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| The Paradigm Development Model of Treatment |
| Feature Articles - Treatment Strategies or Protocols | |
| Written by Georgi DiStefano, LCSW & Melinda Hohman, PhD | |
| Thursday, 30 November 2006 | |
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Counselors who work with clients who are undergoing alcohol and other drug (AOD) treatment may occasionally lose their sense of direction or move in a direction that is not in sync with a client's readiness to change (DiClemente & Velasquez, 2002). The Paradigm Developmental Model of Treatment (PDMT) was designed by the first author to provide counselors with an overall framework to conceptualize what to do in AOD dependency treatment and when to do it (DiStefano & Hohman, in press). The PDMT is a progressive model using developmental stages and is compatible with and builds on other developmental models, such as Gorski's Progressive Stages of Recovery (Gorski, 1998) and Brown's Developmental Model of Recovery (1985). These models help individuals conceptualize where they are in their own recovery, particularly in their work with their sponsors. The PDMT is different in that it conceptualizes treatment as a developmental process requiring appropriate goals and strategies that may continually shift as the client grows or stumbles in recovery. The model enables counselors to identify what types of clinical modalities and tasks would be appropriate for individual clients, depending on which paradigm and stage of change the client is in regarding the recovery process. The model allows for cultural considerations and individual contexts. Four paradigm shifts The model conceptualizes four paradigm shifts that represent a client's clinical movement through the recovery process:
A paradigm is defined as changes in the way someone views him or herself in the world, and the response to these changes. Each paradigm is a stage that includes key issues and themes to be addressed by counselors as they assist their clients in stabilizing and moving forward in recovery. The themes in each paradigm are extrapolated from the 12-steps of Alcoholics Anonymous (AA) and represent the core of the treatment focus, however, they do not focus on the spiritual/religious aspects of the 12-steps but rather, clinical themes inherent in the steps. This may give some clients an alternative perspective that may be more congruent with their own belief system.
The paradigm framework encompasses several evidence-based therapy models to help facilitate clients' movement through the treatment process. Within each paradigm, counselors utilize the Stages of Change (Prochaska & DiClemente, 1986) for each theme in order to assess where clients are with regard to their readiness to change behaviors, or in recognizing an important issue. These stages include:
The PMDT also uses Motivational Interviewing (MI) (Miller & Rollnick, 2002), a client-centered, non-judgmental counseling style that provides facilitation for discovering and utilizing the client's own internal motivators, and for moving clients from precontemplation to action. Cognitive behavioral therapy (CBT) (Beck, 1995) is utilized for clients to examine their thoughts or cognitions about various issues and to practice alternative behaviors. Twelve-step facilitation (TSF) (Nowinski, Baker, & Carroll, 1995) methods are also used by counselors to help clients integrate a support program into the recovery process. Using the PDMT as a framework, counselors ask themselves the following questions, which will enable them to systematically think about the client and respond appropriately:
Paradigm one: recognizing the problem and accepting help The first paradigm in the PDMT is focuses on problem recognition and accepting help. Themes in this paradigm include: problem identification, looking beyond self, and letting go. In this stage counselors assist clients in discussing and beginning to recognize the identified problem, and help them to realize that they can reach out and trust help, even when they are in a forced situation. For example, a client named Robert G. comes to a Driving Under the Influence (DUI) program and is not certain if he has a problem with alcohol. He had been arrested with a blood alcohol level of 0.20 and admits that he has driven drunk before but has not been caught. He is married, employed, and very upset by his sentence to DUI classes. During an individual assessment interview, the counselor, using an MI style, helps Robert to recognize his own internal motivators, which in this case are that he does not want to lose his license nor face ongoing problems with the legal system. Emphasizing these motivators, the counselor takes a thorough history of Robert's alcohol use and discovers that Robert has been arrested in the past for disorderly conduct while drunk in public, and that he has had numerous job changes and separations from his wife, which may be related to his alcohol use. The counselor initially assesses Robert to be in the contemplation stage of change regarding his drinking. That is, Robert is not sure if he has a problem, but he is open to talking about it. The use of MI has allowed the counselor to engage Robert in talking about his situation in a non-judgmental manner, so that Robert can listen to his own thinking about his possible drinking problem. Using CBT, the counselor works with Robert to create a consequence history regarding his drinking, helping him begin to link his drinking to these other problems in his life. Robert also completes the assessment tools required by the program. With all this various information, the counselor provides Robert with feedback that he meets the criteria for alcohol dependency. Robert indicates that he does not agree with this feedback but is willing to comply with the program and will attempt to remain open to further discussion of his assessment. Using an MI style, the counselor responds positively to Robert's openness and willingness and does not force the issue. Robert must attend weekly AA meetings as a requirement of the DUI program, as well as attend weekly DUI group and individual sessions. Utilizing TSF methods, the counselor explores with Robert his reactions to the 12-step meetings - the topics, the members, etc. The counselor also encourages Robert to with meet with AA members before and after the meeting, and to ask how they determined that they were alcoholics. As Robert moves through this paradigm, he comes to the point where he can state that he believes that he is alcohol dependent and wants to accept help with quitting drinking and staying out of trouble with the legal system. During the first paradigm Robert