Outpatient Substance Abuse Treatment The Impulsive Lifestyle Counseling Program for Antisocial...

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Therapy and Comparative International Journal of Offender

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published online 23 August 2011Int J Offender Ther Comp CriminolBirgitte Thylstrup and Morten Hesse

Outpatient Substance Abuse TreatmentThe Impulsive Lifestyle Counseling Program for Antisocial Behavior in

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International Journal ofOffender Therapy and

Comparative CriminologyXX(X) 1 –17

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416331 IJOXXX10.1177/0306624X11416331Thylstrup and HesseInternational Journal of Offender Therapy and Comparative Criminology

1Centre for Alcohol and Drug Research, Copenhagen, Denmark

Corresponding Author:Birgitte Thylstrup, Centre for Alcohol and Drug Research, Artillerivej 90, 2300 Copenhagen, Denmark Email: [email protected]

The Impulsive Lifestyle Counseling Program for Antisocial Behavior in Outpatient Substance Abuse Treatment

Birgitte Thylstrup1 and Morten Hesse1

Abstract

Antisocial behavior is associated with low quality of life for the patient and with adverse effects on society and those close to the antisocial patient. However, most patients with antisocial behavior are not seen in treatment settings that focus on their personality but rather in criminal justice settings, substance-abuse treatment, and social welfare settings. This article describes the adaptation and implementation of a highly structured manualized treatment, Impulsive Lifestyle Counseling (ILC), based on the Lifestyle Issues program, a 10-week psychoeducation program studied in prison settings. ILC consists of four sessions over 4 weeks and a booster session 8 weeks later. The goal of treatment is described to patients as “to help people identify their impulsive thoughts and lifestyle leading to problems with drug use, other people, and the police.” Two clinical examples and reflections on our experiences with the training and implementation of the ILC program are presented.

Keywords

Antisocial behavior, manualized treatment, outpatient services, substance abuse

IntroductionPatients with serious antisocial behavior constitute a large problem for society and for themselves. Antisocial behavior as measured with the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994)



2 International Journal of Offender Therapy and Comparative Criminology XX(X)

criteria for antisocial personality disorder exists on a continuum from absent to severe (Marcus, Lilienfeld, Edens, & Poythress, 2006). The overlap between various disorders characterized by antisocial behaviors, such as drug and alcohol problems and antisocial personality disorder, is best modeled as an underlying continuum of risk for multiple disorders within an externalizing spectrum (Krueger, Markon, Patrick, & Iacono, 2005).

Antisocial behavior is related to personality pathology, especially to psychopathy. There is increasing evidence that patients with psychopathic traits can be subdivided into several subtypes (Blackburn, Donnelly, Logan, & Renwick, 2004; Hervé, 2006). Importantly, some patients with high levels of psychopathy have very low empathy and low levels of anxiety and depression, are high on traits such as callousness and narcissism, and show a strong tendency to use instrumental violence. Other patients have high levels of symptoms, such as anxiety and depression, and high comorbidity of conditions, such as borderline personality disorder. This latter group may be more responsive to treatment and appears to have the ability to form a working alliance with a therapist or counselor (Bateman & Fonagy, 2008; Gerstley et al., 1989).

However, although such patients may be able to form a working relationship in treat-ment, they are not likely to seek treatment for their problems (Gardiner, Tsukagoshi, Nur, & Tyrer, 2010; Tyrer, Mitchard, Methuen, & Ranger, 2003). The patients who present in mental health services rarely participate in outpatient follow-up treatment (Crawford, Sahib, Bratton, Tyrer, & Davidson, 2009). However, these patients are likely to be encountered in criminal justice settings, where they may participate in programs to reduce reoffending (Pelissier, Camp, & Motivans, 2003) or in substance-abuse treatment settings (Verheul, 2001).

Most treatment options that have been developed for patients with antisocial per-sonality disorders have been designed to treat patients with comorbid substance-use disorders (SUDs) and personality disorders. Very few have involved treatment options that specifically target the antisocial personality. Instead, treatment has either addressed substance use or other behavioral problems, such as social problem-solving skills (Gibbon et al., 2010). A recent trial from community mental health services and foren-sic psychology and psychiatry settings in the United Kingdom showed that most patients with antisocial personality disorder and a history of violence will show up to at least a few sessions, when offered psychotherapy for their problems (Davidson et al., 2009). Thus, refusal to participate was less of a problem than is normally expected from this group of patients.

