Revisions Of Declare Method

On the Revision of the DECLARE 1

On the Revision of the DECLARE Model for Addiction Therapy

Dr. Purcell Taylor, Jr.

University of CincinnatiDepartment of Psychology

Cincinnati, Ohio513-556-1618

[email protected]

On the Revision of the DECLARE Model for Addiction Therapy

Abstract

DECLARE is an acronym representing seven stages of change for viewing problems

faced by the substance abuser: Denial, Esteem, Confusion, Loss of Significant Resources,

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On the Revision of the DECLARE

Acceptance, Resolution, and Entry. That is to say, the drug abuser typically: engages in denial of

the use of drug(s), has diminished self-esteem, is confused, has lost physical, psychological, and

social resources, accepts reality of abuse or dependency, resolves to seek therapeutic assistance

and later enters traditional society as a chemically-free individual ready to begin the lifelong

process of recovery. The DECLARE Model was described earlier by Taylor in (2005a) as an

approach for assessing and treating substance related disorders. In rethinking the model, the

author made significant modifications as a result of experience and recently collected data that

pointed out limitations found in the model. For the mental health counselor, modifications in the

model should improve and enhance its usefulness in addressing issues regarding assessing and

treating persons with substance related disorders. This article provides an addiction treatment

model that is easy to remember, administer and that has clear and timely treatment strategies.

THEORETICAL MODELS OF DRUG ABUSE

In the addiction field, various models have been proposed to understand the etiology of

addiction and its treatment (Fisher & Harrison, 2000). Among these models is the moral model

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which assumes that the individual is responsible for the development of the addiction problem,

as well as for changing or failing to change the addictive behavior. Unfortunately, this model

often result in a “blaming the victim” mentally (Connors & Rychtarik, 1989; Dimeff, Baer,

Kivlahan & Marlatt, 1999; White, 2002; White, 2001& White, 1998).The disease model has a

wide acceptance due to its medical orientation. The model posits that an addiction is a

manifestation of an underlying disease process rooted in an individual’s genetic makeup

(Jellinek, 1960 & Nace, 1987). Another accepted model in this field is the harm reduction

model which emphasizes reducing the problem of usage rather than the amount of alcohol and

other drugs (AOD) the individual is using (Kinney, 2003). The model attempts to approach use

of AOD as a reality that occurs (Faupal, Horowitz, & Weaver, 2004). The Biopsychosocial model

of addiction is a popular model in the field because it incorporates all relevant variables in the

etiology and treatment of addiction (Kumpfer, Trunnell, & Whiteside, 2003; Fisher & Harrison,

2000). The spiritual (Twelve-Step) model considers the abuser as being personally responsible

for their addiction. The model posits that the abuser addiction is the result of alienation from

spiritual pursuits or engagement in excessive use of alcohol or other addictive drugs. Thus the

solution to their problem can only come through a spiritual source.

Although the drug abuse treatment community has attempted to adapt many of these

models to meet the needs of drug-dependent clients, more still needs to be accomplished in the

development of new and modification of established models (Dimeff, Baer, Kivlahan & Marlatt,

1999; Kaminer, 2001, & Taylor, 2005a).

THE DECLARE MODEL

In response to this need, The DECLARE Model was developed by Taylor (2005a), as an

approach for assessing and treating substance related disorders. The model offers clinicians a

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means of readily identifying the stage of a client’s drug use and a means of developing treatment

strategies to alleviate the client’s drug abuse problem.

THE CONCEPTUAL BASE OF THE DECLARE MODEL

The present model is founded, in part, on three notions. One of these, is the importance of

an admission (declaration) by clients, at some level of self-conscious awareness, that they have a

problem with drugs or that they are chemically dependent. Making a declaration is an essential

step before effective intervention can be initiated (Miller, 1985; Taylor, 1988, 1990, 2005a).

Second, is having a schema that is easy to remember and to administer. Third, have clear

effective and timely treatment strategies.

Arnold Lazarus’s widely recognized integrative Multimodal Behavior Therapy Model

(MMT) (Lazarus, 1976) is a key building block in the development of the DECLARE model.

The MMT is a comprehensive assessment and multimodal treatment approach that offers a

framework that assists in defining a client’s problem and experiences (Keat, 1979, 1990). The

MMT Model provides a structured means of assessing the relative levels of problems of the

client in seven general domains in an acronym called the BASIC-ID. This acronym refers to the

following modalities: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationship

and Drug/biology. The D refers not only to drug/biology but all physiological information such

as medication, nutrition, and exercise. The MMT is a broad spectrum behavior therapy model

that is eclectic and goes beyond the narrow stimulus response forms of behaviors (Lazarus, 1976,

1989a, 1989b, 1990a, 1990b, 1990c, 1995; Lazarus & Beutler, 1993; Lazarus, Beutler &

Norcross, 1992). Lazarus’s approach allows the counselor to observe the level of disturbance in

each domain and then determine their interrelationships by determining their triggering

sequence. The MMT model then suggests interventions that correspond to the dimension of the

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client’s experience that has been affected by the problem. In its early development the

DECLARE Model adopted this spectrum behavior therapy approach. However with experience

and the accumulation of new data it became necessary to make modifications in the approach.

In contrast to the MMT model, the focus of problem activation in the DECLARE model

is the identification of stages rather than dimensions as the organizing principle of problem

development. The rationale for the change from modalities to stages was to better account for

the movement of change on a continuum of change seen with the abusers. Similar to the

MMT approach, the DECLARE Model also identifies broad classes of interventions that may

be recommended as a function of the client’s stage resolution. Therefore, behavioral

strategies are recommended when the client is in a stage of active resolution, such as denial

where there is a need to utilize strategies of raising awareness, while cognitive exploration

and/or insight strategies is/are recommended when a client is in the stages of loss of self-

esteem or confusion.

