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This is an Intermediate Level course. After taking this course, mental health professionals will be able to:
This course is based on the most accurate information available as judged by the author at the time of writing and revision. Psychological approaches to understanding and treating disorders of psychoactive substance use change and grow daily, and new information may emerge that supersedes some content in this course. This course will provide clinicians with knowledge and skills for planning effective treatment to reduce problems associated with a client’s use of psychoactive substances, as well as guidance in developing relapse prevention strategies as part of the treatment plan. Given the vast range of psychoactive drugs and alcohols and the complexity of individual behavior, not every treatment context can be specified nor can efficacy be guaranteed; however the course will prepare the clinician with useful ideas and tools for planning collaboratively with clients with a wide spectrum of substance use disorders and concerns.
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 problematic substance use 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 treatment goals using: a) objectives for enhancing a client’s self-efficacy and motivation for changing problematic substance use and related behaviors; b) psychoeducation about the processes of therapy and recovery; and c) methods for relapse prevention. We will also consider ways to personalize treatment through responding flexibly and testing hypotheses based on the client’s unique presentation.
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 misuse 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, 2014) 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 treatment plan designed to address a client’s drug or alcohol use. 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 use 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 use, 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 misuse psychoactive substances to best use 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: Assessing for Substance Use. 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 population of clients exhibiting symptoms of disordered substance use.The course is based on three 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.
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 and can also help clients engage in change efforts beyond therapy. 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. The tasks, goals, and bond that develop through collaborative treatment planning all contribute to strengthening the working alliance between the therapist and the client. 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. Evidence supports the theoretical proposition that the way the working alliance unfolds predicts therapy outcomes (Stiles, Glick, Osatuke, Hardy, Shapiro, Agnew-Davies, Rees, & Barkham, 2004). Metaanalytic studies of goal consensus and collaboration in therapy consistently demonstrate significant moderate effect sizes related to favorable therapy outcomes (Tryon, Birch & Verkuilen, 2018).
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.
Recent work points toward the value of tailoring treatments to individuals in their specific sociocultural contexts. Therapists engage in “treatment personalization” when they respond in a flexible manner to clients’ beliefs about therapy and expectations of outcome (Coyne, Contantino & Muir, 2019). Therapy dyads can also generate and test “person-specific” hypotheses about the functional relationships between relevant factors indentified in the case formulation of the client’s concerns (Mumma, Marshall & Muir, 2018). 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.
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. The importance of personalizing the relevance of measures taken and responding flexibly to clients expectations will also be emphasized. 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 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 treatment of substance use disorders 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 and related concerns are detailed in Glidden-Tracey (2005) along with considerations for planning termination.
Clients who misuse drugs or alcohol 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-5 criteria for Substance Use Disorders capture the potential for life disruption through repeated risks or troubles encountered under the influence of psychoactive substances. Further alluding to the chaotic nature of a substance use disorder, diagnostic criteria specify that the symptomatic 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.
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 and realistically want from life. By thus identifying problems, discrepancies, and goals, the therapist can help clients choose how they can use their time together in therapy sessions to promote progress toward those goals. Collaboration to identify and prioritize specific goals and strategies with timeframes for reaching those goals helps the therapist and client together develop a treatment plan tailored to the individual clients interests and concerns (Washton and Zweben, 2006). Motivational interviewing strategies (Miller, 2006; 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 periodic 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 nonbinding 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.
Goal consensus and collaboration extend across most all theories of counseling and psychotherapy process (Tryon, Birch, & Verkuilen, 2018). These authors define goal consensus as agreement between a therapist and a client about what goals to work on and how to do so. And collaboration refers to a respectful, mutual, co-operative relationship of therapist and client working together to achieve therapy goals.
Miller (2006) specifies that behavior change is more likely when a person articulates a commitment to intentions and plans in the context of an interpersonal conversation. 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. Therapists also need to be both responsive and flexible with changing beliefs and expectations over the course of therapy (Coyne, Constantino & Muir, 2019).
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. In other contexts, planning may include detailed specification of functional hypotheses in a case formulation along with encouraging the client to help identify personalized repeated measures to test those hypotheses (Mumma, Marshall & Mauer, 2018). In any case, 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 use screening or therapy often reveal or reiterate external pressures placed on them to attend. McClelland (2006) reports that in specialty substance abuse treatment facilities, 50-60% of clients are referred by the criminal justice system, and the welfare system, employers, and employment agencies each account for about 15% more referrals. Such clients may say they don’t see their substance use as a problem even though someone else says it is. 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. 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.
Table 1. Initial Treatment Plan for Cody, Client Diagnosed with Alcohol Use Disorder Assessed in Precontemplation Stage of Readiness for Change
When clients feel they share consensus on goals with their therapists – those goals established through active collaboration – therapy dyads may get quite specific in their treatment plans. Therapist may suggest methods like keeping logs or tallies of particular thoughts, feelings, and behaviors. Clients may agree to homework assignments like keeping records, filling out questionnaires, trying out new behaviors, writing journals, or exploring other expressive channels like art or music or poetry. And if they show skepticism at the word “homework,” another descriptive term can be negotiated to refer to activities the client engages in between sessions to continue moving toward therapy goals. Over time, therapists and clients can compare number of days consuming drugs or alcohol per week, for example, and note progress and even set additional or modified goals toward change in this or other designated behavior.
The literature shows increasing empirical support for personalized treatments rather than only standardized treatment using manuals. This is consistent with long-standing calls for tailoring mental health counseling and therapy to each individual within their cultural and environmental spheres. From this perspective, practitioners may generate treatment plans by sharing hypotheses with clients about what functions their problematic symptoms serve, as well as what it would take to change those patterns of cognition, emotion, and action. A treatment plan can reflect the symptoms and problems the dyad decides to track, the indicators and evidence they count, and any change in those variables over time plus intervention. As Langkaas, Wampold, & Hoffart (2018) among others have noted, effective practitioners monitor identified indicators of client change and therapy progress over time to help decide when to continue with a planned course of intervention, when to modify the intervention strategy, and when to discontinue an intervention.