In general, the specific mechanisms by which antisocial behaviors and attitudes can be targeted have received comparatively little attention from clinical psychology and psychiatry (see Bateman & Fonagy, 2008; Nauth, 1995). Treatments that are intended to target antisocial behaviors may well be informed by guidelines for potentially help-ful treatments for psychopathy: using moral reasoning as an active part of treatment, using a cognitive-behavioral approach, applying a social information–processing approach, and planning for relapse prevention (Wong & Hare, 2005). Several treat-ment programs used in prison contain many of these components, such as the Lifestyle



Thylstrup and Hesse 3

Issues Program (Elliott & Walters, 1997; Walters, 1999, 2004, 2005) and the Aggressive Behavior Control program (Wong, Gordon, & Gu, 2007).

Apart from these elements, these treatments are generally highly structured and contain very clear goals for patients with antisocial personality disorder. We believe that this is helpful for this group of patients for the following reasons: When patients with DSM-IV antisocial personality disorder encounter a very clear structure, they tend to complete treatment successfully, whereas in less-structured environments, they do not (Hesse & Pedersen, 2007), and when they encounter a less-structured treatment environment, they are likely to play out their antisocial behaviors and values in a way that is potentially counterproductive for treatment (Bateman & Fonagy, 2008).

However, in many settings, the potential usefulness of programs developed for use in prisons is limited. To reach a wider group of people with antisocial personality dis-orders, treatment programs need to be adjusted to the nonprison settings, such as out-patient services for SUD, social services, and homelessness services. Such adjustments include shortening treatment to a length that is feasible in outpatient settings. This work is an attempt to do just that: to adapt a treatment developed in a prison setting that contains several of the important elements in treatment of antisocial patients in outpatient settings.

Description of the Impulsive Lifestyle Counseling (ILC) ProgramThe manual for the ILC program is based on the Lifestyle Issues program developed by Glenn D. Walters (Elliott & Walters, 1997; Walters, 2004, 2005). The manual written by Mathew D. Geyer was sent by Dr. Walters to us in October 2010 (unpub-lished manuscript). The original approach was changed in four main areas: (a) to adapt the approach that was designed for a prison, many examples were changed to refer to nonprison situations rather than situations within the prison setting; (b) to adapt the approach to individual therapy, many exercises and discussions were changed; (c) to allow the counseling to be completed in just four sessions, much of the original manual had to be dropped in the ILC. This includes changing the focus from change in belief systems to the identification of destructive behaviors and belief systems and, thus, to awareness raising, rather than aiming at the patient gaining a deeper insight into the psychological mechanisms underlying the disorder; and (d) to also target patients in substance-abuse treatment whose antisocial behavior is not expressed exclusively in terms of criminal offenses, we labeled the target of treatment “the impulsive lifestyle” rather than “the criminal lifestyle.” Besides criminal offenses, typical problems that can be associated with impulsive lifestyle are problems with drugs, family, friends, or the ability of doing things that are important to the patient.

Because of the changes and somewhat different approach in the ILC program, data supporting the efficacy of the Lifestyle Issues program should not be considered as evidence for the ILC program. However, the ILC is heavily inspired by the approach, method, and theory of the Lifestyle Issues program. In line with the Criminal Lifestyle




Theory (Walters, 1990) and Lifestyle Issues program (Elliott & Walters, 1997; Walters, 2004, 2005), the ILC intervention is presented as an approach to change life. Although an outline of Lifestyle Theory goes beyond the scope of this article, the key to changing a negative lifestyle is experiencing a crisis in the current lifestyle, taking responsibility for addressing the problems that lead to the crisis and seeing the mean-ingfulness in change of lifestyle. It is these experiences that the ILC attempts to promote.

The ILC program consists of four main sessions and a booster session. All sessions of the ILC program begin with a mood check (“How are you feeling right now?”) and with the completion of self-report inventories to monitor progress. Each session ends with the client completing the Session Rating Scale (Duncan et al., 2003). The first session involves a description of the purpose of the ILC program, that is, to work with four areas related to antisocial thinking and setting positive life goals. After the mood check, the counselor asks the patient how he or she felt about coming to the session. Next, the counselor asks the patient about why it might be important to address the patient’s impulsive lifestyle. Then, a handout is given to the patient, describing the goal of treatment: “to help people identify their impulsive thoughts and lifestyle, as these lead to problems with drug use, other people, and the police.” Then, four areas of an impulsive lifestyle are introduced as follows: (a) irresponsibility, (b) self-indulgence, (c) interpersonal intrusiveness, and (d) social rule breaking, and the counselor dis-cusses with the patient how these areas apply to the patient’s present lifestyle. Toward the end of Session 1, the counselor discusses life goals with the patient and describes how these goals need to be specific, well defined, and reasonable. Homework consists of a sheet with three questions that focus on the patient’s life goals and suggestions on how to overcome obstacles that will make it difficult to obtain these goals.

