Selling an Idea or a Product by yaohongm

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									Providing Substance Abuse
Treatment in Private Practice

 Joan E. Zweben, Ph.D.
 Executive Director: East Bay Community Recovery Project
 Clinical Professor of Psychiatry; UC San Francisco
                       IN COLLABORATION WITH

 Arnold Washton, Ph.D.
 Recovery Options
 New York, NY & Princeton, NJ
                       Today’s Topics
 Addiction Treatment versus Psychotherapy
 Recovery-Oriented Therapy: Integrative
  Model
 Psychodynamics of Addiction & Recovery

 Motivational Interviewing & Stages of Change

 Assessment Techniques

 Stage-Specific Treatment Interventions
Addiction Treatment
   & Psychotherapy
             Rift between psychotherapy and
             mainstream addiction treatment

 Different beliefs about the fundamental nature of
  addiction
 Many addiction treatment programs subscribe to a
  biopsychosocial model; some are rigidly disease model
 Prevailing view among psychotherapists is either a
  learning/behavioral model or a psychodynamic model
 Many believe that if the behavior is learned, it can be
  unlearned, changed, or controlled or that insight will
  produce change
                 Rift between psychotherapy and
                 mainstream addiction treatment

 Psychodynamic therapists tend to view addiction as
  merely a symptom of underlying psychological
  problems or unresolved conflicts
 Therapists who search for the “root causes” of an
  active addiction can be compared to a paramedic
  rushing to the scene of an accident with injured
  victims lying bleeding on the ground and taking time
  out before attending to the victims to ask what caused
  this accident to happen.
                 Rift between psychotherapy and
                 mainstream addiction treatment

 Seeing addiction as a symptom fosters the unrealistic
  belief that once the underlying problems are resolved
  the person can return to using alcohol or drugs
  moderately.
 Psychodynamic therapy can be very helpful during
  latter stages of recovery when abstinence is reasonably
  secure, but in the early stages it can serve as a form of
  enabling and also stimulate further alcohol/drug use
  when highly charged emotional issues are uncovered
  too early in the recovery process.
             Rift between psychotherapists and
           mainstream addiction treatment field

 In the early abstinence stage, the emergence of highly
  charged issues (e.g., childhood traumas) threatens to
  overwhelm the addict’s shaky sense of self and fragile
  commitment to abstinence. Feelings that have been
  medicated and numbed for years by alcohol/drugs
  often emerge once the chemical blanket is removed.
 Mainstream addiction treatment has traditionally
  downplayed the psychological aspects of addiction and
  devalued the role of psychotherapy in fostering long-
  term recovery. Some believe that AA alone is enough.
    Recovery-Oriented
       Psychotherapy

An Integrative Approach
     Stages of Recovery-Oriented Therapy

1. Assessment with motivational feedback
2. Engaging the client who is actively using
3. Negotiating an abstinence contract
4. Helping the client to stop using (early abstinence)
5. Consolidating abstinence, changing lifestyles,
   developing adaptive coping skills (relapse prevention)
6. Addressing developmental/interpersonal issues
   (psychotherapy)
         Recovery-Oriented Psychotherapy

 Framework that integrates disease model addiction
  treatment with abstinence-based psychotherapy
 Individual, group, & couples therapy

 Supports, facilitates , and encourages but does not
  mandate involvement in AA
 Therapist’s tasks shift according to the patient’s stage
  of recovery
 Collaborative stance toward the patient
                            Therapist’s Role
 Facilitate change
 Mobilize motivation
 Non-judgmental coach, advisor, and guide
 Educator
 Voice of reason and reality
 Safety net and backstop
 Steady, reliable resource
 Supply ego functions that the patient lacks
            Stance of the Therapist
 Primacy  of the therapeutic alliance
 Respect for patient’s autonomy while
  providing forthright feedback
 Respect for change as a process

 Respect for individual differences

 Awareness of transference &
  countertransference dynamics
                        Countertransference
   Abrupt or unilateral changes in the treatment plan
   Rejecting, controlling, stereotyping behaviors
   Disengaged or over-involved
   Rescue fantasies
   Preoccupation, dreams, anxiety
   Emotionally depleted- “burnt out”
   Hoping that the patient cancels or no shows
   Excessive self-disclosure
   Need to be idealized
                            What NOT to do
 Warn of dire consequences
 Impose negative consequences

