiveness. If a therapist believes this is valuable for...

  7. Dual Relationships
    (pp. 39-40)

    The rural clinician who practices in the region where he or she has lived for many years—or perhaps for an entire lifetime—is faced with the likelihood of having multiple role relationships with clients. In an urban setting where clinicians and clients are unlikely to meet, avoiding “dual relationships” is not difficult. The term “dual relationships” refers to the condition where the therapist and client have role relationships in addition to the clinical relationship. For example, the rural clinician’s banker might seek drug and alcohol abuse treatment and turn to the clinician for assistance. In a large urban agency,...

  8. Risk Management
    (pp. 41-42)

    Although approaches to the special problems that therapists might face when working with rural clients are discussed in this manual, it is important to give special attention to the clinical responsibilities related to risk assessment and risk management. For this purpose, “risk” refers to the presence of factors that can lead to or significantly increase the probability of harm to a client, the therapist, or third parties affected by treatment. Risk is not always obvious. In fact, it is wise for therapists to assume that in every clinical relationship some element of risk is present. A risk assessment determines whether...

  9. Clinical Supervision
    (pp. 43-44)

    Effective drug and alcohol treatment is enhanced when therapists have clinical supervision. While manual approaches like this one provide procedures for therapists, manualized treatment includes a number of potential issues that support the need for clinical supervision. Witte and Wilbur (1997: 78) identify four areas:

    1. Therapists’ conformity to the manual may be too “strict.” In other words, therapists might prioritize manual adherence rather than actual client needs, which could lead to failure to select appropriate interventions.

    2. Therapists might not adapt the treatment. In this situation, therapists use language or terms that are irrelevant or alienating for clients, which...

  10. Helping Clients Remain in Treatment to Meet Treatment Goals
    (pp. 45-46)

    In some treatment approaches, treatment planning has limited client participation. Some therapists believe that using preformatted treatment eliminates the need to involve clients in treatment planning. Structured Behavioral Outpatient Rural Therapy takes a different approach. Therapists continue to use motivational interviewing to actively engage clients in developing a client-oriented treatment plan.

    Most clients who enter treatment have significant and numerous problems. Craving and the fantasy of drug use can be overwhelming. Opposition or apathy by significant others can cause clients to drop out of treatment. Economic hardships can make treatment difficult. Clients need support to stay and participate in treatment....

  11. Case Management
    (pp. 47-55)

    Case management is an essential part of substance abuse treatment and aftercare. The term “case management” means different things to different people. For example, case management has been defined as “a method of providing services whereby the [professional] assesses the needs of the client and the client's family . . . and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client's complex needs.” (NASW, 1995) A common thread in the various definitions of case management is coordination to link services to individuals with the possibility of monitoring activities (Leukefeld, 1990).

    These standards...

  12. Behavioral Contracting
    (pp. 56-61)

    Changing drug and alcohol use can be enhanced with a behavioral contract. A behavioral contract is a written agreement between the client and the therapist. Sometimes significant others are also part of a contract. Using a contract to establish specific therapy goals has been widely used and has important implications for treatment involvement. While these kinds of contracts are not legally binding, signing a name to an agreement often intensifies the importance of the agreement and encourages client participation (Gambrill, 1997).

    Behavioral contracts have been widely used in many areas of education and therapy. For example, contracts have been found...

  13. Thought Mapping
    (pp. 62-69)

    Thought mapping is a way of helping clients learn from their experiences by organizing their personal thoughts (cognition) and behaviors visually, like a road map. Substance abuse clients in early recovery frequently have problems with understanding, learning, and managing abstract notions (Grant et al., 1977; Meek et al., 1989; and Czurchry et al., 1994). Thought mapping has been an effective way of assisting clients in early recovery to overcome cognitive deficits (Knight et al., 1994). Thought mapping has been found to be effective with cocaine abusers (Joe et al., 1994), individuals with attention deficit problems (Czurchry et al., 1994), and...