The second session begins with a mood check and an evaluation of the homework. Then, the concept of “cognitive maps” is introduced to describe the link between cogni-tions and actions. Next, the counselor and patient work with the Antecedents-Behavior-Consequences (ABC) model, an adapted version of the Antecedents-Beliefs-Consequences model from Rational-Emotive Behavior Therapy (Ellis & Dryden, 1997), which is a key component of the Lifestyle Issues program. However, in the ILC program, we chose to use the ABC model somewhat differently, using a problem-solving rather than a cognitive approach. We did this for several reasons. Our aim was to address and facilitate patient problem awareness and instigate motivation to change within a very short time. Where the original ABC model focuses on identifying inmates’ criminal belief systems that lead to irresponsible, impulsive, and criminal behavior, the ABC model in the ILC primarily concentrates on linking the patients’ impulsive behaviors and their immediate consequences. Thus, the model focuses on patient descriptions of everyday life situations where the patient displayed an irresponsible, impulsive, and/or criminal behavior. Afterward, the patient is asked to describe the following: (A) What in the situation triggered this behavior? (B) what was his or her reaction to the situa-tion? and (C) what was the consequence of the situation (what did it “cost” the patient




or others)? In the session, the counselor first goes through some examples of how to use the ABC model, after which, the patient is asked to work with examples from his or her own life.

The last part of Session 2 concerns being honest and taking responsibility for own actions. The homework is a continued work with the ABC model, this time using an active problem-solving focus, asking the patient to suggest more constructive ways of reacting to “triggers” in conflictual everyday life situations. In addition, the patient is asked to describe the consequences that his or her conduct has had for himself or her-self or for others and to list reasons for why the impulsive lifestyle is appealing.

Session 3 focuses on feelings of pride connected to being “streetwise” (named “criminal pride” in the original material). In this context, streetwise pride is described as a way of thinking that produces self-confidence through actions that violate the right of others. The session continues with a guided discussion of how the patient may have justified actions by blaming others or outside circumstances. The discussion also touches on how the patient has used drugs to deal with anger and frustration and how he or she perceives others. The session proceeds with talking about how the patient sees his or her self-confidence, self-esteem, and being streetwise as related and how these factors can be counterproductive to the patient’s life goals concerning positive lifestyle changes. The ABC model is used to incorporate everyday life examples. Through the concept of streetwise pride, the ABC model now directly links impulsive and destructive behavior to specific value systems and beliefs connected to an impul-sive and criminal lifestyle. At the end of the session, the patient is asked to describe the appeal of an impulsive lifestyle and of being streetwise. The homework in Session 3 concerns patient experiences of feeling streetwise pride and everyday actions that the patient does or can start doing that produce positive self-esteem.

Session 4 is about values. In this session, the counselor introduces the concept of values and discusses what values the patient finds problematic in his or her life. Then, the eight negative values are introduced as follows: dishonesty, exploitation of others, keeping things to oneself, irresponsibility, laziness, ignorance of self, denial of a need for change, and unwillingness to learn. These values are discussed in relationship to how the patient can relate them to his or her behavior and lifestyle. Afterward, the counselor describes eight positive values: honesty, relatedness, self-disclosure, respon-sibility, industriousness, self-awareness, flexibility, and erudition. Again, the coun-selor and the patient talk about how the eight values relate to the patient’s lifestyle and present life situation and how they may be helpful in the future. The patient is encour-aged to work with the ABC model up till the booster session and to practice using the positive values as support for change of behavior and trying out more constructive ways of reacting.

The booster session takes place 8 weeks later and is an open follow-up session, where patient and counselor may discuss any issues from the four counseling ses-sions, depending on what the patient finds most essential for his or her present situation.




Teaching Counselors How to Work With the ILC

The ILC manual can be taught in a 2-day in-line course, an approach that was used in this study. The manual and training programs were sent to the participating staff mem-bers before the course, so they could familiarize themselves with the content. At the beginning of the course, the staff members were informed about the project in more detail and introduced to the criteria for the antisocial personality disorder according to the DSM-IV and to the specific patient and treatment challenges when working with this disorder. The rest of the course focused on going through each session in the manual, aiming at two sessions per day. Apart from reading and discussing the ses-sions, each section within one session was role-played several times, leaving time for discussion and group reflections.

