Substance use Interview
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A Health-Oriented Substance-Use Interview
By Eugene T. Tinelli, MD, PhD


In both medicine and psychotherapy, health-oriented approaches are becoming increasingly common. The psychotherapy paradigm has shifted from a problem-oriented, pathological focus of human behavior through solution-focused therapies to possibility-oriented therapies. The assumption that substance use can be an attempt at health is often thought of as heresy and met by rigid resistance by many professionals in the field. This is an unfortunate legacy of the “moral” basis of America’s current drug policies.
As treatment professionals, we have become sophisticated in our substance-use assessments, but most of us share a bias toward a pathological view of substance use that leads us to miss essential information and an opportunity to increase our rapport with clients.
A moral framework
The use of mind-altering agents has been a prominent human behavior throughout recorded history. Some say the desire to alter one’s consciousness is a fundamental drive (Weil, 1998). Yet many societies view the use of psychoactive substances in a moral framework, assigning goodness or evil to particular molecules. For example, if the consciousness-altering white powder is fluoxetine (Prozac), it is viewed as good. But if it is cocaine, it is considered evil. Despite a long history of molecules varying in acceptance, the substances themselves remain the same. This reflects our ambivalence about our own consciousness and results in a climate of pathology surrounding both the diagnosis and treatment of substance-use disorders.
Our inability to ask questions about the health effects of substance use makes assessment more complicated and less effective. We have stage-oriented models of how people change over time (Prochaska, Norcross, and DiClemente, 1992) and motivational and skill-enhancing techniques to help people move through the stages of change (Baer, Kivlahan, and Donovan, 1999). Our sophisticated assessment instruments can measure this behavioral change, yet the fundamental health question on which most individual psychoactive substance use is based is rarely asked. The following is a simple four-question health-oriented interview to address this problem and to establish a tone of choice, health and realistic hope.
The four questions
1. Why are you here?
This simple question is not always asked. It provides subjective client information in addition to any opinion that may have preceded the client and can provide data from the client’s perspective about his/her motivation in participating in an interview about potentially socially deviant behavior. It is also useful in clarifying any secondary issues that need to be addressed, such as probation, parole, or job performance issues.
2. What is your drug of choice?
This question allows clients to identify one substance as the most useful in their life. Again, this client-oriented question avoids making assumptions from previously scanned information about the client and shifts the frame of the interview toward an internal, client-oriented locus of control. It also implies responsibility for the client’s behavioral choice.
3. How does your drug of choice work for you in a healthy way?
This question separates this interview from other substance-abuse interviews. It is paradoxical and dramatically shifts the focus of the interview from pathology to health. It assumes that learned repetitious behavior - substance use - was acquired not for pathological reasons but for reasons of health.
4. What are the disadvantages of your drug of choice?
This question is often included in substance-abuse interviews as the initial question, thus framing the interview with a pathological focus.
Clients’ responses
Clients’ responses must be subjective when answering these questions, which then provide a missing balance for objective reports. Clients’ accuracy in self-reporting increases, due to the neutral and/or health-oriented frame of the questions.
Often, Question 1 elicits a client’s negative affects, such as shame, anger, distress or fear. Question 2 replaces those affects with curiosity and interest. Most clients have never been asked about choice with respect to their substance use. Interviewers often assume choice plays little part in clients’ identifying a substance that works well for them. This may be due, in part, to a disease model of addiction that has minimized or ignored the large volitional component associated with substance use (Schaler, 2000).
Question 3 prompts the most interesting responses. Initially, clients are usually startled or surprised as most clients have no prepared response to this health-oriented question. Often, clients recover from their surprise and provide learned negative cognitions they have been told about their substance use, in effect denying any health effects of the substance in question. Gentle persistence, perhaps with the comment that “people are not fools and they tend to repeat what works for them,” leads some clients to examine their original or current healthy goals in using their drug of choice.