  14. Structured Storytelling
    (pp. 70-71)

    Storytelling has been called one of the building blocks of culture, like manufactured tools and cave painting (Schank, 1990). Storytelling was not simply an entertaining pastime. It enhanced both individual and group survival by improving memory and recall, allowing an efficient means of communicating, and retaining large amounts of information from generation to generation. Storytelling also helped our ancestors select effective actions to project from the past into the future (Rush, 1996). Just as language is related to the structure of the human mind (Chomski, 1957, 1968), storytelling is related to the structure of language. Language is a symbolic representation...

  15. Social Skills Sessions
    (pp. 72-75)

    After engaging, assessment, and behavioral contracting, clients are ready to begin the second phase of treatment: social skills training. Social skills training is an approach to drug and alcohol treatment that is based on cognitive-behavioral theory. Understanding the approach can help the therapist deliver effective social skills training groups.

    The ideas behind cognitive-behavioral treatment are very different from expressive treatments like psychodynamic therapy. Instead of working with internal psychological structures like the “ego,” behavioral theory focuses on how people learn specific behaviors over time. For example, children learn how to respond to social situations through watching their caregivers and then...

  16. Skills Session 1: Managing Thoughts and Fantasies about Alcohol and Drugs
    (pp. 76-88)

    The purpose of this session is to discuss and identify thoughts and fantasies about drug and alcohol use, as well as the feelings that they can evoke. This session helps participants explore how thoughts and fantasies might lead to relapse so that each client can develop beliefs and skills to manage thoughts and fantasies productively.

    It is helpful for clients to understand that long-term use of any drug causes changes in the structure and function of the brain. These changes are the underlying cause of both thoughts and fantasies about drug use as well as urges and cravings. Although the...

  17. Skills Session 2: Coping with Cravings and Urges
    (pp. 89-95)

    In rural areas, coping with craving triggers can be difficult, because there is often no way to avoid them. Residents of rural areas generally place high regard on family, and if there is significant family drug or alcohol use, it may be difficult to escape triggers. It is unlikely that the newly recovering person will make a choice to avoid “kin” totally (Keefe, 1988; Looff, 1971). In small communities it can also be difficult to avoid contact with people, places, and situations associated with drug use, simply because of geography. There aren’t as many people to choose from for friends,...

  18. Skills Session 3: Relaxation
    (pp. 96-108)

    It is important to help clients recognize that there is a difference between participating in diverting and pleasant activities, which distract them from the cares and worries of daily life, and learning how to relax deeply even in difficult situations. Some individuals may find fishing, for example, both deeply enjoyable and relaxing. Such individuals may find the experience of being near the water very positive. Concentrating on the conditions of the water, the habits of the fish, the type of bait most likely to produce results, the best technique for presenting the bait to the fish, and a hundred other...

  19. Skills Session 4: Increasing Pleasant Activities
    (pp. 109-113)

    Developing activities that are pleasant is necessary if a person is to avoid returning to abusing drugs and alcohol. In rural areas work, commitment, and responsibilities are lifestyles and highly valued (Hicks, 1992). Developing pleasant activities may seem difficult. Group members may be uncomfortable taking time for themselves or developing a plan for leisure that does not include family (Looff, 1971; Keefe, 1988). These may be issues that need to be discussed in the group.

    In addition, it is possible that pleasant activities are hard for group members to identify because of logistics. In small towns, there may not be...

  20. Skills Session 5: Problem Solving
    (pp. 114-122)

    In rural areas, where people usually value independence and self-sufficiency (Beltrame, 1978) there may be reluctance to talk about problems, especially with persons outside the family. Talking about problems in a treatment group may feel like betraying their family for some. Clients may struggle with fatalism—the strong belief that problems should be endured because they cannot be solved (Eller, 1996). This has resulted from years of financial and social exploitation of the Appalachian region, as well as the lack of political and economic power to address social problems (Gaventa, 1980). Therefore, group members may place more emphasis on coping...