A third foundation piece of the DECLARE model is Carl Rogers’s Client Centered

Therapy, a non-directive client-centered approach to therapy which is a widely regarded

humanistic theory of personality (Kowalski & Westin, 2009). Rogers believed that human

beings are basically good but their personalities become distorted by interpersonal

experiences. Consequently he advocated an approach in which a counselor should try to

understand a person’s phenomenal experience in order to be of aid to the individual. Thus,

the primary tool of the counselor was active listening to the client’s description of what

his/her life is like.

The DECLARE model’s foundation for working with substance abusers indorses many

of the principles and techniques of Rogers’s client centered approach. Among those

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principles and techniques accepted and adopted by the DECLARE Model are: (a) belief that

people tend to move towards growth and healing, (b) listening and attempting to understand,

(c) treating the client with the utmost respect and regard, (d) therapist being transparent (self

aware, self accepting, and having no mask between oneself and the client), (e) use of active

listening and hearing, reflection of feelings and clarification, and (f) the use of empathy

(Rogers, 1951,1961,1980; Rogers & Sanford, 1985).

The DECLARE Model of chemical dependency involves an interaction of biological,

psychological, and social factors. On the biological level, the model focuses upon the client’s

prior history of psychiatric illness, current and prior substance use, toxic exposure, effects of

prescribed or over-the-counter medications, and family history or genetic predisposition. On the

psychological level elements of concern are emotional development, loss of important figures in

childhood, and history of trauma or abuse. At the cognitive level, the model emphasizes the

client’s intelligence, self concept, socioeconomic status, financial stability, problems with

primary support group, occupational functioning, current relationships, ethnic issues, physical

living environment, legal problems, religion, and recent trauma. The DECLARE model

represents a nonlinear, multifaceted, cognitive-behavioral, directive approach. It is considered to

be a viable and effective means to answering the challenge of chemical dependency (Taylor,

1990, 2005a).

Essentially, the model presents a results oriented approach to the assessment and

treatment of substance-related disorder. It contains a paradigm for conceptualizing substance-

related disorders, a treatment procedure, and a method for the pursuit of scientific inquiry into

the etiology, diagnosis, treatment, disengagement, reintegration, and aftercare of persons with

substance-related disorders (Taylor, 2005a). Thus, the model is a comprehensive and flexible

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treatment methodology that allows for intervention on seven stages (outlined below), offers

specific procedures for compiling information, and provides clinicians with a schema that is easy

to remember and simple to administer within a biopsychosocial framework.

STAGES OF THE DECLARE MODEL

The DECLARE model was born out of a need to assist those who use and abuse chemical

substances despite their negative consequences. The model provides clinicians with a therapeutic

approach that permits them to use this method flexibly within their own biopsychosocial

framework (Taylor, 1988, 2005a). The model is an approach utilizing methods for assessment,

and treating chemical misuse, abuse, and dependency based on seven biopsychosocial stages.

The model has some aspects in common with the Social Learning Theory, Motivational

Interviewing (Miller & Rollnick, 1991, 2002), Stages of Change, (Prochaska, DiClemente &

Norcross, 1992), and Positive Psychology (Seligman & Csikszentmihalyi, 2000). The model

utilizes an approach that fits the treatment to the client rather than the client to the treatment.

The DECLARE is an acronym representing seven stages of change (Taylor, 1988, 1990,

2005a), for viewing the problems and issues of the substance abuser: Denial, Esteem, Confusion,

Loss of Significant Resources, Acceptance, Resolution and Entry. That is to say, when entering

treatment for drug abuse, a client typically engages in denial of the use of drug(s), has

diminished self-esteem, is confused, and has lost physical, psychological, and social resources.

As treatment progresses, the client accepts the reality of abuse or dependency on alcohol/drugs,

resolves to seek therapeutic assistance and later enters traditional society as a chemically free

individual ready to begin the lifelong process of recovery. The seven stages of the DECLARE

model are described in more detail below.

Initial Stages

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(1) Denial. The client refuses to believe or allow conscious awareness of the

threatening or unpleasant aspects of drug abuse.

(2) Esteem. Issues arise concerning feelings of personal self-worth. Self-worth can be

defined as a basic psychological feeling that all human beings possess in varying

degrees. This feeling is compromised or absent completely among those who abuse

drugs.

(3) Confusion. The client begins to recognize the effects of having little or no

regularity or predictability concerning normal life experiences. The lifestyle of the

drug abuser is chaotic, unmanageable, disorganized, and controlled by the

demands of the drugs.

(4) Loss of Significant Resources. The client develops overt awareness of the problems

that begin to occur as the result of the loss of the individual’s most important

possessions. Examples are mental health, family, friends, job, finances, legal status,

etc.

The first four stages of the DECLARE acronym -- Denial, Esteem, Confusion, and Loss of

Significant Resources -- represent the assessment and diagnostic phases of the model. The model

utilizes four instruments to evaluate an individual’s use, abuse and addiction levels. These

instruments are the Taylor Drug and Alcohol Historical Questionnaire (Taylor, 2008),

Multifaceted Assessment of Chemical Dependency II (Taylor, 2008), Biphasic Analysis

Reintegration Sequence Forms II (Taylor, 2008), and the DECLARE Screening Questions

(Taylor, 2008) which may also be used to manage issues regarding denial.