At other times, the therapist might comment on the persistence of the behavior despite severe negative physical, social and occupational effects, indicating to clients the tremendous positive role their substance use must have in their lives. If this proves inadequate, the therapist may wish to review the positive effects of psychoactive substance use, either generally or in terms specific to the substance. The desired effects of psychoactive substance use usually involve enhancement of positive effects, or, more commonly, the reduction of negative effects (Table 1).
The positive effects of specific drugs
For example, when alcohol is the drug of choice, positive high-dose effects include the numbing of physical and psychological pain, the attenuation or abolition of terrifying flashbacks, and/or the induction of sleep. At lower doses, alcohol is one of the quickest substances to lower anxiety or shame (Nathanson, 1992). Though a poor choice for long-term health, alcohol can work in the short run. Marijuana and heroin can reduce anger, anguish and enhance contentment. Cocaine can produce a short-term sense of excitement that can overwhelm negative effects. MDMA (ecstasy) can attenuate fear.
Question 3, when framed around health, frequently elicits trauma histories, data that clients have often been unwilling or unable to disclose to other healthcare professionals.
Having a trauma-treatment framework when exploring ways in which people reduce their suffering can dramatically humanize the substance-use interview. As clients become aware that the therapist’s focus is on health, roadblocks to communication tend to dissolve and the interview fulfills three of the five early strategies of motivational interviewing – asking open-ended questions, listening reflectively, and affirming (Miller and Rollnick, 2002). (The other two strategies are summarizing and eliciting self-motivational statements.) This allows clients to be enticed, rather than commanded or coerced, into therapy. This type of interview also follows all five principles of motivational interviewing (Table 2).
Coming at the end, question 4 is often much more useful and revealing, as the client is more focused on health. This makes the construction of a decisional balance sheet, an informed consent on his or her own behavior, considerably easier because clients can safely look at the ambivalence surrounding the benefits and costs of (1) their substance use and (2) changing their behavior (Miller and Rollnick, 2002).
The interviewer’s attitude
An interviewer with a judgmental style or confrontational attitude toward psychoactive substances and/or the substance user lowers self-report accuracy and client/therapist rapport. The most effective nonjudgmental style is one of curiosity; which when combined with the inherently paradoxical nature of Question 3, tends to shift the client out of denial and into self-curiosity.
Often, a substance-use interview focuses on only two variables, the substance and the substance user. This can reinforce rigid attitudes in the interviewer and the client. A third variable is the relationship between the person and his/her substance of choice (Weil and Rosen, 1993). Weil, a pioneer in observing the positive effects of psychoactive substance use, has identified four characteristics that can distinguish good or bad relationships with substances (Table 3). Weil’s and Rosen’s relationship questions tend to summarize and reframe the client’s perspective on substance use.
Treatment goals and planning
The first treatment goal can be derived by using a stage-of-change format, either the original five-step model (Table 4) or the co-occurring disorders/MICA (mental illness/substance abuse) modification, the Substance-Abuse Treatment Scale (Table 5). Questions about the course of substance use and the client’s subjective impression generate the first treatment goal, i.e., the next stage of change. The individual processes of change between each stage define the methods of goal one, allowing more focused treatment matching.
Question 3 elicits the positive effects of substance use and defines the second treatment goal. The therapist can then construct specific skill-enhancement techniques to achieve outcomes previously obtainable only through substance use. Behaviorally, it becomes considerably easier to help clients explore different tools for getting some, if not all, of the positive effects from their substance of choice because it accepts clients where they are. It assumes that the positive effects derived from their drug of choice are their desired goals. It also is a strong impetus for clients to begin focusing on the next stage of change and counters the pernicious assumptions that their substance of choice is evil, their behavior is a vice, or they are bad or weak-willed.
Co-occurring disorders
