Might as Well Face It, There's Addiction Among Your Clients: Treatment Planning by Cynthia Glidden-Tracey, Ph.D. 5 Credit hours - $74 Last revised: 11/16/2008 Course content © copyright 2008 by Cynthia Glidden-Tracey, Ph.D.. All rights reserved. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com maintains responsibility for its courses. ASWB provider #1107. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com solely is responsible for all aspects of the program. NBCC provider #6323. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net DBA SocialWorkCoursesOnline.com is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801. Take the Course Take the Test Buy your Certificate

This is an Intermediate Level course. After taking this course, mental health professionals will be able to:

• Describe how substance abuse treatment planning can be a collaborative intervention.
• Name one goal and four corresponding objectives that can be incorporated into a plan to help a client increase self-efficacy for change.
• Explain two goals and related objectives that help tailor a treatment plan to the client’s stage of readiness for change.
• Discuss four important issues to address in psychoeducation about how therapy works and what the client can expect in therapy to address substance abuse.
• Assist clients in weighing risks and benefits of using psychoactive substances by discussing the physiological and psychological effects and long-term consequences.
• Help clients identify, counteract, and cope with factors that could trigger relapse and thus interfere with therapy goals.
• Explain four ways in which treatment planning can be used to reinforce and expand a client’s successful efforts to prevent relapse.

Introduction

This course is designed to acquaint the generalist mental health professional (hereafter called “the practitioner”) with knowledge and skills for planning effective treatment to reduce problems associated with a client’s or patient’s use of psychoactive substances. Emphasizing that concerns related to a client’s alcohol or drug use may emerge at any point in the course of therapy, this course will prepare the practitioner to develop treatment plans to address a client’s substance abuse and to implement and revise those plans in response to the changing nature of the therapeutic relationship. In particular, the course will instruct practitioners to plan collaboratively to meet a client’s substance abuse treatment goals using a) objectives for enhancing a client’s self-efficacy and motivation for change, b) psychoeducation about the processes of therapy and recovery and c) methods for relapse prevention.

The first section of this course articulates a structure for treatment planning by which clients can participate in setting meaningful goals and objectives for therapy. Noting that clients who abuse alcohol or other drugs often exhibit low confidence and/or low motivation for altering their behavior, the course offers specific objectives aimed at goals of increasing self-efficacy and motivation for change. These behavior regulation objectives are derived from Bandura’s (1977, 1997) work on types of information that can influence a person’s self-efficacy plus Prochaska, DiClemente, and Norcross’ (1992, 2007) transtheoretical model of the stages of change.

The second section of this course focuses on the utility of incorporating psychoeducational objectives and methods into a substance abuse treatment plan. By both providing information and attending to the client’s reactions to that information, practitioners help clients to better understand the therapy process, the impact of the client’s substance use, and the nature of successful recovery from problematic drug or alcohol use.

The third section of this course gives practitioners guidance in developing relapse prevention strategies as part of a client’s substance abuse treatment plan. Addressing the possibility of relapse is important because relapse is a likely occurrence in the recovery process. Building on the work of Marlatt and his colleagues (1985, 2005), this course suggests methods for strengthening a client’s abilities to prevent relapse. These methods include recognizing and responding to relapse triggers, substituting healthier activities for substance abuse, coping with and learning from relapse if it happens, and reinforcing the client’s successful efforts at relapse prevention.

Together these treatment planning tools can increase the practitioner’s effectiveness in engaging clients who abuse psychoactive substances in best using therapy to modify problematic behaviors. This course fits with and extends the material from this author’s extant course Might As Well Face It, There’s Addiction Among Your Clients (Glidden-Tracey, 2007). The first course covers substance use assessment, and this second course facilitates treatment planning when an assessment indicates a problem associated with the client’s substance use. While the two courses comprise a highly compatible sequence of continuing education opportunities, each course can also stand alone as a fully contained training module relevant to a specific aspect of professional practice with the substance abusing population.

The course is based on several chapters from the following book: Copyright (2005) from Counseling And Therapy With Clients Who Abuse Alcohol Or Other Drugs: An Integrative Approach, by Cynthia Glidden-Tracey. Reproduced by permission of Taylor and Francis Group, LLC, a division of Informa plc.

Section 1 - Planning treatment to enhance self-efficacy and motivation

Therapists plan treatment with clients in efforts to establish meaningful goals and a strategy to reach them. Treatment planning continues as long as the client keeps returning for therapy sessions. Ideally, a treatment plan emerges from negotiations between the client and therapist to decide what problems are to be addressed in therapy, what goals are reasonable and worthwhile, what pathways and techniques are available, and what steps the client is willing and able to take toward those goals. Periodic review is built into the plan since treatment plans often change as new details come to light or as the client’s situation and the therapeutic relationship evolve.

A plan for therapy gives both the therapist and client a sense of direction for their work together. A well articulated plan also potentially enhances treatment efficacy by providing a clear means for tracking progress toward established goals. The therapist has several purposes in developing a treatment plan for a client with a substance use disorder. First and foremost, the therapist wants to motivate and empower clients to make beneficial changes in their substance use behaviors. To that end, the therapist structures the task at hand by helping the client identify a range of available options, and by encouraging the client to make informed choices from among those alternatives. In addition to increasing the client’s knowledge, the therapist also plans treatment to boost the client’s sense of self-efficacy, so that clients will have some confidence in their abilities to make good choices and to implement plans of action. Treatment plans that are negotiated directly with clients invite the client to share both initiative and responsibility for determining the course of therapy, including both end goals and the steps to take in striving to reach those goals. In sum, a workable treatment plan is responsive to the client’s stated interests, provides flexible structure, reinforces client choice, supports decision-making, and promotes responsibility for outcomes of client behaviors.

COMPONENTS OF A TREATMENT PLAN

Therapists accomplish these purposes by organizing plans into meaningful components. The first component is the rationale provided to the client for generating a plan; this includes the therapist’s thoughtful response to the client’s reaction to the planning proposal. Once the client agrees to collaborate on a plan, the second component specifies the problem(s) to be addressed in therapy. Third, planning involves clarification of goals to be attempted, with the desired general result to be either resolution of the problem or at least reduction of its detrimental impact. The fourth component, setting objectives, consists of breaking the distance between the problem and the goal down into identifiable, meaningful, and achievable steps. These steps toward the goal help make the process of changing behavior more understandable and manageable for both the client and the therapist. Fifth, planning specifies methods to be used for working on each objective, or tasks to be undertaken in attempts to move toward goals. Finally, the therapist and the client may wish to agree on timeframes for attempting specific tasks, reviewing the plan to assess progress, and achieving objectives and goals.

The present section is structured around these six components of a treatment plan. The rationale for involving the client as much as possible in formal planning of a course of substance abuse therapy will be followed by a presentation of some common problems focal to many cases of substance use disorders. These include low motivation and low self-efficacy for changing problematic behaviors. General goals for addressing these focal problems will be elaborated in the context of relevant theoretical and empirical literature. These goals include (a) increasing the client’s motivation and self-efficacy for change, (b) enhancing clients’ understanding of their thoughts, feelings and behaviors associated with substance use and related problems, and (c) engaging clients in action planned to promote change. Within the sections covering each general goal, feasible objectives, methods, and timeframes will be outlined, with a particular focus on pertinent objectives for each goal. Methods and timeframes of particular relevance to substance abuse treatment will be considered in greater depth in the following sections on psychoeducation and relapse prevention planning. Interventions to address additional problems associated with substance use disorders are detailed in Glidden-Tracey (2005) along with considerations for planning termination.

OFFERING RATIONALE FOR GENERATING A SUBSTANCE ABUSE TREATMENT PLAN

Substance abusing clients often lack structure in significant parts of their lives. Because their time is highly organized around alcohol or drug-related activities, or because their substance use blunts their capacity for executive functioning (or both), they may have trouble setting realistic goals, developing workable plans, or maintaining motivated effort in realms of life outside of substance use and the activities necessary to keep using. The DSM-IV-R criteria for Substance Abuse disorders capture the potential for life disruption through repeated risks or troubles encountered under the influence of psychoactive substances. The criteria for Substance Dependence further allude to the chaotic nature of a substance use disorder in specifying that the substance dependent individual tries to quit using but cannot, or neglects important life roles in favor of continued substance use, or keeps on drinking or drugging even in the face of seriously negative consequences. Individuals whose days have been organized around drugs or complicated by alcohol have much to gain from the structured activity of planning treatment with a therapist.

Treatment Planning as a Collaborative Intervention

Skilled therapists can use the initial treatment planning discussion to explore with clients how they are presently dealing with life and how that compares with what they ultimately want from life. By thus identifying problems and goals, the therapist can help clients choose how they can use their time together in therapy sessions to promote progress toward those goals. Motivational interviewing strategies (Miller & Rollnick, 2002) are often useful in this context, and will be discussed below. Once the client agrees to a negotiated plan, the therapist will refocus on the planning process when needed to clarify problems through further assessment. Therapists can also undertake review of the treatment plan to help specify client options and to choose and implement actions. Additionally, review of a treatment plan also encompasses evaluation of the outcomes of those actions and revision of the plan as the work progresses. Sample treatment plans will be provided to illustrate these points.

Engaging a client in collaborative treatment planning is in itself an intervention that contributes to progress in therapy. Hopefully it is already clear that I wish to focus on the active process of planning treatment as well as the obtained product of a document to be filed in the client’s record. Often a written plan is a desirable—and in some settings, a required—commodity. It can serve as a contract of sorts to guide subsequent transactions in the therapy relationship. But the underlying premise is that without incorporating the client’s perspective and activating the client’s initiative, the document will be worth little more than the paper it is written on. Telling an alcoholic client that he needs to stop drinking will not help until the client agrees to quit. Insisting that a woman who has stated a goal of reducing habitual marijuana use should stop hanging around with her friends who still use pot will not keep her from smoking until the client decides she can and wants to implement steps to keep her from smoking. The most useful plan for a client is a living, working document that reflects the client’s perceptions, motivations, and input as well as the therapist’s definitions, suggestions, and expertise. A productive plan mobilizes the therapist to assess the client’s motivation for treatment and address any resistance. Effective planning elicits client input and encourages client choice wherever possible; it provides structure and an underlying rationale for treatment, and it helps select formats and goals that meet clients where they live.