During the project, staff members received at least one visit from one of the authors as well as monthly mails on project progress, and were encouraged to contact both authors if they experienced a need for consultation or support regarding on how to work with the manual.

MeasuresThe aims of this study were to test the acceptability and feasibility of offering the ILC program within substance-abuse treatment settings. At baseline, participants were administered the Mini International Neuropsychiatric Interview (MINI; Lecrubier et al., 1997; Sheehan et al., 1997), the Thinking and Behaving Scale (TABS; Hesse, Guldager & Holm, submitted), and the drug and alcohol section from the Addiction Severity Index (ASI; McLellan et al., 1992).

The MINI is a structured layman interview designed to assess anxiety disorders, mood disorders, psychotic disorders, eating disorder, SUD, and antisocial personality disorder. The TABS is an 11-item measure of manipulative and interpersonally aggres-sive behaviors. The time frame for the TABS is generally either 4 weeks or 1 week. Each item is rated on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (very often). Item examples include the following: “During the past 4 weeks, I have manipu-lated others” and “During the past 4 weeks, I have lied about small or big things to obtain something.”

The ASI is a widely used evaluation instrument for drug and alcohol problems. The time frame is 30 days for current problem situation.

At each session, the patients filled out the TABS, the drug and alcohol section, including a question on criminal activities from the ASI (McLellan et al., 1992), and the Session Rating Scale (Duncan et al., 2003).

At follow-up, the patients completed the ASI drugs and alcohol module. They also were asked about percentage of days abstinent, a commonly reported outcome in substance-abuse treatment, and given the Client Satisfaction Questionnaire, a frequently used measure of treatment satisfaction that has been validated with drug-abusing patients (De Wilde & Hendriks, 2005).




In the following, we will present two case examples from the study to illustrate how the ILC sessions may take place in clinical practice.

Case ExamplesThe examples concern two male clients from two different treatment settings. We chose these examples because they illustrate how the ILC program can take place in different clinical settings and because the differences in the client characteristics indi-cate the variety in antisocial behaviors and patients’ life situations that staff members meet in clinical practice. The first case involves a male patient who is 27 years old, has limited experience with drug-abuse treatment, and is not opioid dependent. The other case is a male patient who is 44 years old, has been through a very large number of treatment episodes in residential rehabilitation, and has been in methadone mainte-nance for a number of years. The prescores and postscores on clinical outcomes for both patients are summarized in Table 1 and will be commented in the discussion of treatment effect following the case presentations.Case 1. Danny was in his late 20s and recently enrolled in an outpatient substance-abuse treatment for polysubstance dependence, with cocaine, amphetamine, and hash as the main problem drugs. Danny had a history of being a debt collector for a biker gang and had been to prison a number of times. During the past 6 months, he had attempted suicide and was committed to a hospital after a violent outrage where he was picked up by the police. He was usually polite and cooperative in the clinical set-ting, pleasant, clean, and reliable with regard to appointments but seemed to be depressed.

Danny’s caseworker asked whether he would participate in the study, and within 2 weeks, Danny was screened according to the MINI, Version 5 (Lecrubier et al., 1997). He satisfied all adult criteria for antisocial personality disorder and was ran-domized to receive ILC. At baseline, Danny reported using alcohol, cocaine, and amphetamine for 3 days and hash for 20 days within the last month. His baseline drugs

Table 1. Overview Pre- and Postscores of the Case Examples

Baseline Follow-up

Danny ASI drugs composite score 0.37 0.07 ASI alcohol composite score 0.12 0.09 Thinking and Behaving Scale 19 13Frank ASI drugs composite score 0.38 0.50 ASI alcohol composite score 0.00 0.00 Thinking and Behaving Scale 16 18

Note: ASI = Addiction Severity Index.




composite score was 0.37, and his baseline alcohol composite score was 0.12. A little more than 2 weeks after the baseline screening, he had his first session, and he com-pleted the four ILC sessions for the next 5 weeks.

Session 1. At the start of the first session, Danny told the counselor that he dreamed of becoming a father and a lawyer. When asked about why he found it important to address his impulsive lifestyle, he explained that he would smoke a joint when he was angry and upset instead of solving his problems and that he had a tendency to look for trouble. He liked fighting, and when he was out in town, he provoked other guests in bars and discotheques so that they would “take him on.” This behavior had caused problems with his friends, who were reluctant to go out in town with him because of the trouble and violence that often would occur. When the counselor introduced the four impulsive lifestyle areas, Danny recognized three of them: self-indulgence, inter-personal intrusiveness, and social rule breaking. At the end of the session, when he was asked to describe his personal life goals, Danny told that he wanted to finish a 2-year high school equivalent diploma course that he had left prematurely several years ago and that he had a meeting with the social worker at the social services next week about his future work life.