An intriguing approach is described by Mumma, Marshall, and Mauer (2018). From a cognitive-behavioral stance, they propose developing “person-specific” hypotheses for each client about the functional relationships between the individual’s triggers, cognitions, distress, and dysfunction, and then testing these with data from the client. In addition, they suggest developing a unique measure relevant to the particular client for the client to complete on a regular basis over time to track responses to therapy. The individualized measure would ideally include some general and some person-specific items across different domains of expression, and the content, frequency, and duration of each assessment episode could be determined in the collaborative discussions involved in developing this type of treatment plan.
This type of planning works well when the therapist and client have worked together to reach some agreement on goals, and when the client is motivated and active in completing “homework” and filling out repeated measures. In many cases, however, clients may not see the relevance of setting goals and hypotheses, may decline to agree to or complete homework, and may not respond sincerely or at all to repeated measures about aspects of treatment. In such treatment planning situations, the therapist can use flexible responding and motivational interviewing to address ambivalence and resistance that understandably arise over a course of treatment, and hopefully build up to a collaborative interaction in time. When psychoactive substance use is among the focal issues, clients may be even less inclined toward detailed treatment planning, especially initially, if they are unsure at best about whether they want to give up using alcohol or drugs that provide strong experiential and social reinforcements. They may be vague or uncertain about planning treatment if they have come at the urging or requirement of someone else. Even if motivated during sessions, in between sessions clients find that other urges and cravings compete with working on treatment goals. Thus, it is crucial for practitioners counseling clients who exhibit problems with alcohol or other drug use to learn how to effectively work with client resistance to treatment planning.
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.
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. Miller (2006) similarly discusses the value of negotiations evolving from a match between the request made by one person and the other person’s willingness to commit to meeting that request. Miller further emphasizes that while disordered substance use itself is certainly a primary target of intervention efforts, encouraging proximal behaviors like attendance and retention in treatment and adherence to change efforts can also facilitate positive outcomes, including reduction of substance use.
To facilitate collaboration in planning with clients, the therapist needs skills for balancing structure with flexibility. Planning treatment to address substance use disorders 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 severe Alcohol Use Disorder. 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.
Table 2. Revised Treatment Plan for Barry, Client Diagnosed with severe Alcohol Use Disorder and Assessed in the Preparation Stage of Readiness for Change
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.
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 treatment of a client’s substance use disorder. 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.
Client initiative can be mobilized through the choice of problems to be addressed in therapy. Among the difficulties therapists routinely encounter in planning treatment with clients who have used drugs and alcohol to the extent that problems result are 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.
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. Some clients who use report using alcohol or other drugs without fitting the full criteria for a Substance Use Disorder 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). Miller (2006) discusses self-efficacy as one of several “reasonably reliable” predictors of behavior change; others including expressions of motivation and commitment as well as taking specific steps to attend and adhere to change efforts. “More successful changers are those who believe that there are effective ways to accomplish change (general efficacy) and that they themselves are able to make use of them (self-efficacy)” (page 143). 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 treating substance use disorders.
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 users 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 as an experiment, 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. Research indicates that gains made early in therapy are crucial for enhancing both treatment participation and longer-term treatment success (DiClemente, 2006). 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 users in therapy 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 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 confidential 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 therapy for substance use disorders 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 to help 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 addiction or substance-related disorders 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, real and 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.
Reaching these objectives and strengthening self-efficacy can be facilitated through an effective relationship with the counselor or therapist. Miller (2006) highlights the impact of interpersonal interaction on the participants’ motivation and commitment. He discusses research indicating that the quality of the therapeutic alliance as judged by the client predicts outcomes, further emphasizing the value of empathic acceptance and interpersonal reinforcement in promoting explorations of discrepancies in one’s own life and expressions of commitment to change.
Planning treatment according to a client’s assessed readiness for change ties into the transtheoretical model of personal change (Prochaska and Norcross, 1994; 2014). The client’s stage of change is crucial for the task of planning treatment, 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.
The process of change through therapy has been equated to the natural changes produced by individuals who successfully change without treatment (DiClemente, 2006). With or without professional assistance, changing one’s own behavior involves subsequent tasks of becoming concerned, deciding that benefits of change outweigh costs, committing to a viable plan, carrying out necessary actions to promote the change, and consolidating the change into a sustaining lifestyle. According to DiClemente’s life-course perspective, treatment interacts with self-change efforts as a time-bounded phase of a larger natural change process. For different clients, the therapeutic event may take place at different phases of the natural recovery process. The therapist who views treatment as a component and facilitator of natural recovery is in a position to use treatment planning to help address broader aspects of the client’s life course beyond therapy.
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 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. Motivation is most productively viewed as multidimensional, fluctuating in relation to both intrapersonal goals and interpersonal processes (Miller, 2006). A therapist can infer a client’s motivational state not only through psychometric assessment, but also through attention to the natural language and behaviors of the client, particularly specific identified behaviors such as those stated in treatment planning. Miller (2006) points out the continuum of commitment strength reflected in a person’s speech, ranging from “I’ll consider it” to “I will” or even “I promise.” Therapists working motivational considerations into a substance use treatment plan can listen for the signals about level of commitment and readiness for change that are expressed in the client’s natural speech and behavior.
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 planning treatment. 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.
Miller (2006) summarizes research indicating strategies that do and don’t work to motivate change in substance use. Attempts to enlighten, confront, or punish clients consistently failed to elicit reductions in substance use. Findings supported interventions that employ the following components (captured in the acronym FRAMES): personalized Feedback relative to substance use norms, client Responsibility for change, encouraging Advice to reduce or stop drinking or using, a Menu of options for changing behavior, Empathic counseling style, and Support for self-efficacy and optimism. These effective strategies help create an interpersonal context in which motivations to change troublesome substance use can be explored, developed, and acted upon.
In discussion of their transtheoretical model, Prochaska and Norcross (1994; 2014) 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 use disorders, 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, 2014). 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.
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; 2014) 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 use. (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; 2014), 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.