The collaborative, motivational, and harm reduction approach is especially useful for those with co-occurring disorders. Carey (1996) proposed a five-stage treatment model for this population, including evaluating the cost-benefit ratio of continued substance use and individualizing the goals for change. The health-oriented substance use interview is a refinement of that approach. For those with serious and persistent mental illnesses, such as schizophrenia and bipolar disorder, a health focus provides new information (Warner et al., 1994) and facilitates movement from sequential or parallel treatment for individual disorders to an integrated form of treatment (Mueser, Drake, and Noordsy, 1998). With the integrated approach, the substance-use disorder and the mental illness are treated at the same time by the same treatment team whose members have complementary goals and objectives. Treatment of the whole person becomes easier because a health orientation can focus on both adherence to prescribed medications and non-adherence to psychoactive substances that increase harm
For those with trauma disorders, a health-oriented substance-use interview usually reveals that the drug of choice is being used to attenuate the strong negative affects of shame-humiliation, anger-rage, despair-anguish, or fear-terror. This allows the specific affect, with its life history, biography, and associated scripts, to be identified, facilitating substance-use disorder treatment, resource installation, and trauma treatment either by general methods or specific interventions (e.g., EMDR or the use of serotonin reuptake inhibitor antidepressants to lower shame and arousal). The health orientation also facilitates the shift from victim to survivor and allows clients to see their courage and resiliency in surviving.
Easing the pain of war
Many Vietnam veterans carry not only the traumas incurred from war (which contains all known human traumas) but also from being blamed for the war when they returned home. Alcohol and marijuana were the most common drugs of choice on return from combat as numbing (to attenuate flashbacks) or shame reduction are often the desired effect of alcohol and rage reduction is often the desired effect of marijuana. When these veterans are asked what they would have done if they had lacked access to alcohol or marijuana when they came home, many say they would have committed suicide. With a health-oriented approach, they can see that both substances had survival value, and this strongly facilitates rapport, abstinence or non-problematic use, and trauma treatment.
Many people diagnosed with severe personality disorders have trauma as a main etiology of their rigid personality style. For example, a comparison of the DSM-IV criteria for borderline personality disorder and posttraumatic stress disorder reveals that they are very similar. The health-oriented focus allows people with severe personality disorders and trauma histories to more easily identify and tolerate dysphoric affects, making them more amenable to specific cognitive-behavioral interventions (Linehan, 1993).
Conclusion
Though a health-oriented harm reduction approach elicits improvements in health and physical well being, and empowers and motivates those most in need of hope, it is not a panacea. In the addicted population, continued substance use over time can alter neurochemistry via biological adaptation. This fuels continued substance use and addictive behaviors, chiefly by increasing the intensity of compulsive behaviors and decreasing the subjective sense of volition and choice. Interventions ranging from detoxification to self-help resources also must be built into the treatment plan.
The health-oriented interview is not meant to substitute for a comprehensive, stage-oriented treatment plan, especially with co-occurring disorders (Minkoff, 1998). It is also not a substitute for other assessment instruments (e.g., MAST, ASI, and AUDIT), but neither does it interfere with their use.
Given these limitations, the simple health-oriented substance use interview is an effective and compassionate tool for assessing possible substance-use disorders. It is effective in that it increases the probability of obtaining a relevant history of clinically useful data in a short period of time, data that often is unexplored or well defended. It is compassionate in that it fits three of the principles of harm reduction – accepting psychoactive substance use as a part of human behavior, ensuring that users have a real voice in their treatment, and not minimizing or ignoring the many real and tragic harms associated with substance use (Marlatt, 1998). It also fits current harm-reduction psychotherapy approaches, well delineated in Denning (2000).
By focusing on the current or most important substances of choice and probing for the health-oriented desires fueling the behavior, this type of interview is an excellent vehicle for integrating treatment, enhancing motivation, and allowing individuals to perform an informed consent on their own behavior. Finally, it also counters, at an individual level, many of the pernicious and pathological effects of America’s “War on Drugs” that often poison the climate of a substance-use interview.