Session 2. Danny was very well prepared and motivated and told the counselor that he appreciated the ILC and found it very useful. He had finished his homework, describing his life goals as taking an education and becoming a Danish sport cham-pion. As for obstacles that could prevent him from obtaining these goals, Danny men-tioned about becoming homeless, his temper, and his substance abuse. He suggested that he could counter these obstacles by getting signed up in a housing association, working with anger management, and participating in the group treatment that he was offered at the treatment center.

At this point, the session moved on to working with the ABC model. Danny pre-sented two examples from his own life that he and the counselor could work with. The first example was how he always felt like provoking the police. Using this example in the ABC model, Danny told that this behavior was caused by his many negative expe-riences with the police (A) and that his reaction when he met them would be to pro-voke them (B), often causing him to spend 24 hr in the detention at the police station (C). His second example was how he would use drugs when he got angry to calm himself down. This situation occurred when he was involved in arguments and he got angry (A), choosing to smoke hash to calm down (B), and continuing his substance abuse (C).

Session 3. In his homework, Danny had worked on two new examples in the ABC model and had suggested alternatives and more constructive ways that he could react in these situations. The first example concerned situations when other people shouted at him, and his immediate reaction was to give payback (A). These feelings would make him shout and scream and want to punch someone (B)—a behavior that he stated was not very constructive (C). When describing how he could react more construc-tively, Danny suggested that he instead kept his voice down and exhibited more self-discipline (B) and that this would lead to a more constructive handling of situations where he felt provoked, instead of ending up in violence (C).




When talking with the counselor about how he solved his problems and socialized with others, Danny told that he, in general, tried to avoid problems, to forget them, or to leave them behind so that he would not “go ballistic.” He perceived strangers as threats and that he had to get to know people well before he would trust them and that he still considered the gang members that he had grown up with as his best and closest friends.

When the counselor brought up feelings of streetwise pride, Danny stated that he found that this was less relevant compared with the other topics in the session and that he did not recognize either feeling or acting out being streetwise. However, he came up with several examples when he and the counselor used the ABC model to investi-gate situations when he exhibited that a behavior was linked to feeling streetwise pride. The first example concerned his behavior during his numerous incarcerations. Here, he would be the new guy on the block (A), coping with this by “putting his foot down from the start” by being verbally or physically aggressive (B). In this way, he would make sure that the other inmates left him alone and showed him respect (C). The other example concerned his socializing with his “mates from the gang.” Often, they would get together and drink and brag about their “streetwise accomplishments” (A), and in these situations, Danny would join the scene and streetwise conduct (B), feeling “part of the gang” (C). Interestingly, the work with these examples opened up for Danny being able to relate to streetwise pride. He now described how it gave him a feeling of being part of “the gang.” He also explained that some of the appeal of belonging to this gang was that it was relatively simple to find a place in this kind of group hierarchy because “arguments and fights are taken up front” and “right there and then.”

Session 4. Danny’s ambivalence and reluctance toward recognizing streetwise pride showed in his homework from Session 3. Here, he only listed one example of situa-tions where he had experienced streetwise pride, and the example was very toned down and described in blurry details as “an evil practical joke that he and his mates had pulled on someone.” He mentioned no examples of positive actions that did not include being streetwise, which he took on a daily basis to improve his positive self-esteem, although he suggested that he could start working out in the mornings. Again, Danny stated that he certainly did not find being streetwise as a problem and that he found that it was “crappy to brag” about one’s own achievements.

In the talk about life values in the beginning of Session 4, Danny told that his strong sense of honor could get him into trouble because he would make threats and take on fights when he found his honor disrespected. At the same time, he found that honor and “being a man of his word” were vital guiding lines and that these guidelines sup-ported him in making lifestyle changes. Positive values that Danny related the most to were flexibility, honesty, responsibility, and positive relationships. Again, the value that he put to being a man of honor indicates Danny’s ambiguous and conflicting feel-ings toward feeling streetwise pride.