Inviting the client’s participation. The therapist commences treatment planning by explaining to the client the purpose of developing a plan. The therapist tells the client,

I suggest we start by coming up with a written treatment plan. I like to do that with new clients for at least two important reasons. First, a plan that we both can read, discuss, and sign helps make sure we agree on how we’re going to use our time in these sessions; and second, it gives us a way to track progress over time. A treatment plan is like a road map to give us some direction, but it’s also not engraved in stone. We can take it out and look at it now and then, and if we want to, we can pick a new route or even redraw the map.

Most clients, when asked their reaction to such a proposal, will consent to a discussion of planning, either because they have problems in mind to address or because they are willing to give their new therapist, who seems to be offering a reasonable starting point, the benefit of the doubt. The therapist’s opening educates them about what to expect next and also piques curiosity about what the therapist will do. Notice that therapists do not say that they “have to” come up with a plan, nor does the therapist tell the client that the purpose of writing a plan is to satisfy agency requirements or any other third party. The client will be more motivated to engage in the planning process with the therapist when the plan is presented as the therapist’s own initiative in the client’s interest and with the client’s active participation, rather than as an externally imposed obligation.

It is not imperative that the plan be written together in session. In some settings and with some clients, it is acceptable to talk about the plan for therapy and negotiate an agreement without putting it on paper in the client’s presence or requiring the client’s signature. However, it is highly recommended that the therapist develop some plan, ideally in collaboration with the client, to guide the therapy process. Also the therapist is advised to keep a record of any plans discussed with the client. Careful documentation of plans as a component of progress notes is essential to therapist memory, credibility, and accountability. The ongoing process of treatment planning involves clearly and consistently communicating to the client what the therapist proposes to do and why. The process also incorporates the client’s reactions and ideas. While it is important to maintain a written summary, not every aspect of a plan can be put into writing. At many points during a session, a therapist is planning what to say next, with aims to offer choices to the client wherever therapeutically viable so that the client will be empowered by the act of choosing in the interest of therapeutic change. This emphasis on collaborative choice underlies the present recommendation for a written plan developed and signed together in session.

Identifying a focus. Once the client has agreed to engage in planning, therapists then ask if the client has concerns or problems on which the plan can focus. If the client mentions more than one, the therapist notes each one and asks the client to prioritize them. Starting with the client’s definition of the problem, even if the client sees the problem outside the domain of substance use, enlists the client’s involvement in planning. After listening to the client’s description of each concern, the therapist writes the problem down in the client’s own words or paraphrases it as closely as possible. (To establish rapport, the therapist is encouraged to listen carefully and empathically before the therapist starts writing.) Then therapists can read back to their clients what they wrote, asking if the written statement captures the client’s concern, and revising the wording if needed according to the client’s suggestions. When a client is vague, verbose, or uncertain in describing a problem, it is important for the therapist to negotiate and help refine the wording of the problem statement into one the client will endorse.

Some clients who use drugs or alcohol say they do not have any problems, or at least none they are interested in discussing with a therapist. The therapist then asks the client’s reason for coming to therapy, being careful not to imply that the therapist agrees the client has no good reason to be present. In response, clients referred for substance abuse therapy often reveal or reiterate external pressures placed on them to attend. The therapist can reframe this encumbrance as the client’s problem to be addressed. For example:

So your main problem right now is that your spouse is threatening divorce if you don’t come to therapy, even though you don’t see your drinking as a problem, and you’d like to get him (or her) to lay off of you. So is figuring out what to do about that problem something we could work on in here?

To elicit participation from a client who feels coerced into therapy, the therapist’s message is, “Well, as long as you have to be here, is there anything you and I could talk about or sort through that would be worth your time?”

Specifying goals and objectives. Once the therapist has a firm conception of the client’s definition of a problem and a sense of the client’s motivation to work on it, the therapist aims at articulating relevant goals and corresponding objectives, which can be explained as steps toward a goal. Beginning with the client’s conception of the problem and the work to be done means that the therapist attempts to pace the course of therapy to move only as far and as fast as the client is willing to go, testing that boundary by pushing gently against it and adjusting the approach according to the client’s reaction.

At the outset of planning treatment, the client may report many troubles, a small number, or none at all. The therapist refines the focus by helping the client select a workable number of issues to target. For clients with clear ideas about personal goals and priorities, this part is not difficult. However, clients with diffuse or multitudinous problem statements can be reminded that setting and clarifying priorities makes more efficient use of the time available in sessions. The therapist can acknowledge the legitimacy of all the client’s expressed concerns and still encourage sharpening the focus of the treatment plan. When clients deny any problem or cannot think of a specific one, the therapist can create momentum by reflecting one complaint the client has mentioned already even if the client did not label it as a focus for therapy. A viable treatment plan requires only one goal that both (or all) parties agree to work on, although it certainly may consist of more goals depending on the client’s current understanding. The therapist who responds, “You’re telling me the main thing you want out of coming here is to get out of trouble by satisfying the judge’s order that you get therapy. I’d say that’s something we can work on together,” will often obtain the client’s willingness to continue the conversation. That one goal can become the basis for an initial treatment plan to satisfy all aspects of the court order by considering what steps the client would need to take in order to do so. A sample plan written to reflect such a discussion between a court mandated client and his new therapist is presented in Table 1.

Planning Treatment in the Face of Client Resistance

Certain clients object even to the process of planning treatment. They may indicate that they “just want to talk” or that they “don’t really like things so structured,” or even that discussing a plan “feels like going through the motions” to fulfill someone else’s expectations. If such a client repeatedly resists the therapist’s attempt to establish a formal plan, the therapist may, rather than losing the client, agree to proceed by minimizing immediate overt discussion of the plan. Instead the therapist can reiterate reasons for suggesting a plan and request to revisit the topic later if either party sees the need arise. By at least temporarily deferring to the client’s wish to decline planning, the therapist can listen attentively to whatever the client talks about instead and can tease out information relevant to the therapist’s own conceptualization and planning. The therapist can use this information outside of session to formulate a tentative plan that can be offered to the client in a subsequent session.

In this manner, the therapist is still involved in planning, with emphasis on how to engage the client in collaboration with the planning process. Initially reluctant clients frequently buy into a plan which the therapist developed outside of session and offered in a subsequent session because the therapist accepted their initial stance, took time outside of session to work on the client’s case, and wrote up a plan that not only reflects the client’s behavior and words, but also takes up only a small fraction of a session to go over unless the client has questions or clarifications.

Revising the Treatment Plan as Needed

Thus in addition to the client’s starting point, the therapist simultaneously entertains ideas about problem definitions and resolution strategies based on what the client has said and done in sessions. The therapist is devising plans as the therapist gets to know the client. In negotiating a plan with the client, the therapist continually estimates how far the client’s ideas are from the therapist’s own, and how ready and willing the client seems to be to hear alternative perspectives the therapist has to offer. The therapist continually decides how and when to introduce the therapist’s private thoughts into the joint planning process. The therapist’s decisions will rest on an assessment of how far the client has come, how far the client is willing to go, and what resources the client has available to support taking the next step between those two points. The therapist can enhance opportunities for collaboration by telling the client up front that together they can review the treatment plan periodically to decide whether to stick to the game plan or go back to the drawing board.

To facilitate collaboration in planning with clients, the therapist needs skills for balancing structure with flexibility. Planning treatment for substance abuse can involve negotiation with clients who are unfocused, skeptical, or resentful about treatment, or who may be trying to test or deceive the therapist. The therapist tries to give the client a framework to clarify expectations and guide progress, but also to remain open to modifying that framework as suggested by the client’s interests, needs, and attitudes.

Table 2 gives an example of a revised treatment plan, developed by a therapist with her client Barry, who was at the time of intake reluctant to commit to intensive outpatient therapy, even though he met criteria for long term Alcohol Dependence. The initial treatment plan had thus been negotiated to specify that Barry would try weekly outpatient therapy for six weeks, and if at the end of that time period he had not made sufficient progress toward his abstinence goals, he and the therapist would reconsider the recommendation for intensive outpatient therapy.

After four weeks, Barry told his therapist that he appreciated her efforts, but he could already tell that therapy once a week was not enough to keep him from stopping at his regular liquor store on the way home from work. Although he had reduced his weekly average number of binge nights, he still found himself sneaking into his garage about three times per week to drink one or more of the fifths of vodka he had hidden there. He said he was now ready to try intensive outpatient treatment. His therapist validated Barry’s honesty, efforts, and reduction of drinking, and suggested they revise his treatment plan, as summarized in Table 2.

Addressing Therapist’s Issues with Treatment Planning

Therapists are advised to be aware too of their own issues with imposing structure. When a therapist is either over-structured or under-structured, difficulties may ensue in attempts to conduct substance abuse treatment. Therapists who have a hard time asserting a format, offering suggestions, or interrupting a tangential or verbose client may be at a loss with clients who are uncertain about what to expect from treatment or unconvinced that they have a problem. On the other hand, therapists who dictate treatment expectations, goals and objectives without allowing for client input or feedback risk alienating the client and will probably elicit resistant behavior. Over the course of a career, supervision and consultation with respected professionals can help a therapist expand the capacity for flexible structure, especially by providing means to work through issues surrounding appropriate structure.