Treatment or Action Stages

(5) Acceptance. The client now finally accepts their dependency on drugs by saying “I

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want to stop hurting”, “I need help,” “I want/need to change.” This acceptance

signals the beginning of the search for treatment and eventual recovery.

(6) Resolution, The client seeks a course of action. The form of resolution varies from

person to person. The stages of Acceptance and Resolution of the model represent

the treatment phase. The concepts of the model work within both a pre-treatment and

post-treatment context. According to this schema, pre-treatment places greater

emphasis on the biopsychosocial assessment and diagnostic processes, less upon the

Entry process. In the post-treatment, this dynamic is reversed�—that is, greater

emphasis is placed on the Entry/aftercare (psychosocial) process and less on the

assessment and diagnostic processes.

The Aftercare or Recovery Stage

7) Entry. The client has now achieved disengagement from the world of drug abuse and is

in the process of entering/reentering conventional society where drug abuse has no

place. Entry/reentry process follows the Biphasic Analysis Reintegration Sequence

(BARS) process. The Entry stage represents the aftercare phase of the model. The

Entry stage has two phases:

Phase 1: During this initial phase the client demonstrates disengagement from

the world of drug abuse.

Phase 2: In this phase, the client continues maintenance of therapeutic gains;

the client is unwilling to jeopardize those gains made and refuses to continue

participation in self-abusive non-controlled drug taking behavior. The Entry

stage of the model represents the recovery and after-care phase of therapy. The

client is ready for Entry when the individual has achieved full disengagement (at

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least 90 days of complete abstinence) from the world of drug abuse and is

entering/reentering conventional society, where drug abuse has no proper place.

The major focus of this stage is to assist the client in (a) avoiding some of the

most common, often predictable, social/psychological hemorrhaging factors

producing relapse, and (b) developing a reasonably comfortable and satisfactory

lifestyle enhanced by a sense of freedom from the downward spiral of drug

abuse.

In part, the Entry stage involves the assessment of the client’s readiness to change and

return to the normal world. Part of the return to this normal world involves the recognition and

awareness that this world is full of challenges, some of which participated in leading the client to

a life of drug abuse in the first place. Other challenges and choices may involve subtle

biopsychosocial factors such as cravings, resentment, comorbidity, anger, poor social relations,

mood changes, lack of meaningful support and a dearth of sobriety-maintaining leisure time

activities.

By putting adequate emphasis on aftercare and recovery (Entry), clinicians may reduce

recidivism and enhance rehabilitation, enabling the client to return to a community that is

supportive of growth and accomplishment, rather than to an environment that perpetuates

problem behavior. In the Entry stage, the clinician advocates exploring new avenues designed to

move the client to maintain sustained change.

DYNAMICS OF THE DECLARE MODEL

Behavioral Orientation: As described by Taylor (2005a) it is crucial when using the

DECLARE Model to identify the client as having a positive behavioral orientation (PBO) or a

negative behavior orientation (NBO). In the PBO case, the client is moving in a direction in

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which a decision is made not to use or continue to use drugs. In the NBO case, the counselor is

faced with a client who may be forced into treatment by the legal system or by family or friends

but has no desire to discontinue using drugs. The establishment of an individual's behavioral

orientation is critical to the success of the DECLARE Model for it is only after a PBO or NBO is

determined that an effective plan for treatment can be initiated. The DECLARE Model seeks to

promote in clients a motivation for change through giving up their Negative Behavioral

Orientation (NBO) for a Positive Behavioral Orientation (PBO). In effect, it is the NBO and

PBO that provide a focus for treatment, helping the client to develop an awareness of how much

of a problem their use of drugs poses for them and how their use has effected them (both

positively and negatively). Thus, tipping the balance towards change (i.e., PBO in place of a

NBO) is essential for movement from Denial to Entry. Toward these ends, the DECLARE Model

has a number of similarities to Motivational Enhancement Therapy (Miller 1985, Miller &

Rollnick, 2002) and the Stages of Change Model (Prochaska & DiClemente 1982, 1994, 1985,

1986, & Proachaska, 1994). The model also incorporates principles of learning, cognitive, and

social psychology and may be considered as a transtheoretical model on how people change.

Once the orientation has been established, the client may be counseled about behaviors that may

appear during treatment that could potentially prevent positive growth and emotional stability—

i.e. prevent a movement toward empowerment. One of the basic, and most crucial, goals of drug

treatment is to assist the client through his or her journey to wholeness. To become a fully

functioning, well-integrated person, an individual must know himself or herself as completely as

possible.

Ultimately the goal of therapy is to help the client to return to society drug free and

dedicated to achieving long-term sobriety. Therefore, the model attempts to alter the destructive

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use of drugs by encouraging the abuser to set goals; however, no absolute goal is imposed. The

therapist may suggest the goal of complete abstinence or a broader range of life goals. In

utilizing the DECLARE Model, the therapist seeks to develop a discrepancy in the client’s

perception between his NBO and PBO. Many people enter therapy in a state of ambivalence;

they feel two ways about their current situation. In other words “they want it, and they don’t

want it” (Prochaska & DiClemente 1982, 1994, 1985, 1986). They begin to consider the

possibility of change, but are reluctant to do so and give up their NBO pattern. They are in

conflict and the therapist attempts to assist the client in giving voice to this conflict and declare

their abuse or dependency, (i.e. NBO verses PBO). The decision-making conflict is illustrated in