Booster session. At the booster session, which, in Danny’s case, took place 6 weeks later because of the counselor’s work schedule, he still experienced radical mood swings and depressive states with suicidal thoughts when on his own. He had started




his study and found it quite easy and a bit boring but necessary to do to get to where he wanted in life. He told that he got along well with the other students but that he still found his old mates more important and cool. He found that his old social network still was very important to him, although he could find it challenging to hang out with his mates because they now used more drugs than he did. Danny used the ABC model on a regular daily basis and found it very useful, and he disclosed that it helped him not to engage in many conflicts. After he had started walking away from conflicts, he described how his mates were not as scared of him and his anger was not as it used to be. He also told that he would like to enroll in an anger management course so that he could learn to control his temper and rages. Ironically, at the same time that Danny told about the positive gains connected to controlling his anger and violent outbursts, he was well aware that his reputation as a “lethal psycho” was part of why he still felt respected and included in his old social circles.Case 2 . Frank was in his 40s with a long enrollment at one of the treatment centers where the ILC was being offered and was under methadone maintenance and pre-scribed benzodiazepines from the center. Frank had a physical disability because of a gunshot episode that had left him in a wheelchair. He was currently socially isolated and had very little contact with family or friends, describing benzodiazepines and hash as the primary drugs of choice. In treatment, he shifted between behaving needy and being verbally aggressive and openly manipulative toward the staff members. Because of his disability, he had a home care aide from the municipality coming to his house to help him with the cleaning.

Frank had a record of multiple conflicts with the treatment staff and was approached several times at the treatment center by one of the interviewers affiliated with the study before the actual screening took place. He satisfied three adult criteria for antisocial personality disorder and was randomized to receive ILC. At baseline, he reported peri-odic use of illicit benzodiazepines and a daily use of hash. It took 4 months from the screening till Frank had his first session with the counselor at the treatment center, and his four ILC sessions were completed over the next 4 weeks. His baseline drugs com-posite, alcohol composite, and TABS scores were 0.38, 0.00, and 16, respectively.

Session 1. In the beginning of the first session, Frank told the counselor that his dreams were to have a family and not feel lonely, unloved, and useless any longer but respected, experienced, and proud of being a man. He found that it was important to work with his impulsive lifestyle because it caused “drug relapses, loss of control, and stupid actions.” Frank recognized all four areas related to impulsive lifestyle. He described that for him, self-indulgence was when he encountered unbearable feelings that made everything else seem secondary. He related interpersonal intrusiveness to his tendency to be verbally intrusive and social rule breaking to his finding that social norms and rules did not apply to him, although he found that he had improved lately with regard to rule breaking. As an example, he told that he now only stole food when he was really hungry because he had started having a bad conscience when stealing. As for displaying irresponsibility, he reasoned this behavior with his poor memory that caused him to easily forget his appointments with others and with himself. At the




end of the session, Frank described his life goals as becoming a member of a remote-controlled cars club, beginning physical workout, and going to Thailand or Vietnam to live there 9 months a year.

Session 2. Frank had forgotten to do his homework, and he explained this with his bad memory. Because he really wanted to do the homework, Frank and his counselor decided that the medication-dispensing staff at the treatment center where Frank picked up his methadone and benzodiazepines 3 times a week should attach the home-work sheet to his medication supply. Frank suggested that the counselor mailed him, although being unsure of how long he would remain cooperative; fearing angry mails at a later stage, this option was not supported by the counselor.

Working with the ABC model, one of Frank’s examples was when he stole buns in the supermarket, a situation that happened when he was hungry and out of money (A), causing him to steal the buns (B) and getting caught in action (C). Another example involved a conflict with a friend from the Internet. Frank wrote that this friend had lied once and, therefore, was not to be trusted (A), that he had told him that he was angry and upset and had called off the friendship (B), and that the consequence was that they both were upset and that he risked losing one of his few friends (C).

Session 3. Frank had done his homework and brought it to the session. He had con-tinued the work on one of his examples from the ABC model in the last session: his conflict with a friend from the Internet, this time suggesting more constructive ways of reacting. Frank’s suggestion for more constructive reaction was that he could “let it go” by saying “live and let live” (B), although he added that he did not feel like “taking this” from a person that he was close to. Still, he had finished the exercise and wrote that the consequence of letting go would result in more positive feelings instead of “wasting energy on being angry” (C).

In the following talk about how he, in general, solved his problems and interacted with others, Frank told that he often would get extremely angry, try to hide it by jus-tifying his actions but sometimes wonder whether his anger was reasonable. He explained how he saw other people as enemies and rivals and that he was very con-cerned with “not coming out as the loser” and made sure that he was in control of the situation.