Table 3. Initial Treatment Plan for Jason, Client Diagnosed with Cannabis Use Disorder and Assessed in the Contemplation Stage of Readiness for Change, Working Toward Preparation for Action
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 use 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, clients trying to change disordered substance use 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 into concrete tasks a more abstract strategy which the client is considering or on which the client has decided. 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.
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 use disorder 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.
Carroll and Roundsaville (2006) assert robust principles of empirical support for the effectiveness of behavioral and cognitive-behavioral interventions across all major types of substance use disorders. They note that research also supports the efficacy of these therapies for other psychological problems, important considering the high comorbidity of substance use disorders with other mental health concerns. Prochaska and Norcross (1994; 2014) 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 drugs or alcohol are available and desirable) and a response (using a psychoactive 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; 2014) distinguish these two methods of altering classically conditioned responses by pointing out that the first, counterconditioning, 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 users 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 disordered use 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 use, 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.
Table 4. Maintenance Treatment Plan for Juanita, Client Diagnosed with Tobacco Use Disorder, and Assessed in Transition from Action to Maintenance Stages of Change
Another example of planning stimulus control involves Angie, who stopped smoking cannabis 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 use 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 misuse. 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 use psychoactive substances, 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 treatment for addictive disorders 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 use 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 people with substance use disorders 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 problematic substance use, 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 clients with disorders related to drugs, alcohol, or addictive behaviors, making choices to forego substance use 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, a client in early remission from an alcohol use disorder 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. In many situations clients are not in a position to entirely avoid grocery stores (or convenience stores, or restaurants, or beer commercials on TV, etc.) and the consequent cravings. For such clients the treatment plan could include time to discuss alternate interpretations of the circumstances that trigger urges and cravings, as well as behavioral options the client has in response to those various interpretations. In the example above, using cognitive restructuring, the client could learn to 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 users 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). Carroll and Roundsaville (2006) summarize the principles of behavior change common to empirically supported therapies, including enhancing motivation for change, heightening behavioral control strategies, and reinforcing alternative cognitions and behaviors incompatible with the problem behaviors. 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.
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 problematic substance use 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 and objectives 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.
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 use 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 misuse 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. Miller (2006) mentions research findings suggesting the typical failure of educational approaches to change established substance use habits or to prevent initial experimentation. However, educational efforts that focus primarily on the delivery of information may miss the significance of reactions to getting information and the impact of those reactions on personal and interpersonal processes. Open to empirical test (but difficult to operationalize) is the possibility that that psychoeducational efforts fail when they neglect to sufficiently address the learner’s psychological reaction as well as the transactions resulting from those reactions between the learner/client and teacher/treatment provider. This idea is also consistent with Miller’s emphasis on interpersonal communication as an important context for expanding motivation and commitment. 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 use disorders and their 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 open-minded dialogue about their relevance.
Psychoeducational interventions can use the therapeutic relationship to 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 disordered substance use 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 encounter problems with their use of 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 use 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.
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 own understanding of how therapy works. Clarifying expectations, rights, responsibilities, and possible tasks sets the stage for the work to follow.
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 assessment or treatment for substance use disorders 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, after pausing for emphasis and to let that sink in, 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 use 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 or need 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.
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 users who enter therapy with some resentment at the prospect of being told what they must do.
It is further essential to attend to any issues identified in assessment and initial treatment planning that indicate urgent needs for immediate attention to significant risk factors. Imminent danger to self or others, and risk of serious medical or psychosocial consequences of continuing substance use or stopping too abruptly all demand the therapist’s intervention and possible referrals. Addressing risk factors takes first priority whether or not the risks are direct consequences of the client’s substance use (Washton and Zweben, 2006).
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. For a general example, therapists typically inform clients of time boundaries for therapy sessions to begin and end. 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 therapist also lets clients know they can expect a nonjudgmental response to clients’ honest reports of what they are doing, using, thinking, and feeling.
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. In some settings, clients are asked or required to agree not to use any mind or mood altering substances as a condition of treatment. The therapist needs to be clear about expectations in a manner that is true to the therapist’s own beliefs, knowledge, 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 of drugs or alcohol. Second, the therapist believes that more productive work can be undertaken if the client’s mental and emotional functioning is 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 to at least some time abstaining from chemically altering state one’s own state of mind during the course of therapy. 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 elaborate, showing interest in addressing barriers to compliance, and letting the client know what will happen if the client comes to a session after drinking or drugging despite the expectation. If the client remains unwilling to commit to abstaining from substance use on the day session, the therapist has the option of raising the topic of possible referral to more intensive treatment.
The therapist often distinguishes between expectation of client effort and insistence on outcome. In other words, the therapist communicates the expectations that the client will make a good faith effort to abstain from substance use prior to therapy sessions and requests that the client cancel the session if the client has been using drugs or drinking that day. However, the therapist who treats substance use disorders or even other mental health problems will probably on occasion have clients show up under the influence despite stated agreements and perhaps the best of intentions. It is often useful, especially with clients who inquire directly, to inform them early in therapy that if the client is unable to make or maintain the commitment, it indicates something important is happening that demands immediate attention and discussion in the session. For the therapist, this is a primary reason for stating the abstinence expectation at the beginning of therapy, so that there is a shared context for exploring the client’s actual success or difficulty with compliance over the course of therapy.
Some therapists decline to continue working with the client who continues drinking or using drugs, or will cancel the session on the spot if the client shows up under the influence. A more fruitful strategy with clients who do not totally comply with the abstinence expectation is to maintain interaction as long (within agreed timeframes and therapeutic boundaries) as the client is willing and able to talk appropriately about what is interfering with compliance and how abstinence the day of the session can be realistically enforced in the future. Clients who are too inebriated to converse in a reasonable manner can be referred for detoxification, but a client who had a drink with lunch or smoked one “hit” of marijuana before a session may be capable of interaction with the therapist. If the client shows up for session for the first time under the influence, the therapist definitely does not ignore this, but rather initiates candid discussion of what the therapist observes and what the client wants to say about it. The therapist explains that while this incident gives the therapist a better understanding of what the client is like under the influence, the therapist adamantly asks that the client recommit to attending all future sessions sober, reiterating the rationale. The therapist informs the client that this agreement will be discussed again at the next session when the client is sober, and that if the client comes to session under the influence again, the therapist will refer the client for more intensive treatment.
