HIV Insight: Counselors’ Clinical Use of Definitive Drug Testing Results in Their Work with Substance-Use Clients

We conducted a psychotherapeutic examination of the use of definitive drug testing (liquid chromatography with tandem mass spectrometry) in the treatment of substance use disorders (SUD). Employing a generic qualitative method (Caelli et al. in International Journal of Qualitative Methods, 2(2), 2003; Merriam, 2009) we asked SUD counselors to provide narratives about cases where drug testing had revealed new or unexpected information about clients’ drug-taking behaviors. Semi-structured interviews with 12 SUD counselors were conducted by phone and analyzed for themes derived from the literature. These counselors reported many new positive drug tests in clients previously believed to be adherent with treatment. Key themes assessed in counselors’ narratives included initial client denial that was often followed by later acknowledgement of relapse and increased motivation, at times presenting new opportunities for clients to engage in treatment and enhance the therapeutic alliance. These results suggest that definitive drug testing can be used in a non-stigmatizing and therapeutic manner.

...As captured in counselors’ narratives and supported by the brief analysis of client-cognitive change, denial (Blume and Marlatt 2009; Levin 1998) appears to have temporal variability, suggesting opportunities and targets for change in the course of treatment. Other aspects of denial should be considered as well. For example, clients might have outwardly denied continued use revealed by definitive drug testing, despite being aware of the truth. This might be consistent with a fear of potential legal consequences. Alternatively, some cases of denial may have involved self-deception, or maintaining a lack of awareness of the true extent of their own drug-use behaviors. In this sense, shifts in denial may, at times, be associated with changes in awareness. By extension, shifts in denial might also be related to motivation, in that progressing through levels of readiness to change may be related to shifts in awareness and opportunities to observe oneself engaging in new behaviors (Prochaska et al. 1992)...

A less expected but potentially important theme emerging from these counselors’ stories was that individual differences in clients’ traits and temporal circumstances seemed to impact the clinical effects of drug testing at times. For example, in a few cases in which the clients seemed to have more of an antisocial disposition or a lower readiness to change, changes in drug-use behaviors may have been relatively superficial, appearing more connected to the immediate goal of completing the program (Prochaska et al. 1992). However, particularly instructive was the perspective of one counselor who identified the use of clinical drug testing as key during a potentially sensitive period of relapse risk when clients are transitioning from highly structured and controlled environments to ones with greater autonomy. As this is not an unusual circumstance, it may represent an opportunity for counselors to better identify changing patterns of risk factors in their clients that could be addressed with enhanced monitoring and treatment. An important area of future inquiry will be to examine a broader range of traits and situations that impact the therapeutic effects of clinical drug testing...

Full article at: http://goo.gl/rFHBF4

By: Adam Rzetelny, corresponding author