ADDRESSING FOCAL PROBLEMS OF LOW SELF-EFFICACY AND LOW MOTIVATION

Client initiative can be mobilized through the choice of problems to be addressed in therapy. A problem therapists routinely encounter in planning substance abuse treatment is clients who do not take responsibility for active roles in changing their circumstances. Therapists cannot bring about beneficial change without the client’s involvement. The corresponding issues from a client perspective are that clients either lack interest in changing or they perceive themselves unable to change their problematic substance use. In other words, low motivation and low self-efficacy are common focal problems for clients with substance use disorders. Therapists try, using treatment planning as one important tool, to motivate clients to take initiative for change by offering clients options, encouraging them to make choices, and supporting their efforts toward implementing their choices. The options a therapist presents at a given point in a course of therapy can be differentially selected based on the client’s sense of self-efficacy and the client’s degree of readiness to change. Miller and Rollnick (2002) recommend attention to both the client’s sense of the importance of making a change and the client’s confidence in personal ability to make that change. Both are viewed as aspects of a person’s intrinsic motivation.

Goal 1: Increase Client’s Self-efficacy to Make a Beneficial Change

Research on cognitive models of therapy demonstrates that treatments are effective to the extent that they enhance clients’ expectations of efficacy in dealing with personal problems (Thombs, 1999). Efficacy expectations are defined by Bandura (1997) as beliefs that one is capable of sustaining a course of action intended to achieve a particular outcome. Outcome expectations are reflected in the individual’s level of confidence that the anticipated outcome will actually occur. Together efficacy and outcome expectations comprise self-efficacy. Clients who do not genuinely believe either that things can change or that they are capable of bringing about change are not likely to take either initiative or responsibility for changing problematic behavior.

Chemical addictions by definition put clients in positions where they find themselves seemingly unable to stop using their drug of choice even after persistent wishes or multiple attempts to quit. Or they give up activities that were once important to them to continue drinking or using, even in the face of damages probably caused by their substance use. Those clients who abuse substances without fitting the full criteria for Substance Dependence still encounter repeated difficulties associated with their excessive substance use. It is understandable then that clients exhibiting substance use disorders often display low expectations of efficacy to change undesirable behaviors or circumstances. An essential component of planning treatment is motivating clients to believe that change is possible and that they are capable of making change occur. Only when clients have realistic hope and expectations of efficacy will they make choices in favor of positive change, and take initiative and responsibility for promoting change. When the goal is increasing self-efficacy, therapists can assist in identifying objectives with the potential to augment the client’s efficacy and outcome expectations.

Research shows that when persons experience enhanced personal competence, their abilities to function improve, and when perceptions of competence are diminished, the risk of relapse into problematic behaviors dramatically increases (Thombs, 1999). A treatment plan designed to enhance a client’s perceptions of self-efficacy has the potential to improve the client’s functioning by promoting the client’s ability to regulate one’s own behavior in healthier ways. Social cognitive theory (Bandura, 1977) specifies four means by which efficacy expectations can be altered, and these can be directly incorporated into treatment plans as objectives for moving toward the goal of improved self-efficacy. The sources of information, from strongest to weakest, that influence efficacy expectations are (a) performance accomplishments, (b) emotional arousal, (c) vicarious experiences, and (d) verbal persuasion. The subsequent discussion looks specifically at the relevance of these four general categories of information to a therapist’s efforts to alter a client’s self-efficacy for personal change in the context of substance abuse treatment.

Objective 1a: Choosing tasks with strong chances of client success. A client’s performance accomplishments provide powerful information about the likelihood of success in reaching identified goals and objectives. Substance abusers who have encountered repeated troubles, often despite goals of avoiding them, tend to doubt the possibility of change. In some cases this lack of conviction gets rationalized into a lack of desire for things to be different. Such clients argue and may genuinely believe that they prefer using drugs and invite the consequences over the alternatives. The therapist who shows curiosity and interest in the client’s perspective and explores that client’s sense of performance accomplishments in more depth will often run into the client’s ambivalence. Many clients will report some version of the sentiment that they would like to be able to continue using their drug of choice and enjoy its pleasurable effects but simultaneously wish to forego the uncomfortable or debilitating effects.

A treatment plan can incorporate performance accomplishment objectives by specifically looking at what the client can do to reduce or eliminate difficulties the client has previously been unable to manipulate satisfactorily. In some cases, this will involve temporarily suspending judgment about whether giving up substance use altogether will be a necessary condition for successful problem reduction. For example, when the client asserts lack of willingness or ability to abstain from alcohol use, he may still agree to performance objectives including harm reduction strategies, such as monitoring number of drinks, sticking to a limit of drinks per sitting, avoiding drinking on an empty stomach, avoiding drinking when in a bad mood, refraining from driving under the influence, etc. In any case, the therapist’s job is to shape the treatment plan by setting up methods and timeframes that are likely to meet the objective of giving the client the experience of successfully accomplishing a meaningful task. This, of course, is best accomplished through the method of discussing with the client what constitutes an outcome worthy of the client’s effort, and what type of effort the client is willing and able to exert. Additional methods relevant to this objective include expanding the client’s awareness of alternative tasks for approaching the problem at hand, encouraging the client to make deliberate choices from among available options, guiding client efforts to perform the chosen task, helping the client evaluate the outcomes of task performance, and revising the plan as needed to accomplish the objective.

An example of negotiating performance objectives occurs with Jason, who says a month before his college graduation that he is thinking about giving up his daily cannabis habit when he starts his new job right afterward. However, when he has tried abstaining, he repeatedly capitulated to his urges to smoke. Jason is afraid if he waits to quit until the job actually begins that he still will be tempted to use, but he also wants to enjoy graduation festivities with the additional enhancement of marijuana. He calls himself a “pothead,” admitting that it has been weeks, maybe months, since he has skipped a day of smoking. His therapist recommends that Jason commit to abstaining until final exams are over, to see what it is like for him to do so, and to clear his head for upcoming exams. Jason is obviously reluctant to agree, saying he could if he wanted to but he is not ready yet. The therapist suggests that Jason try refraining from any use for the coming week, and then reporting back in the next session how it went and what he wants to do from that point. The client says he would be willing to forego marijuana use on the weekdays, but isn’t willing to commit to that objective for the weekend because of big plans on which he elaborates. The therapist agrees to this weekday abstinence plan, but expresses concern for Jason’s well being over the weekend and raises considerations for Jason to take responsibility for his behavior, both now and in the longer term. The therapist reiterates the plan to talk more next week about Jason’s experience of abstinence on weekdays and his thoughts about next steps in light of his overall goals, and the client agrees.

Another example is Rhonda, who reports a number of physical symptoms she associates with her substance use, but who says she has not had a complete physical in years. When her therapist recommends that Rhonda make an appointment with a medical doctor, the client says it is not worth it because she knows from past experience that she will just spend money to be examined and told that nothing is wrong. In this case the therapist might suggest objectives such as exploring Rhonda’s doubts and fears about a medical consultation, weighing her alternatives, preparing and even rehearsing what she wants to ask the doctor if she does decide to go, or looking up her symptoms on the Internet or at the library. The therapist should certainly find out as well if other objectives occur to Rhonda. From the list of options they generate together, the client can indicate the ones she is willing to try, and the therapist can further explore the client’s reasons.

Encouraging the client to make deliberate choices about the course of action in therapy and guiding action along an achievable course both increase the client’s chances of accomplishing successes that will motivate additional action and further commitment to the therapy process. Treatment plans can evolve as clients partake of the powerful information about their efficacy offered by their successful performance of treatment objectives. The therapist tries to steer the client toward objectives that are likely to provide the clients with the experience early in therapy of successfully mastering a relatively simple task, and then moving toward attempt and mastery of more complex tasks. The types of tasks that can be offered are gauged according to the client’s stage of change, as will be elaborated shortly.

Objective 1b: Learning to manage affect associated with treatment efforts. Emotional arousal in response to a task or goal is a second form of information that affects a person’s self-efficacy to the extent that a task elicits anxiety about the possibility of failure, or confidence about the anticipation of success. Strong anxiety can easily dampen confidence and resolve, leading the anxious individual to question one’s ability or to deny responsibility for attempting the task at hand. Thus the therapist can plan treatment to promote client self-efficacy by building in objectives centered on alternative means of managing intense negative emotions aroused by client’s problems and efforts at resolving them. Clients who have been dealing with their anger, sadness, frustration, or anxiety by masking feelings behind substance-induced affect can benefit from a therapist’s suggestions about other effective strategies for coping with difficult emotions. Glidden-Tracey (2005, Chapter 9) addresses interventions to help clients manage difficult affect tied up with the problems that bring them to therapy. The present course focuses specifically on addressing fear or anxiety raised in attempts to master treatment objectives, including relapse prevention.

Clients who agree to objectives of managing emotional arousal that interferes with effective performance typically need the task broken down into manageable steps. To help plan treatment methods for emotion management objectives, the therapist can draw on the classic approach-avoidance conflict paradigm posed by Dollard and Miller (1950). Already mentioned is the tendency for substance abusers to feel ambivalent about changing their patterns of consumption, since their substance use yields both pleasurable and uncomfortable results. This represents a prototypical approach-avoidance conflict, where the user is both drawn to and repelled by the prospects of reducing or eliminating substance use. Dollard and Miller (1950) empirically validated their hypotheses that the tendency to approach a goal would be stronger when the individual is farther from the goal, but avoidance activity increases rapidly and eventually overtakes the approach tendency as the individual gets closer to the goal.

The substance abuse client sitting in the therapist’s office with primed awareness of the undesirable aspects of substance use that landed the client there is at that point more motivated to approach the goals of therapy than the client will be during the time between sessions when opportunities arise to act counter to goals and objectives. When the chance to drink or take drugs or engage in problematic behavior presents itself, the client’s motivation to avoid treatment goals escalates. Frequently the client gets anxious about the conflicting pulls. The client may be more tempted to avoid thinking about either the goals or the related conflict by giving into the urge to use the substance, which promises relief from conflicting feelings, however temporary.

A client who worries about handling friends who pressure him to drink with them can benefit from consideration in therapy of what he can do in those moments to stick to his goals and deal with the corresponding feelings. Another client who is thinking about trying a support group but struggling with her pervasive shyness also can profit from specifying therapy objectives for managing her fears of inefficacy.