 Take an authoritarian stance

 Reject and/or abruptly terminate the patient

 Ally with others against the patient

 Change treatment plan out of anger or frustration

 Act out savior & control fantasies

 Act out other countertransference dynamics
                    Integrative Approach

 Stages of change
 Motivational interviewing

 Cognitive-behavioral techniques

 Disease model & AA

 Adaptive “self medication” model

 Psychodynamic, insight-oriented techniques
                  Using Different Strategies at
                              Different Stages

1. Initially, focus on motivational issues and treatment
   engagement
2. Once the client becomes willing to change, utilize
   cognitive-behavioral strategies to facilitate transition
   from active use to stable abstinence
3. As recovery proceeds, incorporate insight-oriented
   techniques to address broader issues, but always
   keeping addiction issues in focus
                      Integrative Approach

    Treatment must address more than the
    substance abuse itself:
 Developmental arrest
 Interpersonal problems

 Managing feelings

 Self-esteem issues

 Co-existing Axis I & II disorders

 Other addictive/compulsive behaviors
                              Key Points
   There is no single best pathway to recovery
    for everyone
   Accept that you are powerless to control
    another’s drug use; let go of your control
    fantasies
   Maintain an empathic connection; the single
    most important aspect of treatment is the
    therapeutic alliance
                                 Key Points
   Re-conceptualize resistance as
    ambivalence
   Start where the patient is- NOT where you
    want him/her to be
   Listen to your clients. They will tell you
    what they are ready or not ready to do.
Psychodynamic Issues
   at Different Stages
      Psychodynamic Issues in the Early Phase

   Therapeutic alliance
   Warmth, empathy, positive regard
   Trust, respect, concern
   Unconditional acceptance
   Consistency & availability
   Counteract internalized self-loathing, shame, guilt
   Support self-efficacy, autonomy, reduce dependency fears
   Environment of safety: accountability, limits, realistic
    feedback, boundaries
  Psychodynamic Issues in the Middle Phase

 Ongoing  ambivalence about giving up
  alcohol/drugs
 “I’ve stopped using, but I’m still unhappy”

 Affect management: “self-medication”

 Defining interpersonal, self-esteem, and
  boundary issues
 Shame and guilt issues
Psychodynamic issues in later stages

 Intimacy with autonomy*
 Separation-individuation*
 Affect management: “self-medication”
 Grief and loss

 Early traumas

 Residual narcissistic & controlling behaviors
                          Couples Issues
 Choosing a mate while actively addicted
 Power dynamics: control and dominance

 Equality: no longer willing to be discounted

 Out of synch: personal responsibility for
  behavior/problems, having an “observing ego”
 Lingering resentments: especially infidelities !!

 Jealousy: support system, therapist, group

 Will he/she still want me?
  Will the relationship survive recovery?

 Good Prognostic Signs
 Joined prior to onset of the addiction
 Willing to learn about addiction/recovery and
  use opportunity to enhance his/her own life
 Willing to enter couples or individual therapy
  and Al-Anon to address his/her own
  unresolved issues
    Will the relationship survive recovery?

    Poor Prognostic Signs
 Joined while addiction was active
 Unrelenting anger, hostility, resentment

 Refuses to take any responsibility whatsoever for
  contributing to the mess
 Unable to see the need for personal change: it’s all
  his/her fault, not mine !
 Unwilling to go for therapy or to Al-Anon
                                   Relapse Dreams
 Can occur at any stage
 Wake up not sure whether they have actually used

 Worst fear is that the dream is prophetic

 In early stage often due to ambivalence and self-doubt

 In middle stage often due to fears about relapse- “Is
    there something moving me toward relapse??”
   In latter stages often stimulated by unresolved issues
    and/or being overwhelmed with feelings
                              Relapse Dreams
 What feelings were stimulated by the dream?
 Why did this dream occur at this particular point in
  time?
 What could the dream be telling you about where you
  need to strengthen your recovery plan?
 What issues/problems may have given rise to the
  dream?
 Does the dream signal unresolved or renewed
  ambivalence about giving up alcohol/drugs?
Motivational Interviewing
and the Stages of Change
                      Facilitating Change

 Motivational   Interviewing offers a way to
 conceptualize and deal more effectively with
 problems of patient resistance and poor
 motivation
 Stages   of Change Model provides a
 framework for determining the readiness of
 patients to change their behavior and for
 matching treatment interventions accordingly
                           Stages of Change