As long as the client is capable of reasonable interaction with the therapist, meeting with the client who shows up under the influence of drugs or alcohol also gives time for the client to “sober up” or “come down” from the substance. If the client is not able to engage appropriately in the session, the therapist may choose to end early, and may offer to follow up with a phone call in a day or two to see how the client is doing and to confirm the client’s intentions to attend future sessions sober. Before the client leaves the premises, however, the therapist should also find out how the client got to the session. If the client drove and if there is any doubt about the client’s capacity to drive safely, the therapist asks that a third party be contacted to drive the client home. To the extent that the therapist has used psychoeducation to inform and discuss these potential outcomes with the client ahead of time, the procedures, if necessary, are less likely to elicit resistance from the client who knows about them. Advance notice probably also increases the likelihood that the therapy alliance can be maintained past this point of tension or rupture in the therapy relationship.
Regular report of recent substance use. The second minimum expectation of the client is to honestly report any substance use between therapy sessions. The therapist educates the client about intentions to explicitly ask the client every session about recent use, with the rationale that the therapist needs an accurate picture of what the client is doing in order to work effectively with the client on addressing therapy goals. If the client’s response indicates the need, the therapist explains that the purpose of asking is to create a climate in which the topic can be straightforwardly addressed, not to shame or punish the client. The therapist maintains the intervention over time by then questioning the client each session in a nonjudgmental manner whether the client has used any substances during the interval between sessions. The therapist remains responsive to the client’s reactions or concerns about this procedure as therapy continues. The therapist also should be prepared to address and explore answers from the client that are vague or evasive in a manner that expresses interest and concern rather than suspicion or blame.
If the therapist has not established this ground rule at the beginning of therapy or at the point when substance use concerns are raised, and then later suspects that the client is using substances in a manner that is inconsistent with the treatment plan, it can be quite awkward to raise the question then. Therapists may wonder if they are accurately interpreting indications at hand and worry about offending the client if the therapist’s hunch is wrong. This fear can lead the therapist to avoid or minimize the question. From the client’s perspective, such a question from the therapist can be off-putting if the therapist is incorrect, and threatening if the therapist is accurate but has not provided a compelling rationale for the question. The client who is using substances, perhaps despite agreements to the contrary, but who has not agreed to regularly report any substance use to the therapist, may be inclined to deny the behavior or otherwise falsify information to protect from detection with unknown consequences. But when trust is fostered through regular “check-ins” negotiated early in planning treatment, the client is likely to be more willing and ready to share any recent substance use, even if it is hard to talk about, with a therapist who has shown consistent ability to supportively discuss drug and alcohol behaviors.
After mutual expectations and ground rules are established, psychoeducation about the process of therapy continues with specification of the goals and strategies to be employed. Earlier sections of this course have already alluded to the use of treatment planning as an intervention with psychoeducational components. Through collaboration in developing or revising a plan for therapy, clients learn something about how the therapy process is conducted according to this particular therapist. The client must also decide whether addressing substance use concerns will be among the priorities of the plan. Discussion of possible objectives and methods provides opportunities for therapists to present their own perspectives on how therapy facilitates change and on the client’s choice points in that process. The therapist raises the importance of creating realistic expectations about change, of internalizing the client’s own control and responsibility for outcomes of therapy, and of making meaningful changes in the client’s lifestyle to support efforts towards recovery or change.
While giving the client some structure for expectations is useful for building motivation and rapport in the initial phase of therapy, psychoeducation about therapy also continues across the course of the client’s work with the therapist. As therapy progresses and new interventions are utilized, the therapist pays close attention to the client’s verbal and nonverbal reactions. When the client appears confused, skeptical, resistant, or reluctant, it is often useful to initiate a discussion of immediate reactions and observations. The therapist who offers an explanation and rationale to educate the client about therapeutic intentions and procedures may be able to enlist client efforts. Unless the therapist has a compelling reason for maintaining opacity, articulating what the therapist is thinking, doing, and anticipating helps demystify therapy so the client is better prepared and motivated to take next steps.
No matter when concerns about the client’s substance use emerge in the course of a therapy relationship, the therapist proposes the shared goal of learning more about the role substance use has played in the client’s life. If the client declines, the therapist can suggest revisiting the idea later if needed. If the client agrees, the therapist is then in a position to teach the client information about psychoactive substances and their many impacts, while also finding out more of the client’s history and perspective. Furthermore, this type of psychoeducational intervention includes explorations of the interest and perceived relevance the client attaches to information about alcohol, other drugs, and personal experience with their use.
The therapist often wants to be explicit that one goal is to provide clients with a broader base of general drug and alcohol information that will assist the client in making better informed choices about consuming or using them. Learning more about psychoactive substances and how they affect human beings fits into conversations about what substance use has meant to the client, and how continuing use may influence the client’s future. Therapists will need to ascertain how much clients already know about the substances they have used, and to possess or help obtain accurate information for validating and extending the client’s knowledge. Discussions in session will compare the client’s own experience with using substances to general facts about substances and their effects. Also, the therapist should be open to learning new information from the client and from additional facts sought on the client’s behalf when the therapist’s own knowledge limits are reached.
Another major goal of psychoeducation about drug and alcohol effects is to sensitize clients to the conditions under which they have chosen and could choose to use substances, so that clients will become more knowledgeable about the implications of the factors and circumstances surrounding their own substance use. This goal is more personal than the general one described above. To help clients deepen their comprehension of the significance of their personal substance use, the therapist can make use of the emerging patterns described in Chapter 2 of Glidden-Tracey (2005), particularly the meanings the client ascribes to substance use and the interpersonal messages expressed through the client’s substance use. If the therapist is responsive to the client’s reaction to this exploration, the therapist can guide the client toward taking more responsibility for personal choices about substance use or abstinence.