The therapist who can help the client recognize the dynamics of emotional arousal in response to approaching goals and objectives in therapy will be in a position to teach the client new ways of managing negative affect states as they are aroused. The relative distance of the therapy interaction from situations in which the client has the realistic option to relapse can be used to identify and practice strategies for managing intense anxiety, anger, or sadness. Methods for working toward emotion management objectives include identifying the circumstances the client believes will trigger difficult emotions, generating ideas about how to respond to intense feelings without resorting to substance use or other problematic habits, practicing new responses both in and out of therapy sessions, and rewarding valid attempts and successful outcomes of applying new responses. Establishing clear objectives gives the client hope that progress is possible. As a client learns to better manage the emotions aroused by responding to circumstances that conflict with treatment objectives, the client is likely to increase efficacy expectations for continuing progress.

Objective 1c: Learning from vicarious experiences. Vicarious experiences of success and failure can influence self-efficacy by allowing an individual to observe the behavior of other persons and to learn from others’ successes and failures. Clients can learn to fine-tune their abilities to regulate their own behavior by imitating what they have seen work for others and by avoiding strategies they have observed leading to another’s failure to achieve a similar objective. A treatment plan can set up opportunities for vicarious learning through considering participation in group therapy or a self-help group.

Not all clients are ready for group encounters, so therapists need to screen based on both group selection criteria and client expressions of willingness to try a group. It is not unusual for clients to express at least some reluctance to engage in a more public form of therapy or self-help, but for clients who are willing to at least experiment, the therapist can emphasize the value of comparing experiences with others who are blazing their own paths to the goal of improving their own circumstances. For those clients currently refusing even to attend one group session to evaluate its potential, the therapist can suggest further discussion at a later point in time of the benefits and limitations of group therapy. If the client agrees to write this timeframe into the treatment plan, both parties will be prompted to reconsider the possibility of a group intervention at the next treatment plan review (or at some other date agreed on at the time the method is specified).

In addition to group therapy or support groups, vicarious learning can be promoted by asking clients to name anyone they know who has successfully confronted a problem related to drugs or alcohol. The treatment plan can then include the method of having the client talk to the identified person(s) about their successes and failures. The client can then be encouraged to report back to the therapist or to journal in private about what the client learned from these conversations. Therapists may also at times share their own observations of struggles and successes among their other clients, as long as, of course, no identifying information is revealed.

A therapist should be prepared to respond to a client’s request for vicarious experience through the therapist’s self disclosure of thoughts, feelings, or behaviors associated with drugs or alcohol. Some therapists are comfortable and highly effective using their personal histories or values in a selective manner to motivate clients, while other therapists are reluctant to self-disclose or do so inappropriately. Careful self-disclosure can be useful in substance abuse therapy under the following conditions: (a) the therapist explores with the client the reason for the request, (b) the therapist has a therapeutic rationale and intent for the disclosure, (c) the therapist feels reasonably comfortable making the disclosure, (d) the therapist maintains a focus on the relevance to the client, and (e) the therapist assesses and responds to the client’s reaction to the disclosure.

Being caught off guard by client questions about the therapist’s personal use, opinions, or values with respect to drugs and alcohol can damage the therapist’s credibility. Even if a therapist declines to disclose personal history, the planning process is best served if the therapist can offer a convincing rationale. For example, the therapist could respond to client probes by explaining the “Catch-22” implied in the question (M. Combs, personal communication, November 1996):

I must admit that I’m torn about answering your question. On one hand, if I tell you I have never had my own substance use problems, you could tell me I don’t know enough to help you. But if I tell you I have, you could tell me I have my own problems, so how am I in the position of helping you? So either way, I’m not sure how it will be useful to talk about me. I’d rather focus on you to see if we can find any way to work together on your own concern.

This response will obviously not work for every therapist or every client, but the point is that therapists are advised to think through not only how they feel about personal disclosure of drug and alcohol history, but also how and under what circumstances they would communicate those thoughts and feelings to a client. Therapists who are prepared to answer client’s questions in a genuine, straightforward manner will not only earn the client’s respect, but can model effective communication and elicit valuable new material about vicarious and interpersonal learning regarding the broad range of substance use issues.

Planning ways for the client to vicariously experience the outcomes, but especially the successes, of other people who have also struggled with chemical dependency or substance abuse can contribute to the client’s increased self-efficacy for change. Not only does interpersonal sharing teach the client new perspectives and coping strategies, it also decreases a client’s isolation and potentially enhances social support.

Objective 1d: Persuading clients that they should and can change. Verbal persuasion is the final source of information that Bandura (1977) specifies for shaping efficacy expectations, but by itself, trying to convince clients that they are capable of change is rarely sufficient. Regular, sincere expressions of faith in clients’ abilities and potential can reinforce their efforts to change, but persuasion alone will be weak in promoting change until the client decides to make the effort.

Recognizing the limits of verbal persuasion alerts the therapist to use it judiciously in planning a client’s course of therapy. Self-efficacy theory suggests that individuals are most likely to attempt designated tasks when they believe the desired outcomes are attainable and they are reasonably sure of their abilities to attain those results. A therapist’s verbal persuasion is most motivating when clients are already considering a task they have some confidence to achieve but have not yet accomplished. Through exploration of what clients are willing to try, the therapist can selectively coax clients to endorse objectives with strong chances of yielding performance accomplishments, vicarious experiences of success, and manageable levels of emotional arousal. Although verbal persuasion without attention to other facets of a client’s efficacy expectations usually misses its mark, a therapist can usefully harness persuasive efforts to the therapist’s assessment of where the client is willing to focus energy and attention. The specific objectives and methods that the therapist persuades the client to accept and implement as part of the treatment plan can usefully be matched to the client’s level of readiness for change.

TAILORING THE TREATMENT PLAN TO THE CLIENT’S READINESS FOR CHANGE

Planning treatment according to a client’s assessed readiness for change ties into the transtheoretical model of personal change (Prochaska and Norcross, 1994). The client’s stage of change is crucial for the task of treatment planning, because therapists who try to persuade clients to engage in activity that is inconsistent with the client’s current level of readiness usually elicit client resistance in some form. For example, asking clients in the contemplation stage to take the action of abstaining from drug use before the clients have committed to taking this step and prepared themselves for the task has lower chances of keeping clients’ emotional arousal at manageable levels and of giving clients experiences of successful task performance. Another example of mismatched methods would be to require the client to attend thirty Alcoholics Anonymous meetings in thirty days if the client is still in the precontemplation stage, not yet acknowledging any problem with alcohol. Clients who resist therapist recommendations such as these are sending a message that their therapists may have initially misjudged the client’s readiness to change. In such instances, therapists are recommended to alter their approaches accordingly.

In order to set goals and objectives that clients are willing to attempt, the therapist considers what steps are feasible given the client’s circumstances to nudge clients from their current locations on the path toward change to the next logical point. Continuing from the examples given in the preceding paragraph, the therapist in the first example could try prodding a contemplative client toward preparation to take action by suggesting that the client engage in further discussion with the therapist about the perceived advantages and disadvantages of future abstinence. Or the client could be asked to keep a log of current drug consumption and related thoughts and feelings, or to try abstaining or reducing consumption as an experiment for a finite period of time (perhaps a week, or a month, to be negotiated with the client) with the understanding that further discussions and decisions will be made after the designated time span has ended. These methods keep the client engaged in contemplation and urge movement toward eventual action when the client is ready without foregoing the preparation stage. In the second example, the therapist could recommend that the precontemplative client attend just one AA meeting with an open mind, to see what it is like, and report back. Again, the method is responsive to the client’s conception of the absence of a problem but still invites the client to gather new information that will be useful in making decisions about next steps in facing whatever circumstances brought this person without a self-perceived alcohol problem to substance abuse therapy.

These strategies are consistent with the motivational interviewing approach developed by Miller and Rollnick (1991, 2002). Motivational interviewing prepares people to change by inviting the interviewee to collaborate in the process of evoking the person’s own motivation for change, and by respecting the individual’s autonomy and responsibility for choices about personal change. The principles that guide motivational interviewing strategies are to express empathy, to develop discrepancy, to avoid argumentation, to roll with resistance, and to support self-efficacy. Motivational interviewing is particularly useful in the context of treatment planning. Using methods based on these principles, motivational interviewing helps establish interpersonal conditions within the therapy relationship that communicate the therapist’s interest in working with the client’s perspective rather than imposing the therapist’s viewpoints, thus promoting trust and hope. Also, this approach prompts the client to expand and explore his or her own perspective to consider both good and bad points about substance use, as well as both advantages and disadvantages of change. With this elaborated picture, clients can then be encouraged to reflect on implications of discrepancies in their own viewpoints, and to develop treatment plans that are both realistic and meaningful in light of this mutual reflection with the therapist.

In discussion of their transtheoretical model, Prochaska and Norcross (1994) point out that most theories of psychotherapy emphasize either insight (e.g., analytic and cognitive models) or action (e.g. behavioral therapies) goals. Their transtheoretical model presumes that change requires both. The merger of models into “cognitive-behavioral” approaches has similar implications. Prochaska and Norcross (1994) further list five categories of activities people employ to change themselves, noting that different types of activities are more useful at different stages of change to stimulate transition to the next stage. Activities or methods to elevate awareness include consciousness-raising, emotional catharsis, and choosing from among available options. Action oriented activities include modifying the stimuli that control learned responses, and controlling the contingencies that result from behavioral responses. Prochaska and Norcross further subdivide each of these categories into activities that occur at the level of subjective experience and those operating at the environmental level, again illustrating how different theories of psychotherapy emphasize different types of activities leading to preferred goals. While the authors note the general applicability of these stages and processes to change occurring under circumstances both outside and inside of therapy relationships, the goals, objectives and methods embedded in the transtheoretical model can be directly utilized by therapists in negotiating treatment plans with clients.