 Precontemplation- Not seeing the behavior as a
  problem or feeling a need to change (“in denial”)
 Contemplation- Ambivalent, unsure, wavering
  about necessity and desirability of change
 Preparation- Considering options for change

 Action- Taking specific steps to change behavior

 Maintenance- Relapse prevention

 Relapse- Returning to use or earlier stage of change
Stages of Change
                    Stages of Change Model

 Facilitates empathy- patients seen as “stuck” in a
  particular stage of the process rather than “resistant”
 Defines ambivalence as normal not pathological

 Leads to better patient-treatment matching by
  defining the types of clinical interventions that work
  best with patients in each stage of change
 Provides “roadmap” and sets the tone for more
  positive interaction with “resistant” patients
                       Motivational Approach
   Start where the patient is
   Roll with resistance
   Avoid arguments, power struggles
   Back off in the face of resistance
   Be persuasive not confrontive
   Reframe resistance as ambivalence
   Offer choices to increase patient acceptance and investment
   Negotiate, don’t pontificate
   Acknowledge positive drug effects
   Adjust interventions to stage of readiness for change
Diagnosis
                      Substance USE

 Absence of problems/consequences
 No apparent or significant risk

 No obsession or preoccupation

 Under volitional control
                    Substance ABUSE

 Use is associated with significant risks or
  consequences
 Exceeds medical/cultural norms

 No obsession or preoccupation

 Under volitional control
         Substance DEPENDENCE

 Continued use despite adverse
  consequences
 Impaired control

 Preoccupation/obsession

 Exaggerated importance/priority

 Tolerance/withdrawal (optional)
      NIAAA “Low Risk” Drinking

MEN
No more than 14 drinks per week (2 per day) and no
more than 4 drinks per occasion
WOMEN
No more than 7 drinks per week (1 per day) and no
more than 3 drinks per occasion
SENIORS- OVER AGE 65
No more than one drink per day
                One “Standard” Drink

One  12 oz. bottle of beer
One 5 oz. glass of wine

1.5 oz of distilled spirits
                    “Low Risk” Qualifiers

PRESUMES ABSENCE OF:
  Pregnancy

  Medical or psychiatric conditions likely to be
   exacerbated by ETOH use
  Medication that interacts adversely with ETOH

  Prior personal or family history of substance abuse

  Hypersensitivity to alcohol
                    “At Risk” Drinking

 Frequently   exceeds recommended limits
 No evidence yet of adverse consequences

 Drinking exposes the individual to
  significant risk
 Prime target for preventive efforts
     “Problem Drinking” ALCOHOL ABUSE

 Evidence of recurrent medical, psychiatric,
  interpersonal, social, or legal consequences related to
  alcohol use; OR
 Being under the influence of alcohol when it is clearly
  hazardous to do so (e.g., operating a vehicle or other
  machinery, delivering health care services)
 No evidence of physiological dependence
 No prior history of alcohol dependence
   “Alcoholism” ALCOHOL DEPENDENCE

  BEHAVIORAL syndrome characterized by:
 Compulsion to drink

 Preoccupation or obsession

 Impaired control (amount, frequency, stop/reduce)

 Alcohol-related medical, psychosocial, or legal
  consequences
 Evidence of withdrawal- not required

 Evidence of tolerance- not required
Assessment Techniques
                       Assessment Goals
 Assess nature and extent of substance use
 Assess nature and extent of substance-related
  problems and consequences
 Assess patient’s stage of readiness for change

 Formulate an initial diagnosis

 Provide motivation-enhancing feedback based
  on assessment results
                         Assessment Domains
   Typology of use
   Positive benefits
   Negative consequences
   Need for medical detoxification
   Other addictive behaviors
   Prior attempts to stop or cut down
   Prior treatment and self-help experience
   Diagnostic signs of substance dependence disorder
   Family history of alcohol/drug problems
   Stage of readiness for change
                                    Typology of Use
   Types of substances
   Amount/frequency
   Administration route (oral, intranasal, pulmonary, i.v., i.m.)
   Temporal pattern (continuous, episodic, binge)
   Environmental precursors (external “triggers”)
   Emotional precursors (internal “triggers”)
   Settings and circumstances linked with use (people, places..)
   Linkage with use of other substances (e.g., cocaine-alcohol)
   Linkage with other compulsive behaviors (sex, gambling,
    spending, eating, etc)
              Positive Benefits of Use

 What  first attracted you to this drug?
 How has it helped you?