moved through various stages of change with each theme. For example, he moved through problem recognition (precontemplation, contemplation, and preparation stages). The action stage was externally motivated by program requirements. Robert was honest and stated that he didn't want to go to AA meetings but was willing to comply. Over time, as he came to recognize that he needed help, he became more internally motivated to attend AA, and at least be open to various aspects of the program, such as getting a sponsor. He was able to acknowledge that he could benefit from the input of others regarding his drinking problem. His initial focus of not losing his license was placed in a broader context. Robert was also able to let go of his need to be self-sufficient in his struggle with alcohol. As demonstrated in the example, the counselor utilized an MI style during the initial assessment to engage Robert and learn about his internal motivators. The counselor used CBT methods to help Robert think about how his drinking might be problematic and to encourage him to utilize the steps needed to begin the recovery process, thus moving Robert from contemplation to the action stage of Problem Recognition and Acceptance of Help. The counselor did not try to argue or convince Robert that he was alcohol dependent but provided him feedback about the reasons for this assessment. However, if Robert had not come to this conclusion, the counselor would have needed to continue to explore Paradigm One themes including denial and high-risk behaviors. Finally, it is important to note that the first paradigm includes assessment and stabilization issues in a number of areas. Medical issues must be identified and referred promptly. Psychiatric issues may become evident and will either need to be monitored or referred, depending on the circumstances. Safety is another important area to assess (i.e., drugs, alcohol, or firearms in the home). Evaluating the client's support system is essential in this stage to assure that an actively using partner does not sabotage initial attempts at recovery, and that family treatment is incorporated in the overall planning. Intensity of grief and loss issues may need to be monitored by the counselor along with depression and post acute withdrawal symptoms. Paradigm Two: Accepting responsibility The second paradigm shift focuses on accepting responsibility, which includes maintaining abstinence; identifying self-sabotaging behaviors beyond the drinking; and acknowledging one's strengths/resiliencies. The themes of this stage that are extrapolated from the 12-Steps include: self-examination, taking responsibility, willingness/openness to change, relinquishing control, accountability and the growth of empathy. This means that the client is willing to examine behaviors and attitudes that contribute to an abusive drinking pattern or a dysfunctional lifestyle. This self-examination process can be facilitated by the counselor. It parallels, but does not replace the fourth step work with a sponsor. Again, the counselor can use CBT techniques to help clients to recognize long-standing behavioral responses and thoughts that contribute to their dysfunction. The stages of change are critical in this paradigm as the counselor asks clients to first identify and then prepare to change these self-defeating responses. New behaviors are practiced in the real world and reinforced in group and individual therapy through role-play and other structured behavioral exercises. This process helps the client to become accountable for his or her behaviors and leads to growth in the area of empathy. These themes closely parallel steps four through eight of the 12-steps, and TSF is also useful within this paradigm as clients may concurrently address these themes with a sponsor. In the case of Robert, while in DUI treatment, he began the self-examination process of concerns other than his drinking through structured exercises, in the group aspect of treatment as well as in his individual sessions. Working with his counselor using CBT exercises, which review strengths and liabilities, Robert was able to recognize that what he valued as a strength (i.e., his self-sufficiency had translated into a liability in early recovery, which kept him distant from other people). He also began to recognize that his frequent job changes may not only have been due to his drinking and subsequent absenteeism but also to the "chip on his shoulder" attitude that he carried for authority figures. He identified how he was successful at work but tended to get in trouble when he would argue or challenge his supervisors when his self-esteem felt threatened in any way. Through the group process, Robert was also able to identify that this may have come from his relationship with his alcoholic father, who still intimidated him and ignored his accomplishments. He was open to taking responsibility for his attitude at work and role-played in group various ways he could address his supervisor without coming off as angry or cocky. He didn't feel ready to address his relationship with his father but was able to realize that he didn't have control over how his father treated him and acting out with a boss would not give him that control. The counselor acknowledged and supported Robert's feelings about his father but kept him in the present, resisting the temptation to delve into family of origin issues at this stage of the treatment process. The counselor further assessed Robert as being in the preparation and then action stage of changing his negative reactions towards his supervisor and being in the contemplation stage of addressing his relationship with his father. This was an appropriate focus and movement through the paradigm. The counselor utilized CBT-based role plays, including anger management and stress reduction exercises, for Robert to practice alternative ways of dealing with his supervisor under stressful conditions. Robert also was encouraged to work on his behavioral self-assessment with his AA sponsor as well. It is important throughout this paradigm to focus on the motivators that will most resonate with the client. In this case, Robert was anxious to do well at work and not be fired for his attitude problems. Although this is not an issue in this case example, it should be noted that co-occurring disorders, such as depression and other mood disorders might require that the counselor refer to or work with a mental health specialist. Personality disorders will require additional or more intensive counseling intervention. In this illustration, Robert should be referred for couples therapy to work on some of these same issues with his wife. Clients who successfully