Figure 1

____________________

Insert Figure 1 about here

____________________

At this junction, the counselor attempts to address this conflict by preparing the client to

make a decision to change by evaluating the pros and cons of their drug abusing behavior. The

client is asked to develop a decisional balance scale using the four following categories: (a)

consequences of change to self, (b) consequences of change to others, (c) reactions of self as a

result of change, and (d) reactions of others as a result of change (Prochaska, 2006). After

completion of the decisional balance scale, the client views the self-generated list of pros and

cons of changing drug abusing behavior. In the event the client records more pros than cons of

continued drug use, this indicates a NBO, which suggests a decision not to change. On the other

hand should the cons of not using exceed the pros, this suggests a PBO direction indicating a

willingness to change. The client’s best chance of changing is to have the pros of changing

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slightly higher than the cons of changing. This will tip the decisional balance scale of taking

action to combat the problem of non-controlled drug taking behavior.

The counselor then uses the DECLARE stages to determine the client’s level of change

and find the interventions that fit the particular stage. Clients may spiral through these stages as

the recover process continues. Thus, the counselor needs to look at where the client is in terms

of willingness to change and determine appropriate treatment interventions. Therefore, the

counselor needs to use the change process interventions that will assist the client’s movement

from one stage of the model to another. By knowing the stage of change of the client, the

counselor can choose a best-fitting change process and provide the most appropriate and

effective counseling possible for the client. This will assist the client in the development of

appropriate coping skills, personal styles, problem solving strategies, and interaction patterns.

When clients acquire these skills they can reestablish proprietorship of their own thoughts and

behavior. Ultimately then the client can begins to live as productively and healthfully as possible

once they are free of the mask of abuse and/or dependency (Prochaska & DiClemente, 1982;

1985; 1986; Prochaska, 1994 & Taylor, 2005a).

Biopsychosocial Stages of Change. As already mentioned the DECLARE Model is based

on seven biopsychosocial stages of change. This concept of stages is important in understanding

change. Each stage requires certain tasks to be accomplished and specific processes to be used in

order to achieve change. Ideally, the path is from one stage to the next until Entry is achieved.

For most individuals with drug and alcohol problems, there are often slips, lapses, and relapses

which represent failed Resolution or Entry stages. Most of those who experience relapses go

through the movement back and forth up and down the path from Denial to Entry and back

through the process of change again. It is often necessary to move back and forth several times

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before Entry is permanently achieved. From the DECLARE stages of change perspective, the

model addresses where the client is in the movement towards change and assists the client in

achieving successful sustained change.

MODIFICATIONS TO THE DECLARE MODEL

In rethinking the model the author has made significant modifications as a result of

experience and recently collected data that pointed out limitations found in the model. For

counselor, these modifications should improve and enhance the model's usefulness in addressing

issues regarding the assessment and treatment of persons with substance related disorders.

The following six modifications have been made to the DECLARE model. (1) a change

from the use of Arnold Lazarus's multimodal dimension perspective utilizing distinct modalities

in addressing aspects of the human personality and its functioning. Instead, the model now uses a

multifaceted stage perspective that allows for a better explanation for the process of up and down

movement from stage to stage which the modality approach did not freely convey to either the

client or counselor. (2) conversion of the management of denial questions to that of a screening

tool for both alcohol and drug abuse. In its original form, the management and denial questions

were only used as a tool to assist in the management of denial. Presently, it now allows the

counselor to use it as a brief screening tool to identify those at risk for chemical abuse prior to

conducting a formal assessment to determine if services are required, (3) a revision of the Taylor

Historical Questionnaire (THQ) (Taylor, 2005b), now a more comprehensive drug and alcohol

assessment tool renamed the Taylor Drug and Alcohol Historical Questionnaire (Taylor, 2008).

For the counselor, these revisions include an expansion of the drug and alcohol sections, a

comprehensive mental status examination to aid in diagnosing co-occurring disorders and a

suicide/violence lethality assessment. The revision also eliminated the Multifaceted Assessment

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of Chemical Dependency (MAC-D) instrument from the THQ and converted it into its own

separate instrument. (4) a change in the MAC-D from a modality profile to a stage profile with

the definitions for each stage. The changes in the MAC-D also include a stage severity profile

worksheet that permits the counselor to determine which of the stage(s) are to be targeted after

the assessment is completed for inclusion in the development of the client's individual treatment

plan. (5) The introduction of the decisional balance process (Velicer, DiClemente, Prochaska &

Brandenburg, 1985) that allows the clinician to assist the client in giving voice to the conflict of

wanting treatment and not wanting treatment. This decisional balance process allows the

counselor to assist the client in developing discrepancies between their Negative Behavioral

Orientation and a Positive Behavioral Orientation. (6) revisions in the Biphasic Analysis

Reintegration Sequence (Taylor, 2005b) form which is a daily drug and alcohol self-monitoring

tool that allows the counselor to keep track of the client’s warning signs experienced on a daily

bases. The tool now includes a cravings scale with the client’s weekly self- monitoring results for

later review in therapy session by the counselor.

THE DECLARE MODEL IN OPERATION

The following case report will serve to illustrate the concepts, beliefs and processes

described in the model earlier.

M.R. is a 45 year old Caucasian male, self referred after being arrested for public

intoxication and mounting concerns voiced by friends and family. M.R. states that he has been

using alcohol for the past five or six years. He reported that he has made numerous attempts to

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quit drinking on his own, as well as seeking assistance from an alcohol program. M.R. reported

that all these attempts have failed. He did report that his most recent attempt at abstinence from

alcohol was successful and lasted for three months however, he became too sure of himself and

decided that he could handle “one” beer. After consuming a beer, he made the decision to drink

more and before he realized it he was “off the wagon” and drinking heavily. M.R. reported that

when he is drinking he becomes very confrontational and often pick fights with others in the bar.