 Does it still work as well?

 What would be the potential downside of not
  using it?
            Negative Consequences

 Medical

 Job,Financial
 Relationships

 Legal

 Psychological

 Sexual
        Medical “Red Flags- ALCOHOL
 Hypertension
 Blackouts
 Injuries
 Chronic abdominal pain
 Liver problems
 Sexual dysfunction
 Sleep problems
 Depression/anxiety
         Medical “Red Flags” COCAINE

 Chronic  nasal/sinus problems (snorting)
 Chronic respiratory problems (smoking crack)
 Sexual dysfunction
 Labile moods, paranoia, suicidal ideation
 Sleep problems
 Seizures
 Abuse of alcohol and sedatives
           Medical “Red Flags”OPIOIDS

 For Rx opioids: requests for increased doses,
  frequent refills, multiple prescribers, “lost”
  prescriptions
 Sexual dysfunction
 Amenorrhea
 Sleep problems
 Constipation
 Liver problems
                         Biochemical Indicators
                              of Alcohol Abuse
 Most  markers are late stage and not very
  reliable indicators of alcohol problems
 Best used in combination to confirm diagnosis
  & establish baseline for follow up
   GGT gamma-glutamyltransferase
   MCV mean corpuscular volume

   AST aspartate aminotransferase
                  Urine Toxicology- Drugs

 Detects only recent use (past few days)
 No information about amount, frequency, or
  chronicity of use
 No information about problem severity

 Best used as a clinical tool to monitor
  treatment progress
             Psychosocial Consequences

 Vocational: Work life adversely affected?
 Relationships: Family/marital relationships or home
  life been adversely affected?
 Legal: Any legal trouble? (e.g., DWI)

 Psychological: Mood or mental functioning been
  adversely affected? Suicidal thoughts or actions?
 Sexual: Sex drive or performance been adversely
  affected? Cocaine or amphetamine-related
  hypersexuality and acting out behavior?
         Need for Medical Detoxification

 Benzodiazepines,   alcohol, opioids
 Abrupt withdrawal from alcohol/benzos can be
  life threatening and must be managed
  medically
 Opioid withdrawal is uncomfortable, but not
  life threatening, except when another medical
  condition could be exacerbated (e.g., heart
  problems)
Negotiating Goals and
Strategies for Change
    If patient seems willing to consider change


 Suggest “experiment” with total or partial abstinence
 Suggest reduction of at least 50%

 Suggest alcohol reduction to below “at risk” levels

 Suggest gradual tapering toward abstinence
  (“warm turkey”)
      Value of “Experiment” with Abstinence

 Provides useful clinical data
 Role of substance use in patient’s life

 Reliance on “self medication” to cope

 Experience things through a “different set of eyes”

 Impact of abstinence on mood, affect, coping ability

 Identify internal and external triggers of use

 Indication of how easy/difficult it is to stop using
                     Stage-Appropriate Goals

   Precontemplation- Increase awareness, raise doubt
   Contemplation- Tip the balance toward change
   Preparation- Select the best course of action
   Action- Initiate change strategies
   Maintenance- Learn relapse prevention strategies
   Relapse- Get back on track with renewed
    commitment to change
    If patient is NOT willing to consider change

   Do not react to patient resistance as a challenge to your
    judgement or authority
   Avoid getting into arguments or debates about how much
    drinking or drugging is too much
   Avoid using the labels “addict” “alcoholic”
   Emphasize to patients that only they can make the decision to
    change- you have no desire to pressure them for change
   Agree to disagree: restate your concerns about need for change
   Your primary goal is to maintain an ongoing dialogue about
    their alcohol/drug use and continue to assess
                       Working with Patients in the
                          Precontemplation Stage
GOAL: Help patients see that maybe there is a problem
 Don’t expect immediate agreement or action

 Avoid getting into debates or power struggles

 Discuss the pros/cons: the “good things” and “not so
  good things” about using alcohol/drugs
 Acknowledge positive benefits of use

 Ask patients to keep daily diary of substance use to
  heighten awareness of when/how much they use
                      Working with Patients in the
                         Precontemplation Stage