work through this paradigm have a thorough knowledge of their self-sabotaging patterns and recognize their strengths. They have committed to the therapy process or other support services, such as anger management, couples therapy, etc., to enhance their ability to manage the issues pertinent to this paradigm. Counselors working with clients in this paradigm need to recognize when it is necessary to refer for work on issues that may be beyond the scope of their practice. Paradigm Three: Embracing change and self regulation The third paradigm focuses on embracing change and self-regulation, in which clients create the new self. This is an action paradigm where counselors will observe their clients regularly implement and practice the behavior and responses of healthy living. The themes of this paradigm parallel steps 9 through 11 and include the themes of asking forgiveness/accepting consequences; self-regulation; and spirituality/mindfulness. The key to this paradigm is the concept of self-regulation, which is essential to the therapy process. Clients continually, with the assistance of their counselor, scrutinize their thoughts, feelings, and behaviors. In this paradigm clients learn to accept consequences and grow in their ability to forgive themselves and others, such as parents with alcohol problems. They also may begin to identify and address how being raised as a child of an alcoholic has impacted their current relationships. Grief and loss issues may arise at this stage. In this paradigm the counselor becomes the coach, as the client's ability to self-regulate grows. It should be noted that clients have completed formal AOD treatment prior to this paradigm. Typically clients in this paradigm address many of their concerns in post-treatment individual therapy. Failure to address the issues within any paradigm leaves clients vulnerable to relapse. Often a relapse can be traced to the reoccurrence of old behavioral responses. It is important for clients to revisit themes associated with relapse, and for counselors to be vigilant in listening for behavioral or attitudinal cues of relapse. Counselors may also be instrumental in helping clients to identify new behaviors that are rooted in dysfunctional thinking. As for our case example, Robert completed the DUI program successfully. Robert identified himself as an alcoholic and acknowledged the need for continued abstinence and support. He made use of the support of AA and even began attending Alanon. Robert continually worked on his attitude and realized that only he could make himself a victim. He asked for forgiveness for his behavior from his wife and his current supervisor. He felt that he was better able to control his attitude and realized how negative interactions with his father in the future could be a high risk area for relapse. Prior to his graduation from the DUI program, the counselor utilized CBT relapse prevention exercises in group where group members role-played Robert's father as well as friends who wanted him to drink. Robert identified that he wanted to continue in individual therapy to address his child of an alcoholic issues and the counselor gave him the names of several competent therapists. This new therapist encouraged Robert to identify the spiritual practices that he was currently using, as well as new ones that may support his mindfulness and facilitate the gratitude he had developed in recovery. Working in therapy, Robert moved into the action stage of embracing change and self-regulation. Paradigm Four: Transformation The fourth and final paradigm focuses on the integration of changes that support recovery. In this paradigm clients continually self-regulate and have become comfortable with life-enhancing behaviors. The theme of this stage is transformation, and parallels step 12. Typically clients in this stage are active members of AA and are involved in sponsorship activities. Clinically they have resolved family of origin and other concurrent issues and have secured their recovery from a spiritual, psychological, and emotional perspective. After he completed therapy, Robert increased his attendance at Alanon and became a sponsor. His work in therapy on his family of origin issues allowed him to resolve many of the difficulties he experienced as a result of his suppressed anger at his father. He also was able to make peace with his father to the best of his ability (his father still drank and was highly critical), and was able to relate his experience to help others. He remained abstinent and worked his recovery program as both a recovering alcoholic and recovering child of an alcoholic. Table 1 presents a summary of the paradigm stages, Robert's issues and motivators in each stage, and the counselor's interventions. Conclusion
The PDMT provides a clinical framework for counselors to conceptualize the recovery process in an individualized fashion, by continually assessing the client's readiness to change with regard to key recovery issues and tasks. The model incorporates several models of treatment that can be utilized by the counselor at his or her discretion to facilitate movement through each paradigm. The PDMT is compatible with recovery literature and incorporates themes of the 12-step process. It is important to note that there are many strategies and techniques that can be helpful to the recovering client, however, it is of the utmost importance to recognize the issues and counselor responses that resonate most with the client in order to facilitate movement through the stages of recovery. References
Brown, S. (1985). Treating the alcoholic: A developmental model of recovery. New York: John Wiley and Sons. DiClemente, C. C. & Velasquez, M. M. (2002). Motivational interviewing and the stages of change. In W. R. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (2nd ed., pp. 201-216). New York: Guilford Press. DiStefano, G. & Hohman, M. (2006). The Paradigm Developmental Model of Treatment: A framework for treating DUI multiple offenders. Manuscript under review. Gorski, T. (1997). Passages through recovery. Center City, MN: Hazelden. Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing. (2nd ed.). New York: Guilford. Nowinski, J., Baker, S. & Carroll, K. (1995). Twelve step facilitation therapy manual: Aclinical research guide for therapists treating individuals with alcohol abuse and dependence. (DHHS Pub. No. (ADM) 92-1893). Rockville, MD: U.S. Department of Health and Human Services/ National Institute on Alcohol Abuse and Alcoholism.
Prochaska, J. O. & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (2nd ed., pp. 39-45). New York: Plenum Press.              |
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