He is currently banned from three local bars due to his fighting. M.R. has been known to stay up

for more than twenty-four hours drinking and making “drunken calls” to family members and

anyone else he has a number for. Family members report that when he is like this he can not be

understood and often talks about God and his dying. M.R. reports that he has no recollection of

these comments or his being thrown out of a bar. M.R. indicated that he drinks two cases of beer

per week.

M.R. was administered the DECLARE Drug and Alcohol Screening Questionnaire. M.R.

responded “yes” to questions 1, 3, 4, 5, 6 and 7 on the alcohol screening questionnaire and

answered “no” to all questions regarding use of drugs (Table I a & b). As a result of his

responses he was administered the Taylor Drug and Alcohol Historical Questionnaire (TDAHQ)

to determine the extent of his problems and issues with drinking.

_________________________

Insert Table I a & b about here

_________________________

Upon completion of the TDAHQ, a careful analysis of M.R.’s, response was conducted.

Utilizing the information from the TDAHQ, a stage profile was constructed to determine a

starting point for the development of an appropriate treatment plan and the selection of

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techniques to be used for intervention. The following is the complete stage profile developed

from information gathered from the TDAHQ for this individual utilizing the DECLARE

acronym.

Denial – M.R. is aware of his alcohol problems and that they are out of control. He wants

to refrain from drinking completely in the “future” and lead a healthy life. However, he moves

back and forth on how serious his alcohol problems are. When his drinking gets really bad he

attempts to cut back but after a period of time of being abstinent he lapses and begins to abuse

again.

Esteem- M.R. has very low self-esteem, which he believes is the cause of most of his

problems. His low self-esteem has made him feel like he will never be as good as others. He

often feels that he will never be able to find a woman because no one will ever find him

desirable. His feeling of worthlessness causes him to feel depressed most of the time. As a

consequence, he abuses alcohol because it makes him feel powerful and worthy. Thus, drinking

give him a sense of courage to talk to women and socialize in spite of any negative consequences

Confusion- M.R. is incapable of controlling himself when intoxicated. He usually ends

up driving drunk, calling people at all hours of the day and night and getting into violent

confrontations with others whom he is drinking with. He experiences blackouts and has no

memory of what happen the night before. Whenever he is confronted concerning what he did, he

denies that it ever happened. As a result, he has had numerous arrests and has a strained

relationship with both family and friends.

Loss of Significant Resources- M.R. has many physical and mental health issues

(depression) due to his drinking. He reports headaches, chest pains, muscle spasms and

numbness in his both hands and feet. He has loss his freedom due to several arrests for DUI and

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has had considerable difficultly in finding employment. As a result of his drinking, his finances

are limited, and he depends heavily on his parents for support.

Acceptance- M.R. is unable to refrain from his drinking for an extended period of time

(maximum of 3 months). He constantly struggles with the true nature of his problems and how

to approach them. He is very hesitant to label himself and alcoholic even though he is willing to

attend AA meetings

Resolution- M.R. wants to get better but goes through periods of determination and then

periods of ambivalence towards treatment. He is not completely sure he is ready to give up

alcohol and is not devoted to attending formal treatment.

Entry- M.R. is constantly questioning his abilities and what others think of him. He can

not fully pursue his dreams because he is afraid of failure and rejection. He is also afraid of what

life will be like if he stops drinking because he will ultimately lose several of his very close

friends.

Upon completion of the stage profile, a review of each stage and its implications for

recovery was conducted. Each stage was evaluated utilizing the stage severity profile worksheet

that permits the counselor to determine which of the stage(s) are to be targeted for treatment in

the development of his individual treatment plan. Among those stages selected for inclusion in

M.R.’s treatment plan, were Denial, Esteem, Confusion and Loss of Significant Resources. Each

of these stages was evaluated as being severe or significant in maintaining his self-destructive

noncontrolled drinking behavior. At this junction, it’s important to fit the appropriate therapeutic

interventions for the particular stage(s) identified. Given the scope of M.R.’s, problems his

treatment plan should include processes of change approaches (i.e., psychoanalytic,

humanistic/existential, gestalt, cognitive, and behavioral) such as raising consciousness and

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emotional arousal to address his denial, social liberation in order to boost self-esteem, self-

reevaluation, and decisional balance and self-efficacy to assist in weighting the benefits and costs

of changing his view of himself as being a self changer.

DECLARE INSTRUMENTS

For clinical purposes it is important to have a basic understanding of a person’s drug and

alcohol history as well as their mental health status, violence towards self and others, intellectual

functioning, personality characteristics, environment, social pressures and resources. Therefore,

an adequate assessment includes more than some diagnostic label. It should include a

comprehensive and objective description of a person’s drug and alcohol abuse history so that

appropriate treatment can be initiated.

The following instruments utilized in the DECLARE Model are provided for the clinician

to understand the client’s AOD problems and issues.

Taylor Drug and Alcohol Historical Questionnaire (TDAHQ). The TDAHQ (Taylor,

2008) is a comprehensive instrument developed to aid in gathering information during the initial

interview. It assesses drug and alcohol related issues as well as psychiatric symptoms emanating

from co-occurring disorders. The questionnaire is divided into two major divisions: Division

One includes the following sections: (1) demographic information, (2) biological data, (3) drug

and alcohol use history (4) drug and alcohol treatment history and (5) legal history. Division Two

consists of the seven stages of the DECLARE Model for analysis of the client’s presenting

problem(s). These stages include the following: Denial, Esteem, Confusion, and Loss of

significant resources, Acceptance, Resolution, and Entry. Division Three consists of the mental

status examination and a suicide and violence lethality assessment.