Applying this model to planning treatment for substance abusers, the choice of goals and corresponding objectives, methods, and timeframes rests on determination of what the client needs to facilitate movement from a current stage of change to the next logical stage. Transitions through the first three stages of change (Precontemplation to Contemplation to Preparation) are marked by increasing awareness of a problem and by insight into the dynamics that sustain or resolve the problem. For change to occur, the individual makes further transitions from these insight-oriented stages to the action-oriented stages, called Action and Maintenance. The client’s stage at the time of assessment is important in terms of offering treatment recommendations in a manner that the client can accept (Glidden-Tracey, 2005, 2007). Once this first objective is met, of getting the client to agree to try therapy, planning treatment activities that suit the client’s stage of change (and relatedly provide experiences of success that will motivate further action) gives tools to keep the client invested in the therapy process. The therapist does not make change occur for the client, but helps the client realize the potential to change himself or herself. The transtheoretical model offers two general goals, insight and action, on which therapists and clients frequently negotiate in planning efforts aimed at changing problematic substance use.

Goal 2: Increase Insight into the Thoughts, Feelings and Behaviors associated with Clients’ Substance Use, Related Problems, and Potential Solutions

Objective 2a: Determining whether there is a problem to be addressed. The client in the precontemplation stage is not yet interested in making a change. Clients who report symptoms consistent with a diagnosis of a substance use disorder but deny that their drinking or drug use is a problem are in this stage. So are clients who distort or minimize their actual substance use behavior, though this is obviously harder for the therapist to identify. To move to the contemplation stage, these clients would need to raise their awareness of any undesirable results of their substance use. Prochaska and Norcross (1994) recommend a few types of activities at this stage to move the precontemplative client toward contemplation. The first is consciousness-raising, including both feedback about the individual’s behaviors and education about more general consequences of substance abuse. (Psychoeducational interventions will be addressed more fully below). These activities are intended to present a fuller range of information to clients so they will be in a more knowledgeable position to decide whether they have a problem and whether they wish to change. They prompt clients to address the discrepancy between their own stated beliefs that their substance use is not problematic with the beliefs or suspicions of others who got the precontemplators to show up for therapy.

Another way to conceptualize this is for the therapist to propose further assessment as an initial treatment objective. The therapist can explain to the client that it makes little sense to decide on actions before they have a clearer, shared understanding of the situation and the problem, if in fact there is one. The objective may be phrased in terms of continuing their shared assessment of the client’s complex situation, whether that entails further exploration of the role drugs or alcohol have played in the client’s life, or of the relationship between the client’s substance use and the interpersonal, occupational, financial, or legal problems that pushed the client to seek therapy. The neutral wording implies that the designated assessment will take place before conclusions are drawn, and that therapists will withhold opinions until they have firmer bases on which to make interpretations. This stance can be explicitly stated to clients who express doubt about the value of more assessment and therapy. The therapist can further propose that this extended assessment will be followed by a review and possible revision of the treatment plan. Both the client and the therapist are likely to learn valuable new information from taking the time to discuss the client’s history in greater detail. Among other lessons, the client learns that the therapist is not going to push an agenda or rush to judgment without comprehensive understanding of the uniqueness of the client’s circumstances. The therapist will very probably glean a clearer picture of the nature of the client’s substance use and its relationship to other problems in the client’s life.

As treatment progresses, the dyad can consider their joint evaluations of the extended assessment outcomes in formulating additional objectives and updating the treatment plan. Consciousness-raising interventions are probably more effective when the therapist honors the client’s choices about how to use the information brought to the client’s awareness. If the therapist communicates that the therapist knows the right conclusion and is just waiting for the client to see it, feedback and education will not overcome the client’s resistance. When the therapist does offer feedback through interpretations or confrontations, precontemplators may hear alternative perspectives with less resistance if the therapist clarifies that this is the therapist’s opinion, that clients are entitled to their own opinions, and that the therapist is interested in hearing what feedback the client has to offer.

Therapists can suggest plans to explore clients’ feelings about their substance use histories. According to Prochaska and Norcross (1994), catharsis of pent-up or denied emotions can also help move clients into contemplation. Catharsis relieves internal pressure and releases energy, formerly used to ward off emotion, now available for other purposes. Sometimes the expression of deep emotion about causes, consequences, or related aspects of substance use can also help raise the client’s consciousness of the negative impact of problematic behavior on the client’s life. For example, a precontemplator who hinted at a traumatic initiation into marijuana use was invited to tell the story of how he started smoking pot in the first place. The client revealed that at age twelve, he was pinned down by two older brothers and their friends, and a “joint” was forced into his mouth until he inhaled several times. The client said he had never talked about that incident since it happened, and recalled the fear, anger, and disgust he felt at the time. These recollections along with other current considerations stimulated this client to begin contemplating the possibility of quitting smoking.

By collaboratively planning therapy so that precontemplators gain increased awareness of the complexities of their situations and the feelings associated with them, such clients may make transitions into the contemplation stage of change. When clients come to acknowledge a problem that is worth addressing further in therapy, the next step is to consider options about how to address the issue.

Objective 2b: Identifying and deciding among options for responding to problems that have been targeted for attention. Clients in the contemplation stage have acknowledged a need to change and are typically preoccupied with considerations of what to do about it. Clients who are contemplating change can spend long periods of time evaluating themselves, their environments, and their options. This necessary stage is a natural outcome of prior efforts to expand the individual’s awareness of information and alternative perspectives. A first method to move clients through this stage is to generate options for how to construe the problem and how to promote change. Once potential goals or actions are clear, a second method is to weigh the pros and cons of each option. For clients to move into the preparation stage, they need to choose from among these options and commit to taking action in the foreseeable future.

The sample treatment plan in Table 3 revisits the case of Jason, the self proclaimed “pothead” with the new job starting soon. Jason’s written treatment plan summarizes a fifteen minute discussion with his therapist in the session following his initial intake assessment, and illustrates the utilization of objectives and methods discussed in this section to facilitate transition from contemplation to preparation for action toward behavior change.

The individualized treatment plan needs to account for the reality that the transition from contemplation to preparation can be a very hard one. Many contemplators have difficulty making choices about how to confront an acknowledged problem. In such cases, the therapist can direct the focus using additional consciousness-raising and catharsis to explore with the client the barriers blocking the client from choosing a course of action. Asking clients what they believe is interfering with their decisions to take action to address identified problems will often yield insights into additional specific objectives clients need to address before they can let themselves decide to change.

Clients who express concern that family members or friends will reject or ridicule them if they no longer “party” together can plan with their therapists how to handle interpersonal tensions with particular individuals. They can also be advised to talk about their plans and feelings regarding possible change with those persons the clients are most worried about, and possibly report back to the therapist how those conversations went. (Many will find that others are more accepting and understanding than anticipated!) For clients who voice doubts that they are capable of enforcing their own decisions to change, therapists can suggest methods to boost the client’s self-efficacy and self-esteem. Plans can include agreements to discuss best and worst case hypothetical outcomes of making a decision. During the planning process, therapists can empathize with and validate the client’s feelings about being stuck as well as the client’s hope for change.

Therapist expressions of empathy are crucial for creating therapeutic conditions in which treatment plans can be made and implemented. Clients stuck in the contemplation stage face not just one decision to alter problematic substance use; they confront daily, hourly, and even moment-by-moment chances to change their minds. The client who decides to quit smoking or drinking or using so much (or at all) is repeatedly bombarded with both internal and external messages to go ahead and indulge one more time and to start enforcing the decision “tomorrow.” Beer ads, social events, drug-oriented music, an available “stash,” the promises of quick euphoria and distance from troubles are among the signals of opportunity to continue chasing the familiar highs. Clients who have time and time again postponed decisions to change can come to doubt whether they can or want to enforce their own commitments, which may actually serve as a justification for simply giving into an immediate urge to use rather than suffering the agony of resisting the inevitable. They may tell their therapists that they cannot make decisions about how to address their problems because either they do not want to change or they do not see the point in trying in light of multiple experiences of vowing to control their substance use and then not doing so. Therapists who empathically encourage ruminations on the possibilities and difficulties of changing behavior will help clients to vent frustrations and other negative affect. This activity furthermore gives the client and therapist time to anticipate exactly what situations may goad the client into using excessively in spite of decisions to abstain from or limit substance use.

It is in those moments, when clients are telling themselves that “just one more time won’t hurt, so why not?” or “If I don’t just go ahead and do it, I’ll be immobilized by my preoccupation with wanting to do it anyway,” that the client most needs tools to counter their impulses to postpone decisions to take control. Unless therapists can empathize with the strong conflicts contemplators feel as they move to prepare for change, and can empathize in a manner that clients can hear and believe, clients have few reasons to trust in the therapist’s expertise. Thus in negotiating treatment plans, it is essential for therapists to offer or endorse methods that fully address clients’ obstacles to change as well as their motivations to change.

Methods that can be discussed with contemplators and written directly into treatment plans include (a) identifying optional responses to specified problems, (b) weighing those options, (c) addressing any barriers to making decisions, and (d) choosing a viable strategy for responding to the problem. By breaking the process of contemplating a decision into meaningful steps, the therapist validates the contemplator’s dilemma and offers guidance toward the objective of taking responsibility for choosing a course of action. In this manner, the therapist meets the contemplator at the point where the client is willing to focus and proceeds at a pace that the client is able to progress.

Objective 2c: Preparing to undertake a course of action. When the client has reached the point of deciding on a change strategy and making initial gestures toward implementing that strategy, the client has reached Prochaska and Norcross’s preparation stage of change. Individuals with substance use disorders may present themselves for therapy at this stage, especially if they are having trouble enforcing changes in behavior that they have committed to make; or they may be clients continuing therapy efforts that started with a different therapist during an earlier stage of change. Regardless, clients in the preparation stage have made important decisions about how they wish to tackle problematic substance abuse and have established some groundwork on which to base their planned actions. However, they have yet to manifest significant change in substance related behaviors or consequences. They may be encouraged by early indications of success in moving this far toward change, but they can be just as quickly discouraged by even small signs of regress. To effectively individualize treatment plans for clients in the preparation stage, therapists need to employ methods that reinforce even small steps toward treatment objectives and also address obstacles to the implementation of the chosen strategy.