Psychoeducational interventions about the impact of chemical substances on the body and the brain help stimulate consideration of both the risks and benefits of continuing use. Examining these tradeoffs may motivate the client to reduce or eliminate the assumption of such risks. It is also worth mention that the vast array of information available about substances and their effects includes some controversial and contradictory positions, especially as more U.S. states are reconsidering and changing laws and policies regarding medical or recreational use of marijuana. For example, some clients are familiar with literature and arguments in defense of the benefits of using marijuana (e.g., Conrad, 1997; Holland, 2010) or alcohol (e.g., Ford and Turner, 2005; Mukamal, et al., 2003). From both educational and therapeutic standpoints, the client can profit from weighing competing perspectives with emphasis on mobilizing active client choice about how to use this analysis to meet personal goals.
It is useful for substance use therapists to know enough about the pharmacological actions and behavioral outcomes of psychoactive substances that they will be able to describe these to clients in terms clients can understand. A legitimate question arises about how much the client needs to know about complex drug actions and effects in order to contribute to change in substance use behavior. Psychoeducation about actions and effects of drugs can help the therapist develop the client’s sense of discrepancy between present behavior and future goals, which in turn can motivate behavior change.
Effects on the brain. What therapists want to emphasize with clients engaged in risky substance use is that drugs and alcohol can modify normal functions of the brain in ways that can disrupt a person’s abilities to think, feel, and act in response to immediate circumstances. While some substance-induced alterations of baseline functions are certainly experienced as desirable, the excessive use of psychoactive substances also invites consequences of impaired cognition, affect and behavior that can be stressful and even dangerous.
If a client is interested in more detail about how drugs change brain functions, the therapist can provide it. As the therapist invites the client to comment on personal experiences of these general effects, the therapist should be prepared to address a few possibilities. Clients may report that before they tried drugs or alcohol, their own baseline functions were far from rewarding. Due to either environmental deficits or internal constraints, the client may believe that what was normal for them is different from average or better off persons. Such clients may be convinced that compromising some functions to attain higher pleasure is justified in light of personal circumstances.
In the spirit of avoiding argumentation (Miller & Rollnick, 2002), the therapist will want to empathize with the client’s perspective and further explore its underlying basis. In addition, however, the therapist points out that while the client’s substance use has served an understandable function, the positive effects are temporary while the less desirable ones are likely to persist. The user will need to keep consuming the drug to resume the beneficial impact, but repeated exposure actually induces changes not only in the functions, but also the anatomical structure of the brain, with potentially long term detrimental impact (see Chapter 4 of Glidden-Tracey, 2005). These structural changes compromise the user’s experience of drug reward (if use continues), ability to function, and ultimately quality of life.
As the therapy dyad examines these considerations – that substance use seems justifiable in the short term but risky in the longer term – the intervention focuses on what significance this observation has for the client. The reader will recall that the goal is to motivate the client to make conscious choices about future substance use or abstinence in the client’s own best interests. For some with hope of avoiding or reducing debilitating effects of risky substance use, this intervention will stimulate insight or action toward change. Other clients, however, may argue that the damage has already been done or the alternatives to substance use are too difficult or too painful.
These clients might remain unconvinced that efforts to change are worth their time, or they could remain torn by indecisive contemplation. Even if such clients take action to reduce their risky substance use, they are likely to struggle with fears, anger, or sadness about negative impact their substance use has already made. In cases like these, therapists can employ psychoeducation about the process of recovery from a substance’s effects (to be discussed later in this section).
Effects on the user’s body. To sensitize clients to the potential harm that misuse of substances can inflict on the human body, the therapist also may educate clients about actions the body takes to eliminate foreign chemicals capable of altering or damaging the body’s equilibrium. The thrust of the psychoeducational message is that the intricate structures that can rid the body or counteract the impact of hazardous substances may be injured by high levels of exposure to drugs and alcohol. The therapist can point out that the body functions fairly efficiently to rid itself of moderate amounts of psychoactive substances. However, excessive use can damage organs and their interacting functions to the point of contributing to major health problems, including cardiac and pulmonary effects, weight management difficulties, and neurological and psychological disorders, to name a few.
It is thus important for therapists to know and to help clients consider what it means to the client that the experience of a favorite drug’s effects requires some risk to the user’s body. Again, the client’s interpretation of this tradeoff may differ extensively from the therapist’s, so the therapist intervenes most effectively when equipped with both an open mind and the ability to assert clear, accurate information. Also, since clients are quite diverse in their opinions and analyses of the risks and benefits of substance use in light of psychoeducation about drug effects, the therapist remains attentive and responsive to the individual client’s perspective and cultural norms.
As the therapy dyad or group studies both the general and specific impacts of drugs or alcohol in the context of the client’s decision making and action plans, one theme often emerges. Even when the client acknowledges the risky nature of substance use, the client for whom substance use concerns have emerged in therapy also typically expresses some wish to continuing use to obtain the benefits despite the risks, even substantial ones. A psychoeducational stance permits the therapist to stay more neutral while still prompting examination of different angles on the topic. The inability to control substance use even in the face of debilitating consequences is one prominent criterion of a Substance Use Disorder. In addition to teaching clients about relatively short term reactions in the body to the presence of a drug, the therapist also educates the client about the process of addiction that can occur with repeated drug use.
The human body has natural mechanisms for obtaining reward and minimizing damage from interactions with the environment, including the consumption of exogenous psychoactive substances. Together these two sets of biological functions reinforce the likelihood that an individual will continue using drugs or alcohol.
The therapist basically wants to communicate that if changes induced in the body by drugs are maintained over a long time by repeated drug use, the potential for detrimental consequences continues to increase. Not all of the consequences of continuing substance use are necessarily problematic. However, the rapid actions and euphoric effects of drugs with high addiction potential provide strong gratification that can overshadow the user’s interests in non-drug activities and awareness of delayed costs of substance use. Outcomes like tolerance and withdrawal can stimulate the user to engage in more frequent administration of greater quantities of drugs. In turn, this behavior can enhance the likelihood that the user will come to depend on drugs to feel normal, since drug intoxication is becoming the individual’s typical state of being. Therapists can help substance using clients to identify the characteristics of withdrawal, tolerance and dependence.