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The clinician should use the TDAHQ as a structured interview for gathering needed

information about the client. Upon receiving the information from the TDAHQ, the clinician

should review the questionnaire and clear up any misconceptions prior to developing, with the

client an initial stage profile and treatment plan which is found in the Multifaceted Assessment of

Chemical Dependency Inventory (MAC-D-II). The TDAHQ must be used in conjunction with

the Multifaceted Assessment of Chemical Dependency Inventory (MAC-D-II).

Multifaceted Assessment of Chemical Dependency Inventory II (MAC-D-II).

Together, the TDAHQ and MAC-D-II (Taylor, 2008) are designed to determine the extent of

substance abuse and its physical, psychological (mental status, co-occurring disorders), familial,

social violence, suicidal thoughts and legal consequences. With these instruments, the severity of

each stage is assessed, the pattern(s) of use of all types of abuseable substances is (are) assessed,

with the following factors considered: dosage, quality, duration of use/abuse, expenses incurred

with the procurement of substances, method(s) used to administer the substances, family issues,

interpersonal issues, existent or nonexistence of enablers, physical effects, emotional effects,

psychological effects, tolerance levels, withdrawal, overdoses, specific psychopathology (which

should be well documented prior to treatment), legal status and treatment.

MACD-II is an essential tool in the effective assessment and subsequent treatment of the

client. The Stage Profile Form includes the following information for each stage: (a) pros, (b)

cons, (c) problems or issues, (d) what events led to the stage, (e) what are the consequences of

action or inaction in the stage, and (f) what level of action is required to resolve the stage (i.e.,

low, medium or high). A client’s Stage Profile is developed from information gathered from the

TDAHQ’s section on the Stages of DECLARE analysis of the presenting problem. This

information is transcribed to the MAC-D-II profile form–a worksheet and a guide for use in

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conceptualizing determinants of problems and issues of addiction–based on all seven DECLARE

Stages. This form will facilitate and encourage a systematic approach to treatment planning and

evaluation of the client. This evaluation is further facilitated by the use of the DECLARE

Severity Worksheet which allows the clinician to evaluate the client’s stage assessment results on

a five point risk rating scale ranging from (0) No Problem, (1) Minimal, (2) Moderate, (3)

Significant, and (4) Severe. Each stage is described so that the clinician has easy access to its

definition. Clinician’s need only to review and evaluate each stage based on the information

collected during the assessment and use clinical judgment to ascribe a value for that stage by

employing the numbering system indicated above as to its importance in the functioning of the

client. Clinicians should bear in mind that ascribing either a 3 or 4 to any stage indicates that that

stage must be included in developing an effective treatment plan for the client.

The clinician also has the ability to provide a confidence rating score (1 or 2) of the

client’s level of impairment and/ or their level of distortion of presented information. The use of

the MAC-D-II in the assessment process is similar to Lazarus’s approach of evaluation in that the

clinician assesses each stage for its impact on the entire client record. This intense focusing on

the situation enables the clinician to pinpoint logical therapeutic intervention by examining the

interactive aspects of the specific problem. All information on the MAC-D II form may be

modified, expanded or updated by the clinician to reflect the current status of the client. Despite

any parallels that can be drawn between the multifaceted approach of the DECLARE Model and

Arnold Lazarus’s Multimodal Model, they are clearly distinct approaches with each focusing on

different aspects of the human personality and its functioning. Also, included in the inventory,

are sections designed to gather other important information concerning a client. They are as

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follows: (1) treatment plan, (2) DSM-IV-TR Axis’s, (3) an assessment summary, and (4) clinical

notes and incomplete (projective) sentence stems.

DECLARE Drug and Alcohol Screening Questions. To assist in the diagnosis and

assessment of substance abuse various other psychometric instruments such as the Michigan

Alcohol Screening Test (Selzer, 1971), T-ACE Question (Sokol, 1989), and the CAGE

Questionnaire (Ewing, 1984) have been used by clinicians to obtain a general overview of the

client’s alcohol/drug usage. These instruments assist in selecting appropriate measures to

enhance the clinician’s understanding of the exact nature, dynamics, severity, and effect of the

client’s substance abuse.

In a study conducted with 715 undergraduate students at a Mid-Western University an

internal consistency estimate of reliability was computed for the DECLARE and the CAGE

screening instruments. The seven item DECLARE measure had a Cronback's alpha of .690 with

a 95% confidence interval, lower bound of .645 and an upper of .731which was statistically

significant. The four item CAGE measure has a Cronback’s alpha of .626 with a 95%confidence

interval lower bound of .568 and an upper bound of .678 which was also statistically significant

(Taylor, 2008).

The DECLARE Drug and Alcohol Screening Questions are used to determine if a full

drug or alcohol assessment is required. Should the client respond yes to any one of the seven

questions, on either the alcohol or drug form a full assessment should be undertaken (see Table I

a & Table I b). The DECLARE screening questions may also be used for the management of

denial (Taylor, 2005a), this approach allows the client to express their powerlessness over mood-

altering chemicals. It is important for the client to declare their powerlessness over chemicals

because the foundation upon which recovery is built depends on the acknowledgment of that

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fact. In helping the client to acknowledge their powerlessness and to break the cycle of denial, it

is important that the clinician encourage clients to be honest with themselves, as well as with

others. Unless clients are willing to take an honest and detailed look at what the mood-altering

chemicals have done, there is no opportunity to clearly see the magnitude of the problem; and

unless clients grasps the negative effects of their abusing behavior, it is unlikely they will feel

the need to change.