 Re-state your concerns about medical and
  psychosocial consequences
 Suggest bringing in a family member/significant other

 Ask: What would have to happen for you to decide
  that your use has become a problem?
 Discuss discrepancies between patient’s view versus
  others’ view of the substance use
 Agree to disagree, but continue the dialogue
                              Working with Patients in the
                                 Precontemplation Stage

   Columbo Technique: “Maybe I’m not entirely correct. I suppose
    it’s possible that your substance use is not nearly as serious as it
    might appear. I wonder where I may have gone wrong?”
   At all cost, don’t antagonize or alienate the patient
   Don’t give up assuming that you are just wasting your time:
    subliminal change still may be occurring!
   Express your interest and curiosity, keep the door open, ask
    permission to continue the dialogue, resist your temptation to
    pressure for change
                          Working with Patients in the
                             Precontemplation Stage

   Avoid prescribing action-oriented strategies
   Acknowledge positive benefits of alcohol/drug use
   Draw connections between substance use and presenting
    complaints
   Educate about some of the subtle, insidious effects of
    substance use on values, priorities, self-esteem, coping
    abilities, mood, personal growth
   Ask about the extremes- the worst, the most
   Help patients assess the potential and not-so-obvious risks of
    continuing to use (play the tape forward, what if...)
                    Working with Patients in the
                          Contemplation Stage


  GOAL: Reduce ambivalence and facilitate movement
  toward change
 Don’t jump ahead: If you push too hard for change,
  the patient will retreat and defend the use
 Discuss fears and drawbacks about reducing or
  stopping use
 Discuss potential barriers to reducing or stopping use
                    Working With Patients in the
                           Contemplation Stage

 Being of “two minds” about stopping
 Being unsure, undecided, wavering

 Therapist: “Speak to me from the side of you that
  still feels positively about your alcohol/drug use and
  wants to continue using, despite the problems that it
  appears to be causing you.”
                              Working with Patients
                         in the Contemplation Stage

 Normalize ambivalence
 Acknowledge positive benefits of substance use

 Help the patient tip the balance in favor of change:
     Review the “good” and “not so good” things about use
     Review same for any prior periods of abstinence

     Highlight discrepancies : where you are now versus where
      you want to be (values vs. actions)
     Discuss expectations and anticipated difficulties with
      changing
                           Working with Patients
                      in the Contemplation Stage

 Emphasize personal choice- this is your decision
 Propose a brief “experiment” with abstinence or
  moderation
 What are you willing to consider doing at this point?

 Suggest keeping a diary of use
               Working with Patients in the
                     Contemplation Stage

Ask the “Miracle Question” (Berg & Miller)

“How would your life be different if by
tomorrow morning your substance use had
miraculously disappeared? What would
you notice? What would others notice?”
                             Working with Patients in
                               the Preparation Stage

    GOAL: Choose a realistic plan of action with goals
    that feel achievable to the patient
   Compliment for planning to take action
   Acknowledge any positive steps taken thus far
   Negotiate specific goals and time frame
   Explore what has worked and not worked in past
   Discuss menu of treatment options and offer
    recommendations, but respect patient’s autonomy to choose
              Working with Patients in the
                       Preparation Stage

 Discuss the practical “nuts-and-bolts” of how
  the patient’s goals will be accomplished
 Discuss potential obstacles and how to
  overcome them
                     Working with Patients in
                            the Action Stage
 Support a realistic view of change through small steps
 Create structure, support, and safety net (e.g.,
  frequent visits, drug testing, family involvement,
  linkage with AA)
 Acknowledge difficulties in the early stages of change

 Convey optimism and hope while working through
  initial setbacks
 Assist the patient in finding new reinforcers of
  positive change
       Action Stage Strategies to Help the
                       Patient Stop Using

 External Triggers
 Internal Triggers

 Impulse (Craving) Control

 Onsite Alcohol & Drug Testing

 Short-Term Focus

 Develop Support System
                          Clinical Value of
                      Alcohol/Drug Testing

 Deterrent to impulsive use
 Disrupts denial

 Objective marker of progress

 Rapid identification of use

 Restores credibility with S.O.’s

 NOT intended to uncover lies; avoid “gotcha”
                      Action Stage CAUTIONS!