Eugene T. Tinelli, MD, PhD, is a former Commander in the U.S. Navy, an addiction psychiatrist at the Veterans Administration Medical Center in Syracuse, NY, and an assistant professor in the Department of Psychiatry and Behavioral Science, Upstate Medical University, State University of New York, Syracuse.






References
Baer, J.S., Kivlahan, D.R., & Donovan, D.M. (1999). Integrating skill training and motivational therapies: Implications for the treatment of substance dependence. Journal of Substance Abuse Treatment, 17(1-2), 15-23.
Carey, K.B. (1996). Substance use reduction in the context of outpatient psychiatric treatment: A collaborative, motivational, harm reduction approach. Community Mental Health Journal, 32(3), 291-306.
Denning, P. (2000). Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. New York: Guilford Press.
Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Marlatt, G.A. (1998). Overview of harm reduction. In Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors, G.A. Marlatt (ed.). New York: Guilford Press.
McHugo,, G.J., Drake, R.E., Burton, H.L., & Ackerson, T.H.. (1995), A Scale for Assessing the Stage of Substance Abuse Treatment in Persons with Severe Mental Illness, Journal of Nervous and Mental Disease, 183, pp. 762-767.
Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2nd ed. New York: Guilford Press.
Minkoff, K. (1998). Persons with Co-Occurring Mental Illness and Substance Abuse Disorders (Dual Diagnosis), Report of the Center for Mental Health Services Managed Care Initiative: Clinical Standards and Workforce Competencies Project Co-Occurring Mental and Substance Disorders Panel. (Managed Care Consensus Reports, Publications and Presentations. http//www.med.upenn.edu/cmhpsr)
Mueser, K.T., Drake, R.E., & Noordsy, D.L. (1998). Integrated mental health and substance abuse treatment for severe psychiatric disorders. Journal of Practical Psychiatry and Behavioral Health, 4(3), 129-139.
Nathanson, D.L. (1992). Pride and Shame, pp. 355-7. New York: W.W. Norton.
Nathanson, D.L. (ed.), (1996). Knowing Feeling: Affect, Script and Psychotherapy.
Prochaska, J.O., Norcross, J.C., & DiClemente, C.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, Vol. 47(9), 1102-1114.
Prochaska, J.O., Norcross J.C., & DiClemente, C.C. (1994). Changing for Good: An Evolutionary Six-stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, New York: Avon.
Schaler, J.A. (2000). Addiction is a choice. Chicago: Open Court Publishing
Warner, R., Taylor, D., Wright, J., Sloat, J., Springett, G., Arnold, S., & Weinberg, S. (1994). Substance use among the mentally ill: Prevalence, reasons for use, and effects on illness. American Journal of Orthopsychiatry, Vol. 64(1), 3039.
Weil, A. & Rosen W. (1993). Chocolate to Morphine: Everything You Wanted to Know About Mind-active Drugs, by Boston: Houghton Mifflin.
Weil, A. (1998). The Natural Mind: An Investigation of Drugs and the Higher Consciousness. Boston: Houghton Mifflin



Table 1. Innate Affects
Positive Affects
1. Interest-Excitement
2. Enjoyment-Joy
Neutral Affect
1. Startle-Surprise
Negative Affects
1. Fear-Terror
2. Anger-Rage
3. Distress-Anguish
4. Shame-Humiliation
5. Dissmell
6. Disgust

From Knowing Feeling: Affect, Script and Psychotherapy. D.L. Nathanson (ed.), 1996. New York: W.W. Norton.


Table 2. Principles of Motivational Interviewing
1. Express Empathy
2. Develop Discrepancy
3. Avoid Argumentation
4. Roll with Resistance
5. Support Self-Efficacy

From Motivational Interviewing: Preparing People to Change Addictive Behavior, by W.R. Miller and S. Rollnick, 2002. New York: Guilford Press.


Table 3. Drug Relationship Questions
1. Do you recognize that the substance you are using is a drug and do you have an awareness of what it does to your body?
2. Do you experience a useful effect of the drug over time?
3. Can you easily separate from use of the drug?
4. Do you have freedom from adverse effects on health or behavior?

From Chocolate to Morphine: Everything You Wanted to Know About Mind-active Drugs, by A. Weil and W. Rosen, 1993. Boston: Houghton Mifflin.



Table 4. Stages of Change
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance (Relapse Prevention)

From Changing for Good: An Evolutionary Six-stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, by J.O. Prochaska, J.C. Norcross, and C.C. DiClemente, 1994. New York: Avon.


Table 5. Substance Abuse Treatment Scale (SATS)
1. Preengagement
2. Engagement
3. Early Persuasion
4. Late Persuasion
5. Early Active Treatment
6. Late Active Treatment
7. Relapse Prevention
8. Remission/Recovery

From “A Scale for Assessing the Stage of Substance Abuse Treatment in Persons with Severe Mental Illness,” by G.J. McHugo, R.E. Drake, H.L. Burton, and T.H. Ackerson, 1995, Journal of Nervous and Mental Disease, 183, pp. 762-767.





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