Forty Years of Treatment, Research and Advocacy: Social Work in the Addictions
40th Annual Addictions Institute
Jun Matsuyoshi, LCSW, Director of Recovery and Rehabilitation, Project Hospitality
The Addictions Committee of NASW-NYC presented the 40th Annual Addictions Institute, a milestone in social work in the addictions, on June 5th at Fordham University. The workshops and presentations centered on the theme “Forty Years of Treatment, Research and Advocacy.”
Institute Co-Coordinators Dan Pitzer, LCSW, CASAC, and John Crepsac, LCSW, CASAC, presided at the Plenary Session. The family of the late Jerry Josepher, who served for many years as a member and chair of the Addictions Committee, presented a scholarship award to recent Fordham School of Social Service graduate, Sandra Johnson. Lifetime Service Awards in the addictions field were presented to Lala Straussner, DSW, and Christine Fewell, Ph.D. The keynote speaker, Allen Zweben, Ph.D., addressed the topic “Two Decades of Treating Addictive Behaviors: Integrating Practice Wisdom and Evidence-Based Practice.”
Dr. Zweben is the former Director of the Center for Addiction and Behavioral Health Research and Professor, University of Wisconsin. He is currently Professor and Associate Dean for Research and Sponsored Projects in the School of Social Work, Columbia University. Dr. Zweben’s research and publications have focused on innovative assessment and treatment approaches for substance use problems.
Current Context of Social Work Practice in Addictions
Current trends focus on outcomes rather than process, said Dr. Zweben. The emphasis of addictions work (as well as on social work in general) is on accountability, with a focus on cost-effectiveness. To secure funding, practitioners must concentrate their efforts on achieving results.
Limitations of the Research Based Model
Today’s emphasis on accountability often uses a research based model that employs hypothesis testing, standard assessment tools, and random control designs. While yielding statistical information, the research based model has certain limitations. Statistically significant findings do not necessarily mean that findings are clinically relevant. Statistics do not always give real information on client satisfaction, for example.
Practice Based Model
Traditional social work was based on casework, with emphasis on practice wisdom rather than on data gathered through standardized instruments. There are limitations to a practice based model. For example, practice based findings often yield descriptive information, but are limited in providing causal or correlational information. Practice approaches may be determined by counselors who may believe that “I know what’s best for my clients,” rather than determined by evidence-based or research-backed information.
A New Psychosocial Model
According to Dr. Zweben, it is a good idea to maintain a dialog between practitioners and researchers. If researchers and practitioners work together, they will be able to formulate realistic research questions based on their mutual understanding of clinical work. Typical questions are: “What works for clients?” “How does treatment help?” “What do we agree upon?” These are the kinds of questions that yield useful statistical information.
The goal of integrating practice based and research models is to build a new psychosocial model, said Dr. Zweben. He proposes using three strategies in this new model. The first strategy he described is Brief Motivational Interviewing, which makes use of empathy and helping clients to become more aware of their problems. Instead of getting into a power struggle with clients, clinicians accept the discrepancy between what clients say and what they do. Dr. Zweben said that clients often are unable to tolerate experiences of ambivalence. The worker’s acceptance of ambivalence helps clients to begin to accept their own ambivalence. “Ambivalence is the hallmark of addictions counseling and understanding ambivalence is the paradigm shift that has occurred in the last two decades,” said Dr. Zweben.
Techniques in working with clients include building on the client’s efforts to remain sober and underscoring even small successes. Such techniques help the client to feel better about himself and is a motivating factor. The worker can then help the client explore options and develop a plan for change.
The second strategy Dr. Zweben outlined is Coping Skills Therapy (also known as Cognitive Behavioral Therapy) to develop communication skills. Clients who have trouble expressing anger, for example, must be taught skills to manage their anger. Clients who believe that they needed alcohol or other drugs to interact with others need help in learning to communicate while sober. To develop new behaviors, clients have to shift their expectations about how alcohol and other drugs affect them.
The third strategy that Dr. Zweben proposed is Supportive Significant Other Therapy, such as marital and family therapy. It is not enough for the client to be motivated while in the clinician’s office, said Dr. Zweben, if the spouse does not promote the client’s motivation outside of treatment. Involving the significant other cuts down on “enabling” behavior, such as when the spouse makes excuses for the client who does not appear for treatment. The involvement of the significant other helps to continue the client’s change process in the long term and helps to build a sober support network.
Additional Interventions: 12 Step Meetings and Pharmacotherapy
Studies have shown that frequent AA and other 12-step meetings correlate with increased abstinence. Simply put, “AA works,” said Dr. Zweben.
In addition, Dr. Zweben spoke of medications that can alter brain chemistry and can enhance treatment when used with behavioral therapies. These medications include: 1) Acamposate, which helps to normalize brain activity in individuals whose systems have become dependent on alcohol to remain in equilibrium; 2) Naltrexone, which blocks the effects of opiates is used to prevent overdose in heroin users; 3) Vivitrol, similar to Naltrexone but with less effect on the liver; and 4) Topimarate, an anti-seizure medication that helps people whose alcohol and other drug use has caused brain over-activity.
Ingredients of Effective Therapy
Therapy that works, said Dr. Zweben, includes the following ingredients:
1) Using well-structured evidence-based treatment
2) Establishing a strong therapeutic alliance with the client
3) Employing therapists with a high level of skill who demonstrate empathy, warmth, and acceptance
4) Addressing the client’s ambivalence and supporting his commitment
5) Involving significant others in the client’s treatment
Dr. Zweben concluded with these questions about continued work in the addictions.
1) What kinds of clients and settings are appropriate for these strategies?
2) How do we train practitioners to carry out these interventions?
3) What alternatives are available for those who relapse?
As he had noted earlier, such questions integrate the efforts of researchers and practitioners in creating a new psychosocial model.