Working with the ABC model on examples on how his feelings of being streetwise would show in situations, where he did not feel the respect he expected from others, Frank told about a situation where he was called “Numskull Jack” by his pusher. In this situation, Frank felt that he was shown disrespect (A) and reacted with sadness and anger (B). The consequence was that he first of all decided not to use the same pusher again and that he hated himself for feeling miserable and being pathetic, con-templating that he should have spoken more for himself in the situation (C).

Frank told the counselor that he found being streetwise and having an impulsive lifestyle appealing because it “allowed him to do what he wanted, when he wanted,” and basically “get what he wanted without having to wait for it.” Another attraction to being streetwise was that he felt he was in control of others and the situation and could demand the respect that he wanted. Frank stated that there were so many examples of




how his self-confidence and self-esteem were connected to streetwise pride and that he found it hard to name only a few. Again, the ABC model was used to work with every-day life examples.

Session 4. The plan with the counselor seemed to work because, again, Frank had done his homework. One of his examples of feeling streetwise pride was when he blamed society for all his troubles and saw himself as a victim of circumstances and when he, as a result of the wrongdoings that he had been exposed to, allowed himself to do exactly what he felt like. Unlike Danny, Frank found that he took plenty of actions on a daily basis to increase his positive self-esteem. He wrote that he tried “to take responsibility for my part of the mess I am in” and that he practiced kindness and politeness in his daily life. Frank had three following suggestions on new positive actions he could do: stop going to an area in the town to buy hash, start working out again, and get off the drugs. He was very aware that his streetwise pride was the key problem to his substance dependence and aggressive behavior and that it prevented him from getting where he wanted in life. Although he had survived with this behavior up till now, it had no place when it came to becoming the person he would like to be.

Frank recognized three problematic life values (irresponsibility, laziness, and igno-rance of self) from his own life. As for positive values, he found that these, in general, could serve as practical tools for his lifestyle change and recognized honesty, related-ness, and self-disclosure as positive values that he had already carried out in his every-day life.

Booster session. Frank’s booster session also took place a little earlier because of the counselor’s work schedule, in this case, 7 weeks later. At this point, Frank was nearly finished tapering his benzodiazepine prescription and experienced strong physiological and psychological withdrawal symptoms. He was very determined not to take extra benzodiazepines and bought extra methadone on the street to deal with these symptoms.

Frank told that he used the ABC model on a daily basis to deal with his benzodiaz-epine withdrawal symptoms and his behavior and found it very helpful. He would like to enroll in a residential rehabilitation program so that he could get a close follow-up on his attempt to stabilize his medication and substance use and work more intensely with his psychological problems. Frank explained to the counselor that he was very concerned with his sense of reality and the way he distinguished between right and wrong. He also talked about his concerns on how he could fit in the society.

Patient Changes During and After ILC TreatmentThe case examples illustrate that it is not a straightforward process for Danny and Frank to work with their impulsive lifestyle and antisocial behavior. Although they were able to make small positive lifestyle changes and described an urge to work more intensely with some of their problems, the follow-up interviews show that the changes can be difficult to keep up.

As for Danny, he decreased his substance use during the four sessions and the sub-sequent booster session. Although he was very eager to participate in the program, he




was, in some ways, clearly ambivalent about working with his antisocial behavior, especially when it came to feeling streetwise. Here, Danny seemed to vacillate between perceiving this as a nonissue, acknowledging it as a problem that could challenge the lifestyle changes he was looking for, and considering it a positive strength that was necessary for his survival. During treatment, Danny was able to restart his study and made small progress in a prosocial direction. However, we believe that his emotional bond with his criminal and drug-using network may be the most serious obstacle for Danny and his wish for lifestyle changes—a problem that Danny did not identify dur-ing the ILC sessions.

At the follow-up interview 6 months after the baseline interview, Danny’s drug and alcohol use had dropped slightly, and his TABS score had dropped considerably (see Table 1).

Frank was socially isolated at the beginning of treatment and initially reluctant to begin working with the program. He found that the ABC model was a very useful tool that supported his behavior and the lifestyle changes he was aiming at. Several staff members from the clinic noted that his arrogant, aggressive, and manipulative behav-ior had declined considerably during treatment, and his home care aide stated her sat-isfaction with his progress and started having concerns when she learned that the sessions were about to end.

Frank had started reducing his benzodiazepine use to, by and large, take only his prescription and avoid illegal benzodiazepine before starting the sessions, a process that continued with tapering his prescription benzodiazepine dose as well. At the 6 months follow-up, he remained abstinent from alcohol (see Table 1), but he showed an increase in drug use. The increase was primarily because Frank did not report using benzodiaze-pines daily at baseline, a somewhat contradictory statement, as he had had a prescription for benzodiazepines through the whole period. Although this was not mentioned in the ASI questions, he had tapered his methadone dose substantially during this period. His scores on antisocial thinking and behavior (TABS) had increased to 18 (see Table 1).