Clients who are strongly committed to a decision and capable of undertaking relevant action move quickly through the preparation stage. More often, substance abuse clients struggle with uncertainty about the strength of their convictions or the extent of their abilities to follow through with the options they have selected for responding to problems. The inherent reinforcing qualities and easy availability of psychoactive substances to habitual users conflict with increasing awareness of the problematic consequences of habitual substance use, creating ambivalence even in clients who are preparing to change their habits. They sometimes vacillate from preparation back to contemplation as they encounter unanticipated complexities or setbacks. The process of treatment planning can help clients maintain progress by spelling out realistic expectations of the course of change and by providing tools for combating barriers to continuing progress.

When planning treatment with a client in the preparation stage, the therapist can help break down a more abstract strategy on which the client has decided into concrete tasks. Often, agreeing on timeframes in which a task is to be carried out assists clients in enforcing decisions. Therapists can offer time in session to anticipate possible outcomes of specific tasks and to plan how the client might respond to these different outcomes. A therapist can also build into the treatment plan time for discussing the actual outcomes of a client’s attempts at implementing tasks that are part of the larger strategy, with the stated objectives of rewarding the client’s successes and learning from mistakes.

A good example of this process came about with Paul, who was preparing to abstain from alcohol use on an upcoming business trip by inviting a good friend, Karen, to travel with him. He told his therapist he knew he would drink if he went alone, and because Karen does not drink, he felt confident he could avoid drinking when he was with her. However, upon further questioning, Paul admitted that Karen was not aware of Paul’s plan to quit drinking, nor his reason for asking her to accompany him. The therapist thus proposed spending some time in the present session, since the trip was coming up soon, talking about what might happen if Paul did or did not let Karen know what was going on with him. Paul agreed to this plan, acknowledging that the temptation to drink could still be high and might make him cranky even with Karen alongside.

When the therapist pointed out that Karen might be confused or upset by Paul’s irritability if she did not know what was causing it, Paul decided he should tell her about his intentions. The therapist asked if he was worried that Karen might not want to go if she was aware of his plan, but Paul expressed certainty that she would be interested in helping him. He just did not know how and when to bring it up with Karen. So the therapist worked with Paul to generate a plan for where and when he would raise this topic, and the rest of the session was spent role-playing what Paul wanted to say to Karen and how he could respond to her possible reactions.

During the preparation stage, clients lay foundations of commitment, effort and responsibility from which more substantial actions will be launched. From the understanding of the problem cultivated in working through the precontemplation stage, and from the expanded awareness of possible responses contemplated in the second stage of change, the client decides on a response and establishes the cognitive, affective, behavioral, and interpersonal conditions under which change can occur. This preparation in terms of how the client chooses to think, feel, act, and relate can be facilitated by carefully negotiating treatment tasks at this stage to match the intentions the client has come to endorse. Prochaska and Norcross indicate that individuals in this stage need to set priorities, and can experience “self-liberation” through the conscious creation of new alternatives.

Progress through these first three stages of change parallels the client’s acquisition of insights into the nature of personal problems and into the process of changing them. As clients expand their insights into the desirability and feasibility of change, the goal of taking explicit action to reduce problematic substance use emerges in prominence.

Goal 3: Engage Clients in Action to Promote Change

By the time individuals are ready to focus on the goals of action and maintenance, they have already exerted significant efforts toward prioritizing and planning. An action plan specifies criteria of change, often in terms of behaviors that demonstrate a difference from prior habits. Some examples include a client with a diagnosed alcohol dependence who successfully refrains from drinking for an entire week and resolves to continue abstinence. A cocaine binger overcomes former reluctance to try residential treatment after numerous failed attempts to quit drugs through outpatient treatment, and checks himself into an inpatient treatment facility. A client who has been planning to stop smoking marijuana turns down an invitation from a friend to attend a party where the client knows people will be smoking, and instead attends a group therapy session for the first time.

To help clients put insight into action, therapists can propose altering the stimuli or the consequences that shape client behaviors. When the goal is to change patterns of substance use, clients will need to exert some control over the stimuli to which they are exposed, often by avoiding contact with certain people or situations that elicit temptation to abuse substances, and by replacing those stimuli with new stimuli associated with healthier and still rewarding behaviors. Treatment plans at this stage of change also acknowledge that many stimuli that activate urges to drink or use drugs are not under the individual’s control. In designing action objectives to deal with uncontrollable stimuli, the therapy dyad aims to practice new responses to “trigger” situations. Emphasis is placed on the outcomes of the client’s behavior, with attention to promoting reinforcements to increase the likelihood of continuing new learned responses. Also, the punishing consequences of continuing old habits may be analyzed and, to the degree possible, accentuated to help clients resist resumption of behaviors they are trying to change. For example, the client in the action stage of change may endorse the objective of reminding himself whenever he feels the old, familiar impulse to get high about the worst-case scenarios he encountered during his days of heavy drug use.

Prochaska and Norcross (1994) demonstrate that methods derived in particular from behavioral and cognitive approaches fit the action and maintenance stages of change. The two general objectives and corresponding treatment methods offered below borrow extensively from their formulation of therapy at the action stages of client change. The objectives vary in terms of focus on classically versus operantly conditioned behaviors, and the methods are distinguished in terms of the extent to which the individual has direct control over the stimuli or the outcomes influencing individual learning and behavior.

Objective 3a: Severing the connection between particular stimuli and learned responses. From a classical conditioning paradigm, this objective concentrates on extinguishing a learned behavior tied to the substance use disorder. Of course, this objective can also be worded in a treatment plan in terms much more familiar to the client than psychological jargon. The therapist informs the client that the purpose is to change behavior by cutting the link between a signal (that substances are available and desirable) and a response (abusing a substance) that the individual has learned to make to that signal. The therapist further explains that this is accomplished by learning new responses that shrink the power of the signal, and by reducing one’s exposure to potent signals. For example, the stated plan could be to help a client find alternative, healthier means of reacting to boredom, anger, sadness, or frustration without resorting to drug or alcohol use. In another case, the plan might be to avoid exposure to people, events, or other cues that the client associates with drug use. In both examples, the action involves substituting a new behavior for a former one. In the first method, a new behavior is learned to respond to the same old difficult emotions. In the second case, the plan is to make changes in the client’s environment so that the stimuli that trigger substance use are less available. Prochaska and Norcross (1994) distinguish these two methods of altering classically conditioned responses by pointing out that the first, counter conditioning, focuses on changing the individual’s experience, which the second, stimulus control, emphasizes change of the person’s environment.

Counterconditioning is an especially useful method when a stimulus that elicits substance use cannot be strictly controlled. This is a crucial concern for substance abusers who have become accustomed to reaching for their substance of choice when family members get on their nerves, or when they feel blocked from completing required tasks, or when the end of the work week arrives, because these types of events cannot be entirely eliminated. On occasion, spouses, parents, and offspring will continue to annoy the individual, work will still need to be done, and paychecks keep arriving. The client who wants to stop using drugs or alcohol in response to such stimuli needs not only to be aware of alternative responses besides using substances; the client must actually employ those new responses. The client’s action plan is to implement new responses to signals that formerly elicited abuse of drugs or alcohol.

A treatment plan for a client in the action stage helps countercondition the client by stating the new responses the client agrees to emit in response to unavoidable stimuli that have been previously linked to substance use. The plan should also include criteria that will indicate when the client has successfully completed the action, along with stated intentions to examine the client’s thoughts, feelings and experiences of the new behavior. When the plan gives the client clear ideas about what to expect both from the therapist and from the process of trying something new, the client may be more motivated to follow through with the action.

In situations where the client has some degree of control over level of exposure to a stimulus that cues substance abuse, treatment methods for promoting new behavior involve minimizing the client’s exposure. The therapist typically cannot control the stimulus for the client, but rather teaches the client means of stimulus control. Meeting this objective goes beyond listing situations or people the client will wish to avoid (though this is an important first step). The therapist will further inquire about what it will be like for the client to stay away from triggering stimuli, how the client expects to minimize exposure, and how the client feels about doing so. Methods to build into a plan include identifying particular events that will confront the client with stimuli the client wishes to avoid, articulating specific steps the client can take to minimize exposure, providing behavioral rehearsal of those steps during therapy sessions, giving homework to implement those steps in a relevant context outside of session, and reviewing outcomes of actions aimed at stimulus control in subsequent therapy sessions.

To illustrate, Juanita has successfully stopped smoking cigarettes for one week and two days. She knows it will be hard to deal with urges to smoke when she is studying for upcoming exams. Her favorite place to study used to be a campus coffeehouse, but she tells her therapist that the smoky atmosphere there could add to the temptation to light up a cigarette. The therapist suggests taking some time to decide on other places to study, and on how Juanita can resist inclinations or invitations to go to the coffee house. The treatment plan Juanita and her therapist generated together can be viewed in Table 4.

Another example of planning stimulus control involves Angie, who stopped smoking pot as soon as she discovered she was unexpectedly pregnant. She has decided to keep the baby, but the new stresses of her changing circumstances make her want to indulge a familiar habit of listening to music to help her relax. The problem is that in the past she typically smoked pot while listening to favorite music. Angie tells her therapist that a recent attempt to play these songs was anything but relaxing since she found herself preoccupied with cravings to get high. The therapist recommended discussion of other strategies Angie could use to control this stimulus and manage her stress, perhaps by choosing other music or other activities. Angie accepted the rationale for this plan, but indicated sadness at the prospect of giving up music she loved along with her drug use. Her therapist explained that their plan could include future consideration of reintroducing the music once the new habit of abstaining from smoking was more firmly established. In other words, controlling the stimulus until its connection to the learned response has been extinguished may eventually lead to the possibility of increasing exposure to the neutered stimulus; in this case, Angie’s beloved music.

