Initial Contact With Clients
Receptionists and assessment staff members should be aware of the program's advertisements, public service announcements, or other activities so that they can respond knowledgeably and professionally to telephone inquiries. Research participants report that any initial resistance or confusion by the treatment facility leads to a breakdown in the initiation process. A friendly, empathetic, and understanding atmosphere should begin with the first contact and continue throughout treatment and followup.
If possible, the BMDC component should be assigned its own phone number, and a receptionist answering the phone should respond with that component's name. If an answering system is used, the message can distinguish the BMDC program from others offered by the agency. Callers may raise questions about BMDC's specific components and its track record or demonstrated effectiveness to determine whether it can help them. They may be concerned about whether they will be treated in groups with people who use other drugs (e.g., cocaine) or alcohol. They may be relieved that BMDC specializes in treating "people like them" and pleased to know the program is based on scientific research. Callers need to know that the program is sensitive to their needs, that staff will take them seriously, and that the services are delivered professionally. MTP participants were apprehensive initially and wanted a counselor trained to treat marijuana problems.
The treatment effort begins with the assessment session. Assessment staff should be
· Knowledgeable about marijuana use and its consequences
· Trained to diagnose marijuana dependence and abuse and to document use patterns and related problems
· Sensitive to the ambivalence toward treatment of people who use marijuana
· Trained in MET and how to use the assessment information.
Counselors should be competent in MET, CBT, and case management. Staff members should be selected on the basis of their empathy, warmth, and genuineness, as well as their cognitive style, which should include receptiveness to learning new approaches and willingness to consider that several ways exist to solve a problem. A counselor who lacks empathy and openness to the client's perspective will be ineffective.
Training should include at least three elements:
1. Training sessions covering principles and practices of MET.This manual should be distributed in advance of training sessions to introduce basic material and create interest in the BMDC method. The training should include an introduction to the stages of change and the general principles and strategies of MET. A section of the training should be dedicated to the unique characteristics of the marijuana-dependent treatment population. Incompatible treatment methods need to be identified and discussed. Training can be done individually or in a group format.
2. Regular supervision.Counselors in training should be required to provide videotapes of themselves using MET, CBT, and case management for trainers and fellow trainees to critique. Many counselors are reluctant to allow themselves to be videotaped. To allay their concern, counselors first should view tapes of their supervisors conducting sessions and rate these tapes. Next, role plays with other counselors can be taped. Finally, counselor-client sessions can be taped and discussed. This gradual exposure appears to relieve anxiety related to taping.
Trainers should continue to shape performance until counselors demonstrate competence. Training in CBT and case management may take less time and effort than MET training because experienced substance abuse treatment practitioners tend to have been exposed to the two former treatment procedures. Resistance to MET and a manual-guided approach should be expected; opposition sometimes derives from misunderstanding. Many counselors believe that motivational interviewing means cheerleading. Also, many professionals in the addiction field are committed to their approaches to treatment (traditional approaches often are confrontational and directive) and may be reluctant to try a new method, especially if the underlying philosophy differs from one they are most familiar with.
3. Ensuring the BMDC approach.Regular supervision is needed to ensure competence. Case conferences and periodic session taping are needed to make certain that counselors follow the BMDC approach correctly. Chart reviews may be conducted systematically as a means of monitoring implementation. In MTP, monthly supervision was sufficient to maintain fidelity to the model. Supervision can be done in several ways. The counselor can provide a videotape of a session to the supervisor, who rates the treatment elements employed (MET, CBT, or case management) using a session rating form similar to the one in appendix A. This form provides the counselor with helpful feedback. It also can be useful to have counselors rate other counselors' tapes, comparing their evaluations with those of their supervisor and discussing how to implement the model in various situations.
When rating and scoring taped sessions, counselors' criticism should be gentle, emphasizing what was done right and building on strengths of the counselor being rated. Two videotapes were created to accompany this treatment manual. The first tape highlights the problem of marijuana dependence in the United States, discusses epidemiology, and contains interviews with key figures who have studied this problem. The second tape uses three hypothetical clients to provide practical information and demonstrations of BMDC at work. These tapes are recommended for counselors, supervisors, and agency administrators who want to use BMDC to treat people who smoke marijuana. To obtain more information about the BMDC training tapes, please contact Karen Steinberg, Ph.D., Department of Psychiatry, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030-1410; 860- 79-3712.
From an administrative point of view, a sustainable BMDC program requires at least three counselors to prevent disruption of service delivery. Administrators should provide uninterrupted delivery of BMDC, which may mean training backup personnel in case of resignation, vacation, termination, or prolonged illness.
Sustainability also raises funding issues. Many agencies can use public funding sources to provide BMDC, such as block grants or general revenue funds. Any funding source for outpatient treatment probably can be used for BMDC. Moreover, many persons with marijuana dependence may be willing to pay for treatment out of pocket, especially when weighing the savings that result from stopping their marijuana use.
Another important implementation decision concerns the identity of the program. One option is to offer BMDC as one of many services integrated into a variety of treatments that an agency may offer. However, use of BMDC may increase when it is promoted as a program with its own identity, distinct from other treatment programs, perhaps with its own location, for at least two reasons. First, knowing that a special program exists for people who use marijuana is reassuring to potential clients. Second, confidentiality often is important. Some clients are more comfortable when the program is not identified specifically as a drug treatment center.
Creating a distinct program identity also has the advantage of minimizing staff resistance. It makes it possible to select only those counselors among staff for whom this approach has an appeal or to recruit counselors who are eager to join a new, exciting, cutting-edge program.