Substance-abusing patients are an especially difficult population with whom to establish a commitment to change. A glance at the troubled family life of a substance abuser is instructive. At the height of his other use of drugs, a patient often obtains far more gratification from the drugs than from the love and companionship of significant others, friends, and relatives. Therefore, the positive social reinforcement from a supportive therapist may pale in comparison to the high that the patient gets from a line of cocaine or a hit of crack. Thus, the therapist's capacity to act as an agent of change is more limited and fragile than with many other patient populations for whom the therapist's approval and guidance have greater relative significance.
As a result, the therapist will need to build the relationship when the patient is in a period of diminished drug use or abstinence. During this time, the benefits of having meaningful interpersonal relationships should be underscored at the same time as the drawbacks of drug use are being highlighted. The intention of this strategy is:
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to enhance the patient's perceived reasons for remaining drug free,
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to motivate the patient to strive for relationship preservation, and
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to communicate the kind of therapeutic support that the patient will value.
Additionally, substance abusers often enter treatment with ambivalence about relinquishing their habits (Carroll et al. 1991a,1991b; Havassy et al. 1991). Within the framework of Prochaska and colleagues' (1993) stages of change model, one sees that many substance abusers do not enter treatment at the stages of action or maintenance. Instead, they commence therapy with a notion that it might be beneficial to give up the use of drugs, or with a wavering desire to cut back on their use (i.e., the contemplative stage). In extreme cases, such as when patients are remanded by the courts to attend drug abuse rehabilitation sessions, the patients may not acknowledge that they have a problem with drugs or even that they use them at all (the pre-contemplative stage).
From the very start, therapists will need to ascertain their patients' respective levels of commitment to change in order to have the best chance of communicating an empathic understanding and to minimize the risk of pushing an unwanted agenda onto patients whose resistance then will likely increase. It is generally not a good idea to accuse patients of "not really wanting to change," or of "wanting to suffer," or of "being in denial" (Newman 1994a). It is one thing to confront patients in this manner when they are in the protective confines of an inpatient (perhaps group therapy) setting. It is quite another to do this in an individual outpatient setting where the patient can easily leave treatment and never return if he or she takes offense at the therapist's methods. It is far more preferable to acknowledge that the patient has mixed emotions, and then to assess and get to know the part of the patient that likes to use drugs and the other part that would rather be free of them. In this manner, the therapist demonstrates that he or she is not so naive as to believe that the patient's goal is unequivocal and immediate abstinence, but instead to recognize the complexities and difficulties involved in trying to stop using drugs. Further, the therapist avoids the potentially damaging pitfall of communicating in a judgmental, unempathic tone.