In an effort to assist clients in making a declaration of powerlessness over mood-

altering substances and in acknowledging their loss of control, the therapist should find the

DECLARE Model’s questions for managing denial helpful in developing discrepancy in their

PBO and NBO dimensions. In essence, clients are urged to answer as honestly and openly as

possible to seven questions which are based on the letters of the DECLARE acronym. A "yes"

answer to any one of these screening questions is indicative of a drug and/or alcohol problem,

and the respondent (or family member/friend) should seek assistance from the nearest available

treatment center or chemical dependency professional.

In administering those questions, it is often helpful to encourage the client to respond in

writing and give examples, even though it might be uncomfortable to do so. In declaring

answers on paper, the client may be more likely to realize and untimely acknowledge that a

problem truly exists. Only when the client declares that there is, indeed, a problem can they

begin to do something about it. The DECLARE screening questions for managing denial may be

used either during the interview process or at the end of either the second or third session. After

the initial relationship with the client has been established, answering these questions may enable

the client to have an honest view of themselves. This may be particularly true if a family member

or friend is present during this phase of the interview. Whenever possible, clinicians should have

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their clients respond to these questions with corroboration by a family member or friend. In the

DECLARE Model, this approach has been successful in assisting clients to decrease or eliminate

their use of denial, allowing them to take an honest look at what their use of mood-altering drugs

has done to their lives (Taylor, 1988, 2005a). Clinicians are advised that these instruments were

created and designed for use only with the DECLARE Model. The model is a unique approach

for visualizing the behaviors of those suffering the difficulties of addiction from seven stages

(Taylor, 1988, 1990, 2005a).

Biphasic Analysis Reintegration Sequence II (BARS-II). For addiction treatment to be

successful, the clinician must recognize the fact that sometimes the alcoholic or addict will slip,

lapse or relapse. In fact, this is often part of the recovery process and certainly does not mean

that all is lost, or that the client is doomed to return to a life of drug abuse. Certainly this type of

unrealistic belief will only lead to feelings of hopelessness and powerlessness.

Relapse is defined as a period during which the client becomes either overconfident or

under-confident and ends up losing control, often repeating old destructive behaviors (e.g.,

M.R.). Relapse often begins weeks or months prior to the actual resumption of use. Slips and

lapses, on the other hand, are considered periods during which the individual uses, but is not yet

out of control. Relapses do not occur suddenly or without warning. They generally involve a

gradual movement away from sobriety (Marlatt & Gordan, 1985; Caroll, 1992; Baer et al., 1982

& Taylor, 2005a).

In order to prevent relapse it is important to emphasize to the client the necessity of self-

monitoring (aftercare) on a daily basis. The BARS II (Taylor, 2008) self-monitoring form is the

instrument utilized in the DECLARE Model to facilitate this important function. The BARS II

form may be an important recovery tool for the client. It allows clients to keep tract of their daily

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challenges and choices made in response towards avoiding the substance of abuse and

maintaining therapeutic goals. The BARS II Form consists of three sections, and is a simple tool

to use. In part, clients are asked to list in the spaces provided their responses to challenges

experienced during the day. In doing so, clients will be able to keep track of their efforts to

remain drug- free (Taylor, 2008).

Keep in mind that recovery is a daily routine and is not unlike other chronic conditions

that require careful monitoring, such as hypertension, obesity, diabetes or cardiac disease. The

form includes a craving rating scale from zero to 100 at the top of the form, a list of common

triggers at the bottom of each day’s column, and a place for the clients to record their responses

for each day of the week. Clients are asked to keep track of their daily cravings ratings, the

thoughts, feelings, and triggers that they experience, the actions taken regarding each challenge

experienced, and to record them in the large spaces provided on the form. On section two of the

BARS II form, entitled “Daily Well Being/Weekly Rating”, clients are asked, on a daily basis, to

keep track of how they rated the activities of the day and week i.e. how they responded to the

challenge(s) on a scale of 1 to 10, with 1 representing “poor”, 5 representing “moderate” and 10

representing “optimal”. Clients may, at the end of the day, record their craving rating on the chart

provided on the form. Clients may also record the weekly rating and plot the entire week using

the Wellbeing Declagram (Taylor, 2008). Whenever clients experience difficulty in selecting

appropriate responses to challenges, they may share their responses on the BARS II form with

the clinician during therapy session.

On section three of the BARS II form (Social/Leisure/Hobby/Fun), the client is asked, on

a daily basis at bed time, to select five (non-drug related) activities that give them pleasure for

the next day—e.g., movies, bowling, having dinner at a favorite restaurant, shopping, walking,

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swimming, exercising, spending special time with family, friends or lover. In the spaces provided

for each day, the client is asked to keep track of those activities in which they engage in

throughout the day (Taylor, 2008).

SIMALARIES BETWEEN THE DECLARE MODEL WITH THE STAGES OF CHANGE

MODEL

The DECLARE model shares some similar characteristics with Motivational

Enhancement Therapy (Miller, 1985, Miller & Rollnick, 1991, 2002), and the six stages of the

Stages of Change Model (Prochaska & DiClemente, 1982, 1985, 1986). The following is a

description of the similarities between the other two models. The DECLARE Model counseling

techniques are similar to those of Motivational Enhancement Therapy, such as eliciting self-

motivational statements, listening with empathy, questioning, feedback on assessment results,

affirming the client by a positive working relationship, self responsibility and personal

empowerment, free choice and handing resistance, (i.e. issues of denial).

