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Relapse Prevention Strategies for Clients Arrested for DWI
Driving while impaired is a serious national health problem, and there is a need to develop effective treatments for persons arrested for Driving While Intoxicated (DWI). Motivation for changing substance use behaviors may be critical for avoiding further infractions. Once motivated, the client may more readily develop skills that enhance efficacy to cope with situations leading to DWI. Motivational Interviewing (MI; Miller & Rollnick, 1991) was delivered to DWI-involved clients to enhance motivation to change. It was followed by Relapse Prevention (RP; Marian & Gordon, 1985) to develop coping skills. Clients rated MI/RP more favorably than standard care, evidenced improved coping skills, and showed general improvement at the end of the four-week treatment. This pilot study (N = 25) indicates that more well controlled clinical trials are warranted to study the effectiveness of MI/RP in treating persons engaged in DWI.
Clients were provided with approximately six homework assignments during the course of MI/RP. These consisted of exercises examining the pros and cons of using or not using substances and identifying and coping with antecedents to behaviors, as well as identifying positive and negative consequences of behaviors. Exercises focused on evaluating and enhancing confidence in coping with situations that trigger substance use; goal setting and use of rewards; and identifying and coping with stressful life events, as well as daily hassles and uplifts. Homework was graded using a Likert scale (0-"Very Poor," 1-"Poor," 2-"Adequate," 3-"Good," 4-"Very Good"). Grades were based on application of principles used in the MURP sessions and effort as determined by detail clients provided. Assignments were handed back with detailed therapist comments to provide feedback to clients.
Relapse Avoidance Plan
In a free response format, clients were asked to respond to the following: ( 1) Warning signs that I might be building up to using. (2) What I will do when I experience these signs. (3) What are signs that others might see in me when I might be headed towards a relapse? (4) What I'd like others to do if they see signs of relapse (even if I don't see them). (5) I feel I might have problems in the following areas during the recovery process. (6) I feel the following will be helpful to my recovery. This questionnaire was given as a pre- and post-test to evaluate improvement in coping skills. Each section was graded using the Likert scale described above. Grades were based on detail and specificity provided in the plan and the therapist's judgment regarding the plan's practicality (for example, a low score would be given if an avoidance plan indicated the respondent would drive away from the trigger, yet s/he did not have access to a car). Each plan received an overall score that was calculated by totaling the score on all sections and dividing by six. Feedback on the pre- and post-tests were provided to clients.
Groups met twice per week over four weeks for 90-minute sessions. Sessions closely followed the suggestions and techniques as outlined by Marlatt and Gordon (1985). Group rules were briefly covered along with the basic philosophy of RP: with appropriate information and skills, people can learn to exert more influence over their responses to high-risk situations instead of responding reactively or passively (Dimeff & Marlatt, 1995). Homework and handouts were given to coincide with session content. Initial sessions were aimed at establishing group cohesion, continued motivational enhancement, and assessing the history of problem behavior. Subsequent groups focused on coping with immediate problematic situations, learning to identify and cope with specific high-risk situations, and balancing the client's lifestyle. As needed, motivational issues continued to be addressed. The group exercises were very powerful in further enhancing motivation to change and building self-efficacy in that members learned from each other. RP is comprehensive and multifaceted. It includes, for example, a menu of specific techniques to change cognitions and balance lifestyles. For specific techniques and suggestions, see Marlatt and Gordon (1985) and Dimeff and Marlatt (1995). A standard manual was used to deliver all treatments. The content of the RP that was delivered was as follows: ( 1) a functional analysis of substance use; (2) training to recognize and cope with craving and thoughts about substances, training in problem solving, planning for emergencies, recognizing seemingly irrelevant decisions, and refusal skills; (3) cognitive processes related to substance use (irrational thinking); (4) identification of past and future high-risk situations; (5) encouragement and review of extra-session implementation of skills; and (6) practice of skills within session.
This study described and provided evidence for the feasibility of an innovative intervention program for incarcerated DWI-involved persons with diverse treatment needs. At the outset of MI/RP, some clients (44%) were relatively unmotivated and some (at least 24%) exhibited signs of cognitive impairment. Even so, clients were very receptive to the MI/RP program, were actively involved as indicated by attendance and homework assignments, and generally evidenced positive clinical outcome as noted in clinical summaries. They rated MI/RP as more useful than their mandatory CDTP; however, given client ratings, it appears that they also found CDTP enjoyable and useful for the most part. It should be noted that MI/RP offers a far less time consuming alternative to CDTP and for this reason alone, MI/ RP could be considered a viable alternative. Overall, MI/RP appears to hold promise as an intervention for chronic DWI-involved clients with diverse arrest and substance use histories. It can be tailored specifically to individual needs and is deliverable in a relatively brief group format. These clients were quite receptive to the intervention as evidenced in their comments about treatment. This study illuminated processes of treatment and change that were salient to clients in this setting. Future studies that utilize such process measures, as well as post-release outcome data, will likely make a large contribution to this important public health concern.
- Stein, L. A. R.; Lebeau-Craven, Rebecca; Motivational Interviewing And Relapse Prevention For DWI: A Pilot Study; Journal of Drug Issues, Fall2002, Vol. 32 Issue 4
Reflection Exercise #9
The preceding section contained information
about relapse prevention strategies for clients arrested for DWI. Write three case study examples
regarding how you might use the content of this section in your practice.
What was the focus of homework assignments in Stein’s relapse prevention strategy?
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