Both Frank and Danny face challenges and ambivalence when it comes to working with their identity, status, and coping strategies, and their dreams that function as a drive for engaging in the ILC process are not so easy to fulfill. Still, the sessions have motivated them to confront their problems and reflect deeper on some of them. It is important that both of them showed up for all five sessions and that their ratings on the Session Rating Scale were high at each session, supporting the predictor of a positive treatment outcome. This can be described as an achievement in itself because none of them had been able to engage in positive treatment relationships at their treatment places before the ILC, a typical problem that treatment faces when encountering patients with antisocial features and disorders.

Experiences With the Training and Implementation of the ILC ProgramThe cases illustrate our experiences with the study up till now: The ILC program is acceptable to patients with various degrees of antisocial behavior within outpatient




substance-abuse treatment settings, and it can be taught to drug-abuse counselors with no more than a bachelor’s degree. The ILC program does not depend on extensive psychotherapy training, and once the initial nervousness associated with having to confront patient issues, such as violence, irresponsibility, and having a deviant value set, is overcome, all of the counselors who have participated in the training have been able to implement the ILC program in their daily work and address patient issues related to antisocial behavior and impulsive lifestyle.

In some cases, when treatment was initiated, the counselor already knew the patient quite well, and in other cases, the patient was completely new to the counselor. The counselors have expressed quite an amount of surprise at how easy it was to go through with the ILC program, even when patients were not familiar to them. When patients have refused to participate in the program, it has usually been due to preexisting con-flicts with the counselors that delivered the treatment.

DiscussionIt is our contention that the ILC fills a need in the outpatient treatment of substance-abusing patients and that it is potentially useful for social services and homeless shelters—all places that are likely to encounter, and potentially exclude, patients with high levels of antisocial behavior. It is our hope that it can increase understanding of the role of antisocial behaviors and help increase motivation for further treatment interventions. We also believe that treatment services for people with attention-deficit/hyperactivity disorder or for people with posttraumatic stress disorder can benefit from the ILC because many in these patient groups display antisocial personality disorder or features. We do not believe that four sessions of structured manualized treatment will cure antisocial personality disorder or any other personality disorder for that matter (Millon & Davis, 1997). Although this can be described as a limitation, the intention of this study was to test how a treatment developed in a prison could reach a wider group of people with antisocial personality disorders in outpatient services with this patient sample. What we hope the ILC program can do is to involve antiso-cial patients within various treatment services in addressing their behavioral patterns and, in this way, fill a missing piece in a larger treatment plan.

As the case examples illustrate, the process in the ILC sessions is not a straightfor-ward process. During counseling, both patients and therapists have to face issues involving challenges and ambivalence when it comes to working with sense of belong-ing, coping strategies, and status and life goals. Also, the two case examples show that the dreams that patients have for their life are sometimes difficult to fulfill. However, recognizing them helps to address and facilitate patient motivation to change and sup-ports overcoming resistance against confronting the difficult issues that patients work with in the ILC program. Therefore, we see the ILC program as an add-on treatment to intensive substance-abuse treatment, case management (Hesse, Vanderplasschen, Rapp, Broekaert, & Fridell, 2007), nidotherapy (Tyrer, 2002), or community rein-forcement approach (Roozen et al., 2004).




We believe that it is important to develop treatment methods that address coexist-ing substance abuse and mental disorders and that such treatment methods have the potential to increase patient adherence in a large part of the patient population in substance-abuse treatment. The ILC program does not require numerous economic or staff resources to teach and implement. However, we do recommend that staff mem-bers have access to supervision when working with ILC.

Research is ongoing at the Centre for Alcohol and Drug Research (CADR) to test the efficacy of the ILC program. If the findings support the program, future studies should test the applicability and efficacy of the program in other settings, such as forensic services, homeless shelters, or employment agencies. Further studies should test the therapeutic processes going on in sessions, through video- and audio-taped sessions, and analyze the effects of the intervention on motivation for further treat-ment. Such studies also are currently taking place at the CADR.

Acknowledgment

The authors thank Glenn D. Walters and Mathew D. Geyer for making the manual for the Lifestyle Issues program available to them.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Danish Health Insurance Fund and the Danish Ministry of Social Affairs.

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