In the Stage of Change Model, people who are not considering change in their problem behavior

are described as Precontemplators. In the DECLARE Model, they are described as being in

Denial. The second stage of the model, Contemplation, individuals begin to consider both that

they have a problem and the feasibility and the cost of changing that behavior. In the DECLARE

Model it is described as diminished Esteem, Confusion, and Loss of Significant Resources

stages. In the Change Model, as individuals’ progress, they move on to the stage of

Determination, where the decision is made to take action and change. This stage is analogous in

the Declare Model as Acceptance. In the Stages of Change Model, once the individuals begin to

modify their problem behavior they enter the Action Stage. The Action Stage of the Stages of

Change Model is compatible to the Resolution stage in the DECLARE Model. Finally, after

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successfully negotiating the Action Stage of the Stages of Change Model, individuals move to

the final stage of Maintenance or sustained change. In the DECLARE Model, this stage is

represented as the Entry stage or where the client has achieved disengagement from the world of

drugs. The client now is unwilling to jeopardize gains received in therapy.

SUMMARY

The challenge of illicit drug abuse in our society must be answered with positive,

proactive responses that persuade people not to abuse alcohol and other drugs in the first place.

The DECLARE Model represents a nonlinear multifaceted, cognitive-behavioral, directive

approach for answering that challenge. The DECLARE Model recognizes seven stages. Four

stages derive from a negative behavioral orientation giving rise to Denial, Esteem, Confusion,

and Loss of Significant Resources. The remaining stages derive from a positive behavioral

orientation to produce the threefold process of Acceptance, Resolution, and Entry. In this model,

the therapist indicates the severity of each of the client’s stage(s) and then chooses an appropriate

intervention technique for each stage. Professional counselors and therapists dealing with

addiction clients require a flexible framework for organizing their interventions within each of

the stages, a framework designed specially for assisting the client on his or her road to recovery

Taylor, 2005a).

A successful addiction model must synthesize pharmacological, experiential, cultural,

situational, and personality components in a fluid and seamless description of addictive

motivation. It must account for why a drug is more addictive in one society than another,

addictive for one individual and not another, and addictive for the same individual at one time

and not another (Peele 1990, Taylor, 2005 a). One’s therapeutic approach to addiction plays an

important role in the assessment and treatment process for the client.

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NBODecisional Balance

No ChangePBO

PROS CONS

Decisional Balance

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Change Behavior CONSPROS

Figure 1 DECLARE Ambivalence Model

Table I a

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DECLARE DRUG AND ALCOHOL SCREENING (DDAS-A)

Have you drunk any alcohol during the past year? If “yes,” Please answer all the following questions Yes or No. Thank You.

Directions: The following seven questions concern information about your involvement with alcoholic beverages during the past year. Carefully read each question and decide if your response is “Yes” or “NO”. Please answer each question. Should you experience difficulties with a question, then choose the response that is mostly right.

1. In the past year have you ever engaged in destructive and/or dangerous behavior as a result of drinking Yes/No.

2. In the past year have you needed to use alcohol to start your day or just get through the day? Yes/No

3. In the past year have you ever attempted to control or cut down your use of alcohol because you suspected an abuse or addiction problem? Yes/No

4. In the past year have you lost any of the following as a result of your alcohol use? (family, friends, job, health, legal status) Yes/No

5. In the past year have you ever become angry or annoyed with family, friends, or business associates when they seriously questioned you about your drinking habits? Yes/No

6. In the past year have you ever had feelings of remorse when you awoke in the morning, after being drunk or wasted the night before? Yes/No

7. In the past year has your use of alcohol affected your feelings towards yourself and others? Yes/No

Scoring: Each question is scored on a scale of 0-1 (yes=1 and No=0) with a maximum score of 7. Clients receiving a score of 2 should be evaluated for an alcohol abuse or dependency disorder.

Table I b

DECLARE DRUG AND ALCOHOL SCREENING (DDAS-D)

Have you used any drug(s) during the past year? If “yes,” Please answer all the following questions Yes or No. Thank You.

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Directions: The following seven questions concern information about your involvement with drugs during the past year. Carefully read each question and decide if your response is “Yes or “NO”. Please answer each question. Should you experience difficulties with a question, then choose the response that is mostly right.

1. In the past year have you ever engaged in destructive and/or dangerous behavior as a result of using drug(s). Yes/No.

2. In the past year have you needed to use drug(s) to start your day or just get through the day? Yes/No

3. In the past year have you ever attempted to control or cut down your use of drug(s) because you suspected an abuse or addiction problem? Yes/No

4. In the past year have you lost any of the following as a result of your drug use? (family, friends, job, health, legal status) Yes/No

5. In the past year have you ever become angry or annoyed with family, friends, or business associates when they seriously questioned you about your drinking habits? Yes/No

6. In the past year have you ever had feelings of remorse when you awoke in the morning, after being wasted the night before? Yes/No

7. In the past year has your use of drug(s) affected your feelings towards yourself and others? Yes/No

Scoring: Each question is scored on a scale of 0-1 (yes=1 and No=0) with a maximum score of 7. Clients receiving a score of 2 should be evaluated for a drug abuse or dependency disorder.

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On the Revision of the DECLARE 39

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Documents

Revisions Of Declare Method