When the learned behaviors of substance use are entrenched to the point where individuals see the behaviors as parts of their identities, extinguishing the behaviors is rarely quick or easy. Even when the individual has reached the action stage of change, unrealistic expectations and fears about the pace of success are likely. The therapist can use the ongoing process of planning treatment to prepare the client to anticipate ups and downs, to rely on the support of the therapist in learning from both successes and failures, and to maintain faith and hope in eventual progress and increasing efficacy. The therapist can assure the client that while the nature of change can be frustrating at times, the steps the client is taking are worthwhile and the therapist commends the client’s efforts.

Objective 3b: Changing the rewards and punishments that follow behavior. From an operant conditioning perspective, substance abuse recurs because of the strongly reinforcing properties of the behavior (detailed in Chapter 4 of Glidden-Tracey, 2005). Therapy in the action stage of change can utilize operant learning principles by planning methods to modify the patterns of reinforcement for the client’s behaviors. According to Prochaska and Norcross (1994), to the extent that the consequences of behavior are under control of either member of the therapy dyad, the method of contingency management involves identifying and applying meaningful rewards for behaviors that are incompatible with substance abuse. If healthier, incompatible behaviors, such as abstinence, result in desirable outcomes, especially over time, the “action” client is more likely to repeat the newly learned response as an alternative to continuing substance use.

As behavioral therapists have often noted, the nature of reinforcement is tricky because the potency of a reward varies across individuals, and because the factors reinforcing an individual’s behavior are not always obvious (Cahoon & Cosby, 1972). Functional analysis is prescribed in behavioral therapies to tease out the reinforcement mechanisms particular to individual clients. With those who abuse psychoactive substance, analysis of reinforcement patterns in the service of contingency management should not underestimate the strength of rewards the client derives from using the substance. The pleasure and relief that comes with the impact of the chemical on brain functions is frequently bolstered by social reinforcers.

What this means in planning substance abuse treatment is that efforts to modify the contingencies of behavior, starting with a functional analysis of reinforcement patterns, will work better if the therapist acknowledges the benefits as well as the costs the client has incurred from substance use (Sobell, Sobell, & Sheahan, 1976; Tucker, Donavan, & Marlatt, 1999). In addition, clients are more likely to collaborate in planning with the therapist who validates the sense of loss (i.e., negative punishment by withdrawal of a reinforcer) and fears of not ever finding an equally gratifying reinforcer. Consistent with motivational interviewing principles (Miller & Rollnick, 2002), the therapist needs to balance this empathy with consciousness-raising about the detrimental consequences of continuing use, thus developing discrepancy.

This empathy and discrepancy are important in planning treatment in the action stages of change for two reasons. First, the client’s heightened awareness of such strong, mixed motivations for and against changing behavior helps to anticipate the difficulties associated with taking action that achieves the criterion goal. When clients (and therapists) understand that the desired consequences of action are not always immediate and that competing pulls contribute to a gradual and often erratic process of change, they are better equipped to navigate the journey.

Second, the therapist’s stance of empathy with discrepancy communicates the therapist’s appreciation of the salience of reinforcers competing with the client’s attempts to change. The therapist’s comprehension of the client’s competing motivations helps the therapists “roll with resistance.” A client who senses that the therapist shares the difficulty of the client’s struggle to maintain action tends to feel supported rather than criticized. Under these conditions, the client will feel safer in carrying out the action plan, more confident that even small steps are worthwhile, and even immediate failures can be learning opportunities to modify the plan and promote eventual success. Such experiences also contribute to increases in the client’s self-efficacy for change.

The research literature on treatments of substance use disorders contains several studies of contingency management methods where the rewards for client behavior consistent with therapy goals were under the therapist’s control (e.g., Budney, Higgins, Radonovich, & Novey, 2000; Carroll, Sinha, Nich, Babuscio, & Rounsaville, 2002; Higgins, 1999; Higgins, Wong, Badger, Ogden, Haug, & Dantona, 2000; Tidey, O’Neill, & Higgins, 2002). Token economies and voucher systems, in which clients earn vouchers by exhibiting treatment compatible behaviors, have been widely used in inpatient or residential setting to reinforce abstinence, clean urine screens, and progress toward treatment goals. The vouchers can later be exchanged for desirable commodities or privileges. Applications to outpatient treatment have also been successfully utilized.

Evidence indicates that voucher systems are generally successful in reducing substance abuse during treatment, but that these gains tend to drop off relatively soon after treatment ends (Epstein, Hawkins, Covi, Umbricht, & Preston, 2003; Rawson, et al., 2002). This finding may be related to the problems many substance abusers have rewarding themselves based on contingencies that are less immediately salient than the reinforcements provided by consuming their drug of choice. When the reward (token, privilege, etc.) is under the control of a party external to the client, such as the therapist or treatment provider, clients do not have access to that reward until they perform the contingent response. But when it is up to clients to reinforce themselves for actions that are consistent with treatment or aftercare objectives and incompatible with continuing substance abuse, the conflict with competing rewards emerges. This is crucial to address in outpatient therapies where the client cannot rely on external parties for much of the time that the client’s response and reward contingencies need to be managed. In the less controlled environments where nonresidential therapies play out, the client must learn to control her or his own rewards and responses to the extent feasible.

B.F. Skinner wrote that the greatest flaw in human nature is the tendency to prefer easy, immediate, but potentially harmful consequences over rewards that take more time and effort to obtain, even if their overall benefits to the individual are greater. For substance abusers, making choices to forego substance abuse and to seek other kinds of reinforcement is indeed a challenge that must be faced to maintain changes initiated in therapy.

Thus treatment planning in the action and maintenance stages of change introduces contingency management strategies of both types: (a) where an external party controls administration of the reinforcers for new behavior, and (b) where the client applies self-reinforcement. The former may be more useful in the early phases of action, when clients are more inclined to punish themselves for incomplete efforts or outright failures to reach target behaviors. Or the client may struggle with inconsistent motivation to carry out a self-reward plan contingent on target behavior. An example would be the client who decided to buy herself a new garment after one full week of sobriety, but then went shopping before the goal was accomplished, or talked herself out of the purchase even after successfully meeting the goal because she had struggled so much with cravings during the week that she did not feel she deserved the new outfit. The therapist can explain to the client that,

As you take steps in the direction we’ve agreed on, I’ll do what I can to provide and point out rewards occurring along the way. I want to support your efforts. But another goal I have in mind is to help you develop a solid ability to reward yourself for positive steps you’re taking and to recognize when you’re getting some good results along the way to your ultimate goals. That way you can learn to keep progress moving in a direction you’re satisfied with even when I’m not there to talk about it with you.

This therapist statement alludes not only to efforts to control the consequences on which the client’s behavior is contingent, but also to the method of changing the client’s responses to anticipated outcomes even when the circumstances cannot be influenced at the environmental level. For example, an alcohol dependent client in early remission cannot change the fact that many grocery stores include aisles displaying alcohol, which has in the past provided liquid reinforcement for shopping. However, the client can learn to modify the experience of grocery shopping in anticipation of the urges and cravings stimulated by a glimpse of that liquor aisle. Prochaska and Norcross (1994) refer to reevaluation as the method of changing reactions to expected outcomes when contingencies are not modified. For the client who is not in a position to entirely avoid grocery stores (or convenience stores, or restaurants, or beer commercials on TV, etc.) and the consequent cravings, the treatment plan could include time to discuss alternate interpretations of the circumstances and behavioral options the client has in response to those various interpretations. In the example above, the client could reinterpret the urges incited by the liquor aisle as challenging but not compulsory, and grocery shopping could alternatively be viewed as an opportunity to demonstrate resolve rather than as an automatic “beer run.”

Reevaluation and generation of alternative interpretations are interventions utilizing cognitive restructuring techniques. In the process of planning treatment, the therapist advises cognitive restructuring to analyze the client’s motivations, behaviors, and their outcomes with objectives of identifying maladaptive thought processes and replacing them with messages that facilitate confidence, action, and growth. Research on cognitive therapies with substance abusers suggests that treatment effects show up later in treatment but are maintained longer after treatment when compared to strictly behavioral treatments such as contingency management through token economies or voucher programs (Epstein et al., 2003; Rawson, et al., 2002).

While the research findings could be perceived as a horse race between behavioral and cognitive interventions, from a planning perspective it is more viable to think of building a structure for therapy using multiple available tools and offering the client a coherent blueprint (Onken, Carroll, Rawson, Higgins, & Marlatt, 2000). Giving the client compellingly integrated strategies as part of an action plan helps the therapist sustain motivated action toward treatment goals in the latter stages of change.

SUMMARY AND CONCLUSIONS

I have described treatment planning as a continuous process of offering recommendations, negotiating strategies, and encouraging client choice. Through careful and collaborative planning, the therapist develops a meaningful structure for the course of treatment and promotes increased motivation and self-efficacy on the part of the client. This is accomplished by providing a rationale for goals and strategies tailored to the client’s degree of self-efficacy and readiness for change. Since clients with substance use disorders often embody insufficient senses of structure, motivation, or efficacy to promote change (if not all three), effective planning establishes therapeutic conditions under which substance abuse can be potentially reduced and positive changes in behavior can be undertaken.

In this section I focused on the rationale for collaborative treatment planning along with overarching goals and objectives of therapy to address substance use disorders. Note that the goals do not automatically prescribe abstinence from all substance use, but are designed for each client with that individual’s interests, abilities, and motives in mind. The next two sections will cover specific forms of intervention used to operationalize treatment objectives.