Substance withdrawal. Regarding withdrawal, some clients may not be aware that specific symptoms they experience are attributable to the chemicals they are ingesting. Therapists can help educate such clients to the symptoms generally associated with the particular drugs the client has used (or is interested in using). Furthermore therapists can guide clients’ assessments of their own symptoms in comparison with a general withdrawal syndrome. Other clients are acutely aware of their substance withdrawal symptoms, but say they have learned to live with them or do not believe there is much they can do about them. Still others think they are funny, all just part of a good night on the town. Whatever the client’s perspective, the therapist encourages the client to elaborate, and then to consider possible interventions to address the client’s own symptoms.
Tolerance. With respect to tolerance, the therapist informs the client that just because the user’s experience of a drug’s effects is diminished as tolerance develops, it doesn’t mean the potential or actual damage is reduced. In fact, while tolerance does not guarantee problems, it may well increase the severity of an addictive disorder, especially in persons who are genetically, medically, or psychologically vulnerable. When tolerance leads to continuing use at higher rates and doses, the user also risks other delayed consequences, including health problems.
Some clients who use substances clearly take pride in their high tolerance for their drugs of choice. Trying to convince a client this is unwise will probably only raise resistance. But a psychoeducational intervention facilitates equal consideration of different viewpoints on the same topic, including awareness of reasons to feel nonchalant or smug as well as reasons to be concerned about clients’ reported abilities to handle themselves when intoxicated. In the context of balanced review of relevant perspectives, the therapist can impel clients to think about choices they make about personal substance use.
Addiction. Substance dependence, a term familiar to readers of the DSM-IV, was often equated with addiction, but the term “Substance Dependence” was eliminated from the DSM-5, in efforts to streamline diagnose and simplify its explanation. The DSM-5 still refers to “Substance-related and addictive disorders” in the general heading for the entire diagnostic category, while the severity of the disorder is now described in terms of the number of symptoms reported or exhibited by the client. Addiction, presuming severe and possibly dependent compulsive substance use, can be an especially tricky topic in psychoeducational interventions, for at least three reasons. First of all there is great confusion in the general public, the media, and even among scientists and professionals about how to distinguish chemical addiction from normal, unproblematic substance use. Terminology, explanations, and implications vary widely across persons using them. The therapist models flexibility through willingness to openly acknowledge various, even conflicting perspectives as they arise. The additional ability to steer the client into discussions of personal understandings and questions can facilitate client choices about how to view addiction and its ramifications.
Second, many substance users fear or resent the label of addiction, and may have little wish to discuss or learn about it. An advantage of a psychoeducational approach is the capacity to present material in an abstract or removed fashion, even with an explicit statement that the information may or may not be relevant to the client. For example, the therapist might say:
I’m not in the position to say you do or you don’t have a problem with drugs (or alcohol). That is up to you to decide. But I can show you how my profession defines chemical addiction and the criteria we use to distinguish Substance-Related Disorders from unproblematic normal use. Then if you’re interested, we can talk about how those criteria relate to your own experience.
Otherwise reluctant clients are sometimes willing to review DSM-5 criteria or listen to “third party” descriptions of characteristics of substance-related and addictive disorders if they are assured it is their choice whether to talk about personal experience. Clients may offer comments about their own circumstances in response to learning generalized material, or they may absorb information the therapist shares without verbalizing a response.
The attentive therapist watches and listens for the client’s nonverbal as well as spoken reactions to psychoeducational material. A facial expression, a change in body posture, or a wordless sigh or groan each serves as cues for the therapist to invite comment. If the client has indicated willingness to explore personal relevance, the therapist can probe specifically for details about the client’s personal experience that fit with the material in question. If the client has not agreed to delve into firsthand examples, the therapist can still ask in general terms, “Any thoughts or reactions to what we just covered?”
If the client says no, the therapist can point out the client’s nonverbal cue that triggered the therapist’s question (e.g., “I noticed you raised your eyebrows and sat back in your chair when I read the criterion of persistent desire or unsuccessful attempts to control substance use.”). If the client still declines to elaborate, the therapist can offer the possibility of revisiting this information at a later time if the client is ever interested in doing so.A third reason psychoeducation about addiction can be difficult is that even when clients are interested in learning about it, that interest can be accompanied by fear of implications for the client’s own life. Clients who are engaging in risky drug or alcohol use may worry about developing a problem or disorder, especially if they have a family history of alcoholism or addiction. If they have experienced substance-related disorders in either the past or present, they may express regrets about problems already encountered or fears about consequences, such as health difficulties, that may yet result.
Realizing that confronting such prospects can elicit the client’s ambivalence and resistance, the therapist further pursues discussion of the client’s feelings and perceived options in light of this information. If the client expresses the wish to avoid thinking about this, or despairs of finding a way out of substance related problems, the therapist can offer alternatives and hope. The therapist might acknowledge:
That’s one way to look at it, but I’m in this business because I believe many problems are worth confronting, and that people can learn to control how they deal with those problems. So are you willing to spend some time talking about ways we could proceed from here to address your own concerns?
Both the disease and the learning models of addiction reviewed in Glidden-Tracey (2005, Chapter 4) give reasons to expect progress toward change if the client decides to modify substance use patterns. From a learning perspective, maladaptive behavior that has been learned can be unlearned. According to disease models, some biological and neurological changes induced by drugs can be reversed, and some damages can be reduced if the substance user exerts control over risky or compulsive drug-taking behaviors. Such changes are neither quick nor easy, but recovery of more normal functions is possible with commitment and effort, and therapy can be one useful avenue on the map to recovery. The provision of psychoeducation about drugs and their short and long-term effects thus leads back to further education about the process of therapy and other means of addressing problems associated with the client’s own substance use.
Ideally, learning more about the actions and effects of different types of drugs, plus having a caring therapist to help process this information will stimulate the client to think about what it would be like to relinquish problems associated with the client’s own substance use. Whether the client is considering this prospect only in hypothetical terms or is ready to take action, the therapist can offer additional psychoeducation about the process of recovering from any negative impact of substance use and related disorders.