 This is NOT the time for uncovering psychotherapy.
  It will likely elicit strong affects that the patient is not
  prepared to handle without returning to “self
  medication” with alcohol/drugs
 Contain and postpone work on highly charged issues
  (e.g., trauma, victimization) until stable abstinence
  and recovery has been attained of at least 6-12
  months. Offer strategies to manage feelings, vs
  resolve issues.
                 Working with Patients in the
                         Maintenance Stage

 Reinforce a proactive stance toward preventing
  relapse; educate that relapse is a process not an event
 Address affect management (“self-medication”) and
  other psychological issues (e.g., self-esteem,
  boundaries, relationships, traumas)
 Never lose sight of the SU disorder; remain ever-
  vigilant for early warning signs of relapse
 Respond therapeutically to slips and relapses
              Working With Patients in the
                      Maintenance Stage

 Relapse is a process that begins before the
  person returns to alcohol/drug use
 A key to preventing relapse is developing
  awareness of early warning signs and taking
  appropriate action to short-circuit the relapse
  process that has been set in motion
           Responding to Slips & Relapses

 Express empathy and understanding to counteract
  shame and guilt
 “Relapse Debriefing”- ask for recounting of specific
  events leading up to use
 Focus on antecedent feelings, moods, and behaviors

 Reframe as acting out of ambivalence- “being
  overtaken by the side that still wants to use”
                       Case Example: “James”
 Demographics: 40 yo investment banker, married for
  past 5 years, wife is an attorney who stopped working
  last year during difficult pregnancy and now stays
  home with 1 yo twins
 Presenting problems: marital discord, depression

 Substance use: 2-3 martinis, 4-5 evenings per week at
  local bar before coming home from work. Smokes
  marijuana on weekends. Pattern has existed for past
  year. No prior or family history of SUDs
                 James’ Presenting Complaints
“My problem is that since my wife gave birth to our twins, our marriage
and sex life have gone down the tubes. We are at each other’s throats from
the minute I come home from work until we fall asleep from exhaustion.
The only way I’m able to tolerate this situation is to drink every evening on
my way home from work. But then I wake up the next morning feeling
depressed. Over the past year, my depression has been getting worse and
my wife has become furious about my drinking. I know I should probably
do something about the drinking, but I just can’t deal with the thought of
coming home at night without medicating myself first. The pot is not really
a problem except that it stimulates my appetite and causes me to gain
weight. I came here for help with my marital problems hoping that if I
made some headway I’d be less likely to drink. I don’t think that I’m an
alcoholic and I’m unwilling to even think about going to AA meetings. I
also think that antidepressant medication might help me.”
                                        “James”
   Stage of change?
     For alcohol
     For marijuana

 What else would you want to know about his
  substance use before formulating an initial diagnosis?
 How would you approach him?

 What types of interventions would you deliberately
  want to avoid with James at this point?
                      Case example: “Lorraine”

   Demographics: 38 yo, self-employed as freelance editor, never
    married, no children, lives alone
   Presenting Problems: low self-esteem, intense conflict with
    controlling parents, unsuccessful relationships with men,
    confusion about sexual orientation (bisexual?)
   Substance Use: intranasal cocaine use 1-2 times per month, stays
    up all night with female friend embroiled in intense conversation,
    drinks beer/wine to come down from cocaine, smokes marijuana
    occasionally to relieve work-related stress. Pattern has remained
    unchanged for past two years. Diagnosed with depression as
    teenager. Adamantly against going to a treatment program or AA.
            Lorraine’s Presenting Complaints

“I’m here because I want to feel better about myself. Nothing makes
me happy and I’m confused. I’m tired of chasing after business just to
keep up with paying bills, especially since I stopped taking money
from my parents. I thought my cocaine use was getting a little out of
hand, but I’ve cut down recently. I’ve used it only once in the past two
weeks. I seem better able to control it now. Sometimes I drink too
much while doing cocaine and then feel horrible the next day.
Otherwise, alcohol is not a problem for me. Pot helps me a lot. It’s a
great stress reliever and I don’t want to even consider giving it up.
Actually, it works a lot better for me than any of the medications I’ve
been given by psychiatrists.
                                   “Lorraine”
   Stage of change?
     For cocaine
     For alcohol

     For marijuana

 What else would you want to know about her
  substance use before formulating an initial diagnosis?
 How would you approach her?

 What types of interventions would you specifically
  want to avoid with her at this point?

								
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