Section 2 - Psychoeducation in Substance Abuse Therapy

Frequently, if not always, attempts to reduce the deleterious impact of substance use disorders involve new learning on the part of both the client and the therapist. Psychoeducation combines interventions that provide new information or refine the use of information a person already possesses with careful attention to the individual’s cognitive, affective, and behavioral responses to that information. Consistent with an educational foundation and a process-oriented philosophy of psychotherapy, psychoeducation in the treatment of substance abuse disorders is a form of technology transfer; a means of teaching important information along with means of applying it. Psychoeducation crafted to fit the client’s interests and needs is a useful and often necessary component of therapeutic treatment plans for clients who abuse substances. This section outlines the types and methods of psychoeducation that may be relevant to addictions therapists, their clients, and their supervisors and trainers.

My premise in this section is that psychoeducation works most effectively when viewed as an interactive process. Clients learn much from their therapists, but they have much to teach as well. Similar learning potential exists in the interaction between therapists-in-training and their supervisors. The discussion to follow thus focuses on information about substance abuse and its treatment that both therapists and clients can share in a manner that will promote both client change and the therapeutic relationship. It is crucial not only to know relevant facts, but how to communicate them and how to engage others in dialogue about their relevance.

Psychoeducational interventions can teach a client powerful lessons about (a) how therapy works and what to expect, (b) what past or continuing substance use has meant to the client and how it is affecting the client, and (c) how to motivate efforts toward recovery from problems, to minimize risks of continuing use (if any), and to take active steps toward beneficial change. For the therapist, psychoeducational strategies provide tools for facilitating client insight and action. Furthermore, employing such interventions also can stimulate therapists to enrich their own understanding of substance use problems and their treatment. The intricacies of disordered drug or alcohol use encompass so many variations on biological, genetic, environmental, and psychological themes that all professionals involved in treating substance abuse retain room to expand their own knowledge in addition to educating their clients.

Supervisors and trainers of therapists can also utilize psychoeducational interventions to help trainees extend and apply their knowledge of addictions treatment. This form of intervention can also be used to encourage trainees to explore their own attitudes and conflicts regarding both psychoactive substance use and clients who abuse drugs and alcohol. Furthermore, psychoeducation in supervision can motivate supervisees to develop good clinical judgment skills and to continue their own education and research beyond their formal training. Supervisors and trainers of therapists learning to work with substance use disorders will wield greater impact if they engage in their own ongoing education about the ever-evolving realm of substance abuse treatment.

Psychoeducation embedded in alcohol or drug therapy aims to provide the client with learning opportunities that are consistent both with the client’s level of readiness and the phase of the therapeutic relationship. Over the course of treatment, therapists will educate clients about some or all of the following topics: (a) the processes of therapy and recovery, (b) the types, actions and effects of psychoactive substances, (c) addiction and its behavioral, neurobiological and health implications, (d) means of counteracting addictive behaviors. Each of these topics in turn will be addressed in this section in terms of what the therapist needs to know about the topic itself and what the therapist needs to consider in educating the client about each topic.

HOW THERAPY WORKS AND WHAT TO EXPECT

The preceding sections have demonstrated that both the therapy process and the personal change process are frequently characterized as sets of transitions through definable and somewhat predictable series of stages. Effective therapists utilize the characteristics of the therapy relationship at each stage to navigate the course of therapy. The client’s reactions to each phase of therapy depend in part on where the client stands in terms of the process of change. The therapist’s choice of an appropriate psychoeducational strategy derives from the therapist’s evolving understanding of the present stage of the therapy relationship and the client’s point in the change process.

It is often constructive for the therapist to offer the client some explanation of how therapy works and how change occurs. The specific nature of this psychoeducation will be shaped by the therapist’s predictions of the client’s response to particular information at that time. In the initial stage of therapy, psychoeducation about the nature of therapy can help clients consider the potential utility of therapy as an option. If the client chooses to continue, psychoeducation helps prepare the client to use therapy to decide what problems are to be addressed. The assumption is that clients who have information about what to expect plus a chance to ask questions and to express concerns, doubts, or hopes about therapy are in a better position to decide if and how they will engage in therapy.

To help the client learn where to start and how to move forward, therapists first need to determine what expectations the client has for therapy and to estimate the client’s level of readiness to change. Some clients come with no prior therapy experience (though they may have some expectations, realistic or otherwise, about what therapy will be like). Other clients bring backgrounds of past substance abuse treatment or mental health therapy, which can vary from minimal to extensive, and from beneficial to inert to detrimental experiences. In each case, the therapist helps establish rapport with a new client by finding out the client’s perspective on therapy and by informing the client of the therapist’s understanding of how therapy works. Clarifying expectations, rights, responsibilities, and possible tasks sets the stage for the work to follow.

Addressing Therapeutic Confidentiality and its Limits

Early in therapy, clients are educated about confidentiality in the therapy relationship. While it is, as a matter of course, crucial for clients to be clearly informed of limitations on confidentiality, it is equally important that the therapist emphasize the protections of confidentiality. Many clients who present for substance abuse treatment have encountered some kind of trouble that led to the referral, and these clients are understandably concerned about what the therapist will do with any information the client reveals. Sometimes this concern is quite overt, and clients will ask if the therapist is going to talk to the client’s spouse, or parents, or probation officer, or employer. Even if the client does not raise the question, the therapist has the responsibility to inform clients of their rights to confidentiality, within ethical and legal limits. Ideally, confidentiality needs to be established with each treatment provider to promote rapport with that individual.

Therapists can add to rapport by expressing their own appreciation of the value of confidentiality. For example, the therapist can say,

I want you to know that what we say in here stays between you and me, except under a few conditions, which I will talk about in a minute. But first I want to emphasize how important I believe confidentiality is to the work we can do together, because I know it’s hard to trust someone with personal information unless you believe it will be held in confidence. So I want you to know that confidentiality is a professional value, which I take very seriously.

Then the therapist can add information about situations in which confidentiality cannot be guaranteed, such as when the client reports intent to hurt oneself or another person; when the client reports knowledge of abuse of a child, elderly, or disabled person; or if the client’s records are needed for a medical emergency or subpoenaed by a court of law. The therapist also explains that if any third party requests information about the client outside of these limiting conditions or if the client wishes for the therapist to provide information to a third party, disclosure will be made only with the written, informed consent of the client. Questions the client might have about confidentiality and disclosure are invited and discussed as part of this psychoeducation about therapy.

In some states, minors have rights to seek substance abuse treatment without parental knowledge or consent. In other situations, a minor client may be brought by the client’s parent(s). When parents are present or required, the therapist first discusses confidentiality and its constraints with both the client and the parent or legal guardian. In the minor client’s presence, the responsible adult is informed of existing rights, according to relevant state law, of parental access to the client’s record and to consultation with the therapist about the nature of therapy sessions. The therapist can explain to the adult that the potential for therapeutic progress can be enhanced if the parent is willing to grant additional confidentiality so that the client can speak freely to the therapist without worrying that everything the client says will be automatically reported to the parent. This request can be delivered with the assurance that if anything comes up that the therapist feels the parent has the right to know, the therapist will work with the client to decide how to inform the parent. If the parent or guardian agrees, and after that adult leaves the session, the therapist goes over confidentiality again with the minor client to be sure the client understands, to see how the client reacts without the parent present, and to address any questions the client might have.

Setting Realistic Therapy Goals

When clients enter a new therapy relationship with unrealistic or demoralized expectations, the therapist addresses these directly by specifying the importance of creating realistic goals and objectives. The therapist tells the client that therapy ideally involves the two of them working together to come up with goals that are meaningful to the client and appear feasible to both participants. Also, as goals are established, they will identify and choose workable strategies for attaining the therapy goals.

In the process of deciding and approaching the client’s goals, the client can expect the therapist’s nonjudgmental attention and support for a specified period of time on a regular basis. The client can also expect that the therapist will provide feedback and challenges to the client along the way. The therapist further requests that the client share thoughts and feelings about the course of therapy as it evolves, communicating the client’s right to expect the therapist’s responsiveness to the client’s feedback. This explicit consideration of what the client can expect from therapy is especially useful with those substance abusers who enter therapy with some resentment at the prospect of being told what they must do.

Establishing Ground Rules

Along with educating clients about the value of exercising client choice and input in the therapy process, initial psychoeducation about therapy clarifies boundaries and ground rules of therapy. The therapist indicates what is expected of clients as well as what clients can expect in therapy. As soon as substance use concerns emerge as a focus in therapy, clear expectations should be communicated about reporting substance use. At a minimum, the therapist asks that the client refrain from coming to sessions under the influence, and that the client agree to respond honestly to the therapist’s questions each session about any substance use since the last session.

The abstinence expectation. With respect to the first expectation of coming to session clean and sober, therapists should be specific according to their personal stances on this issue, taking the client’s response to this expectation into consideration. Some therapists require that the client abstain from substance use from the time they awake on the day of a therapy session. Others expect at least twenty-four hours free from substance use prior to a session to avoid the possibility that the client will be experiencing a hangover or acute withdrawal during a session. Still other therapists insist that the client completely forego recreational substance use during the course of therapy. The therapist needs to be clear about expectations in a manner that is true to the therapist’s own beliefs and values, but the therapist is also exhorted to be responsive to the client’s level of motivation to comply with the therapist’s conditions.

Adequate psychoeducation does not mean simply informing the client of expectations, but also involves providing a rationale and being receptive to the client’s reactions. The therapist explains that coming sober to sessions is expected for a few reasons. First, the client is less likely to be able to effectively use and remember the time in session if the client is under the influence. Second, the therapist believes that more productive work can be undertaken if the client’s mental and emotional functioning are not chemically altered. Third, the client’s travel to and from the session is risky if the client has been using substances that day. The motivation of clients who willingly agree to this condition is typically reinforced by such rationale. For clients skeptical of the need to comply or lacking confidence in ability to comply, the therapist’s stated rationale provides a springboard for further discussion.

While the therapist is advised to converse with the client about reactions to this abstinence expectation, the therapist still holds to the expectation of the client’s commitment. Clients may try to convince the therapist that being “high” is actually a normal state of mind for them and thus is not a barrier to their functioning. Or clients may say they will try but cannot promise, or may agree while nonverbally communicating that they do not take the requirement seriously. In these circumstances the therapist asks the client to