While many clients in therapy struggle with tendencies to externalize their problems to sources beyond their control (Teyber, 2006), this inclination is even more pronounced when substance use concerns arise in therapy. Clients who use drugs or alcohol often report that their substance use actually helps or is good for them, and that anyone who cannot appreciate that is the real problem. Such clients may use denial of personal control or responsibility over problems to justify continued access to the desirable effects of drugs or alcohol. Even if the client expresses ambivalence, intoxication further clouds immediate inclinations to think about their own contributions to current difficulties. When these client dynamics are encountered, the therapist gently confronts the client with the ideas that (a) the only things people really can control are aspects of their own behavior, and (b) it is up to each person to consider what they are able control and how much responsibility they are going to take for exerting that control. The therapist can offer support and encourage the client to mobilize other forms of social support. Ultimately, however, dealing with adverse consequences of past substance use or changing behavior to reduce risk of further detrimental consequences depends on the client’s own initiative and effort.
Underscoring the importance of internalizing the rights and responsibilities to address one’s own issues need not and should not come across as purely a harsh or punitive lesson. In fact, taking stock of what one can actually control also exercises the capacity to choose which efforts are worth making. The therapist can thus inform the client that the process of recovery typically involves looking inward to identify problems in need of attention as well as internal capacities and limitations pertinent to resolution of those problems.
Recovery from problems linked to a person’s alcohol or drug use rarely if ever happens by default. Clients for whom substance use concerns have been raised will need to decide if these concerns are to be a focus of therapy. If so, further choices are essential in addressing these concerns meaningfully and effectively.
Therapists educate clients about the importance of making active choices in the recovery process. Therapists assert their own willingness to guide and support the client’s decision process, but also clarify that in the end analysis, the choice rests with the client. The therapist explains that even if it were possible for the therapist to choose what focus or what approach is best for clients, the therapist would decline because that could block clients from learning how to choose for themselves.
The assumption here is that clients who have problems with drug or alcohol use have to some extent come to rely on default or delayed decision making. This can occur with respect to how the client copes with stressors (e.g., “I don’t know what to do about this issue, so instead of worrying about it, I’ll have a drink (or substitute drug of choice) to get my mind off of it for a while.”) Passive decisions may also be made about substance use itself (e.g., “I can always quit tomorrow, so why not indulge one more time today?”) This passivity may fluctuate, as in the example of the heavy drinker who wakes with a hangover and vows not to drink again that day (or that week, or ever), but ends up reaching for another bottle by later that same day.
Interactive psychoeducation about choice in recovery, then, involves the therapist in learning how the client feels about the prospect of choosing more actively, as well as how the client has tended to make decisions in the past. Motivational interviewing strategies (Miller and Rollnick, 2002) can be usefully integrated into therapist’s efforts to empower client choice and client voice. In therapy sessions, therapists encourage clients to choose the extent to which they want to concentrate on substance use concerns. Outside of therapy, clients are further urged to be aware of and take responsibility for the actions they choose.
Therapists should be prepared to address at least two common client reactions to a focus on active choice. First, clients may express or insinuate the wish that someone else (perhaps the therapist?) would fix the problem or tell them the solution. The therapist will probably want to point out possible resentment the client might feel if someone else did tell the client what to do or took credit for any beneficial outcome, or failed to provide resolution. The therapist might add:
I don’t see how either one of us would truly benefit if I tried to fix the problem for you, but I see real potential in us working together to help you decide what you want to do about it.
A second common client response to active choice involves statements of ambivalence, often peppered with low self-efficacy for making decisions. Clients often experience and express competing pulls between wanting to change for the better and not wanting to go through whatever change might take, or questioning whether change is even possible for them. Client ambivalence is increasingly recognized as an inevitable factor in change and recovery (Kell and Mueller, 1966; Miller and Rollnick, 2002; Teyber, 2006). Therapists teach clients that mixed feelings are normal and even potentially useful. Then therapists help clients articulate and examine their own ambivalence with aims of developing decisions and coping skills to resolve competing feelings. Addressing a client’s difficulties with making decisions can be valuable even if the client’s substance use is not the chosen focus.
As clients internalize responsibility for choosing the problems they will tackle and the strategies they will attempt, the therapist can help foster realistic expectations of both the process and outcomes of recovery. Difficulties in maintaining focus can arise when the client expects too much or too little. However, it is not unusual for clients to entertain idealistic hopes or nagging doubts about recovery. Sometimes clients waver between the two.
Therapists directly address their clients’ expectations by inquiring periodically, and also by sharing views from theory and experience about the process of recovery. The therapist offers confidence that the client will see genuine improvement so long as the client makes a good faith effort, taking manageable steps with good chances of success. The therapist emphasizes in addition that recovery is typically a gradual process, and change is rarely total or absolute. Many small steps taken over a long period of time are usually necessary to build toward sustained improvements in the client’s circumstances and well being. Furthermore the therapist admits that the gradual progression of recovery usually encounters some setbacks along the way, but such relapses can be reframed as additional sparks in the stalled engine of change. Of course, the therapist also points out that it is realistic for the client to expect the therapist’s close involvement and support with negotiating the unfolding recovery process, including the setbacks. (More on relapse prevention shortly.)
Clients are asked to share their reactions to this presentation of recovery as a slow procedure requiring concentrated effort with probable bumps along the way. Some clients will express relief and gratitude for the therapist’s forthrightness and support. Others will talk about frustration, disappointment, and maybe hopelessness. Not surprisingly, perhaps, still other clients will vacillate between these sets of feelings. When the client is opposed to the prospect of longer term commitment to therapy and recovery, the therapist can offer the possibility of a time-limited contract, suggesting that it is reasonable to expect progress in that time frame with the understanding that the contract can be renegotiated if needed. The therapist’s job as psychoeducator continues with empathic exploration of whatever reactions the client reveals, both verbally and nonverbally.
Already this recovery section has implied the need for clear, workable tasks to direct client energies toward recovery goals. Either directly or indirectly, the therapist teaches the client the potential value and utility of defining one’s goals and choosing activities designed to move closer to those goals. This piece of psychoeducation links to the concepts of ongoing treatment planning and relapse prevention planning and aftercare. Since these topics are covered elsewhere in this course, a few simple points will be highlighted here.