  21. Skills Session 6: Awareness and Management of Negative Thinking
    (pp. 123-130)

    The therapist needs to emphasize that recovering persons are especially vulnerable to becoming overwhelmed by negative and distorted thoughts that can evoke strong negative moods such as anger, depression, and anxiety. Since many persons use drugs and alcohol to manage such emotions, it becomes important to prevent thinking and feeling from spiraling out of control. Recent research indicates that many recovering persons suffer from residual neurocognitive deficits that can compromise accurate perception and information processing (thinking). Learning to link events, thoughts, and feelings is an important corrective to relying on such distorted perceiving and thinking.

    The way we think influences...

  22. Skills Session 7: Anger Awareness and Management
    (pp. 131-137)

    Dealing with anger effectively may be more difficult in rural communities. Traditional attitudes of stoicism and keeping problems to oneself are common in rural Appalachian families (Keefe, 1988; Eller, 1997). Fatalistic and pessimistic beliefs among rural people dictate that they can only make a little difference (Keefe, 1988; Looff, 1971). While such self-control is prized—especially among males—repressing anger when the stress of controlling anger becomes too great can lead to aggression (Keefe, 1988).

    Many people who relapse report that they first slipped during a moment of anger. Anger is a “normal feeling,” which is usually a response to...

  23. Skills Session 8: Interpersonal Violence
    (pp. 138-143)

    The United States leads the industrialized world in rates of homicide. Researchers are puzzled by the escalating rates of lethal violence in the U.S., especially among males between 16–24 years old. Three causes, being investigated, include the availability and misuse of firearms, the increased violence associated with the illegal drug trade, and the greater willingness of contemporary adolescents and adults to use lethal violence (Potter & Mercy, 1997).

    One line of research that pertains to rural people in the southern parts of the United States such as Kentucky is the contention that southern culture has high standards of personal...

  24. Skills Session 9: Close and Intimate Relationships
    (pp. 144-152)

    Family relationships have long been valued in rural communities. Members of close-knit extended families often have significant emotional dependence on one another (Eller, 1997). In fact, rural people may value loyalty to family above personal betterment or even survival (Cole: 179). Males have traditionally been seen as “. . . provider, law, and protector . . . the family’s agent to the outside world, and teacher to children” (Cole: 177). Keeping family problems within the family is important, and many families exhaust their own resources emotionally and financially before seeking help from others—from “outsiders.” In fact, formal therapy/counseling may...

  25. Skills Session 10: HIV/AIDS
    (pp. 153-158)

    Individuals who are drug and alcohol users are at greater risk of HIV infection and AIDS even though they are not drug injectors. Drug injection has received attention since about one-third of AIDS cases in the U.S. are related to injecting, according to the Centers for Disease Control and Prevention. What is important for this session is the fact that HIV risk is associated with the consequences and relaxing effects of alcohol and drug use. The most important consequences include blackouts and drug/alcohol use, which can put an individual in contact with others who are at high risk for HIV....

  26. Skills Session 11: Enhancing Social Support Networks
    (pp. 159-163)

    A rural person’s social support network is primarily their kinship network. If the family is supportive, they can serve as an effective social support network to enhance recovery. If they are unsupportive or opposed to the recovery process, the rural person will need to look elsewhere for social support. Unfortunately, all too often, there are few resources for recovery in small and rural communities. For example, there may be very few Alcoholics Anonymous or Narcotics Anonymous meetings in particular rural areas, or these groups may meet infrequently. Because so many social support systems are composed of kinship and friendship networks,...

  27. Skills Session 12: Self-Help and Connectedness
    (pp. 164-173)

    Of all the supports to early and long-term recovery, self-help groups are probably the most available and commonly used. Virtually all therapists involved in the treatment of substance abuse are familiar with the philosophy, approach and value of these Twelve-Step programs. Therapists who work in rural areas are aware that self-help groups may often be difficult for clients to access and that self-help group meetings often go in and out of existence without much warning. Despite this, self-help groups are still probably the most readily available and certainly the least expensive means that a recovering person can use to support...

  28. References
    (pp. 174-181)
  29. Appendix: NIDA Cue Cards
    (pp. 182-198)