Set limits

While it is important that therapists work collaboratively with their substance-abusing patients, they must take care not to become so permissive that patients will know that they can take advantage of their therapists' good will.

Limits must be set (Ellis 1985; Ellis et al.1988; Moorey 1989) for example, that a therapy session will not beheld if the patient is intoxicated.

Therapists should establish ground rules during the first session so there will be no confusion or ambiguity later on. Therapists can set limits without sabotaging the therapeutic relationship if they adopt respectful tone and emphasize their commitment to help patients with their problems (Newman 1988, 1990).

For example, Beck and colleagues (1993) describe the case of a patient who arrived intoxicated for a therapy session. The therapist asked the patient if he had been drinking, and the patient acknowledged that he had. The therapist thanked the patient for his honesty and then suggested that the session be postponed. When the patient protested, the therapist calmly stated, "We made an agreement that we would meet only when you were sober and able to fully absorb the benefits of the session, and I think we should stick to our agreements." The therapist went further to point out the advantages of the patient's remaining in the waiting room for a couple of hours until it was safe for him to drive home. The patient was a bit disgruntled, but was mollified when the therapist gave him a newspaper to read to keep him occupied.

The lesson to be learned from the above vignette is to set limits, but be neither critical nor controlling. Emphasize that the patient's welfare is the primary concern, and that the therapeutic alliance is still active and strong in spite of the disagreement. Then, follow through.

III. Maintaining a Positive Alliance over the Course of Treatment
8. Set Limits in a Respectful Manner
While it is important that therapists work collaboratively with their substance-abusing patients, they must take care not to become so permissive that patients will know that they can take advantage of their therapists' good will. Limits must be set (Ellis 1985; Ellis et al.1988; Moorey 1989) for example, that a therapy session will not beheld if the patient is intoxicated. Therapists should establish ground rules during the first session so there will be no confusion or ambiguity later on. Therapists can set limits without sabotaging the therapeutic relationship if they adopt respectful tone and emphasize their commitment to help patients with their problems (Newman 1988, 1990). For example, Beck and colleagues (1993) describe the case of a patient who arrived intoxicated for a therapy session. The therapist asked the patient if he had been drinking, and the patient acknowledged that he had. The therapist thanked the patient for his honesty and then suggested that the session be postponed. When the patient protested, the therapist calmly stated, "We made an agreement that we would meet only when you were sober and able to fully absorb the benefits of the session, and I think we should stick to our agreements." The therapist went further to point out the advantages of the patient's remaining in the waiting room for a couple of hours until it was safe for him to drive home. The patient was a bit disgruntled, but was mollified when the therapist gave him a newspaper to read to keep him occupied. The lesson to be learned from the above vignette is to set limits, but be neither critical nor controlling. Emphasize that the patient's welfare is the primary concern, and that the therapeutic alliance is still active and strong in spite of the disagreement. Then, follow through.
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