Helping clients to internalize their focus, to exercise active choice, and to create realistic expectations for recovery all involve developing a plan that is understandable, meaningful, and motivating to the client. In short, recovery usually requires some structure which the client helps to determine based on the client’s own inclinations.
Clients who meet diagnostic criteria for Substance Use Disorders sometimes come across as having or wanting minimal structure in their lives. Other times it is evident how thoroughly their lives are structured around getting and using, and recovering from, their substance. Typically clients have strong, often mixed emotions about altering the structure by which they are accustomed to living, even if they wish to recover from negative consequences of a life style of heavy or excessive drug or alcohol consumption. Therapists can work with clients to assess the viability of restructuring the client’s activity in light of emerging goals. They can also consider the client’s feelings about doing so.
Certainly the therapist can provide steady support for the client’s recovery. The therapist’s genuine expression of support can be a powerful interpersonal reinforcer of the client’s commitment to therapy. Psychoeducation about recovery also includes exhorting the client to cultivate additional sources of social support.
For clients whose social networks primarily include people with whom they use substances, this can be a daunting task. The therapist can inform or remind clients of general options, such as friends or relatives who do not use or misuse substances, or who have successfully recovered from a substance use disorder; therapy or self-help groups; or other interest groups centered around hobbies, sports, religion, politics, charity, or whatever interests the client. If desired, the therapist can coach the client on articulating requests for support and negotiating interpersonal processes that follow. Where relevant to help build the client’s social skills, the therapist introduces consideration of how communication and relationships have at least two sides, also encouraging the client to view circumstances or conflicts from other perspectives. As before, eliciting and processing the client’s responses is crucial.
To facilitate recovery, clients learn the importance of rewarding their successes and accepting their setbacks. Therapists not only offer this insight at the beginning, but often reiterate this component of recovery at various points along the journey. Clients may agree with the general principle but still run into difficulties applying it in practice.
Therapists can help resume realistic expectations when the client is disillusioned by slow progress. By educating the client of possibilities for reframing small changes as deserving active reinforcement, the therapist can teach clients to reward themselves more effectively. The therapist can also teach clients alternative ways of dealing with regress, so that instead of self-punishment, the client takes useful lessons from lapses.
In this section I demonstrated the essential nature of psychoeducational interventions in therapy with clients who use drugs or alcohol in risky or disordered ways. In teaching new information to the client, the therapist is encouraged to discuss not only the facts at hand, but also the client’s overt and subtle reactions to the information. Furthermore, the section advocates for therapists to engage in active interpersonal dialogue exploring the various interpretations of material at hand and the pertinence of that material to the client’s own decisions. In addition, bibliotherapy can extend the impact of psychoeducation. Recommending relevant books or other media for the client to consume helps keep clients actively involved beyond the therapy session, and therapists and clients can later discuss the content of such reading materials in session. The goal of psychoeducation is to expand the client’s potential for critical thinking and active choice regarding personal substance use by providing broad based information and a relationship in which to consider its import.
The therapist should also account for the following possibilities in the context of psychoeducational interventions about mind-altering substances, disordered use, and the processes of recovery from problematic use. First, clients are most always in possession of information on these topics provided by sources other than the therapist. If the client is or has been involved in other sorts of treatment or education regarding drug and alcohol use, the therapist may not give that client all the types of information covered here. But the therapist will still need to assess what the client knows, how that knowledge meshes (if at all) with the therapist’s own knowledge, and how thoroughly to pursue psychoeducational approaches given the presentation of the client.
Second, the vast literature on substance use and addiction extends into fields that may lie far from the therapist’s own expertise. When the boundaries of the therapist’s own knowledge about drugs, alcohol, and related problems are reached, the therapist is strongly advised to make appropriate referrals, or if plausible, to seek out information or consultation. Especially since there are many health and legal consequences of substance use disorders for many clients, therapists should be careful to refer clients as needed to professionals with the requisite credentials and expertise.
Finally, therapists are frequently in positions when working with substance related and addictive disorders to facilitate communication between the client and third parties. Disordered substance use, frequently associated with recurrent problems or outright failure to fulfill important roles or activities, creates interpersonal responsibilities for clients to address those problems with other involved persons. However, clients may have limited understanding either of what is expected of them by invested third parties, or of necessary steps to satisfy external requests or incurred obligations. Therapists can help clients clarify the nature of the problem and the expectations that need to be addressed to resolve the problem. This may include coaching the client on what to say and how to talk to a relative, employer, judge, doctor, or other party to elucidate obligations and communicate effort. To help clients learn to interact with others in ways that will permit the client to resolve current problems and avoid future troubles with substance use, therapists can teach clients how to assess and implement their options. They can also focus on anticipating likely consequences and possible next steps.
Jeannie stopped smoking pot for the past three weeks as part of the goals she set for herself in therapy. She is pleased to find she coughs less often and seems to concentrate better, but she frequently misses getting high. She tells her therapist the temptation to use cannabis again has been especially strong in the past few days since her best friend returned from a vacation and has been inviting Jeannie to come over and get stoned like they used to do. Her friend said she had some new edible products to try, without the risks of smoking. Jeannie is still unconvinced that her decision to refrain from marijuana use is a permanent one.
Barry has successfully abstained from drinking for three months after completing intensive outpatient treatment (IOP). Barry came for therapy when his wife expressed doubts about staying married if Barry continued drinking himself into a stupor every other night, using the alternate days to recover from massive hangovers. (An earlier version of Barry’s written treatment plan, as he was deciding to enroll in IOP, was described above). Barry now tells his therapist that he feels physically healthier in recent weeks and that urges to drink do not plague him as much as they did in the first month or two sober. However, he is now flooded with excruciating memories and feelings he had been blotting out about his painful childhood with an alcoholic mother, and is beginning to despair of ever finding a less depressive outlook on life, even without the burden of his drinking.
Nathan has expressed great motivation and enthusiasm for continuing the progress he has made toward establishing more satisfying relationships and identifying new occupational options since he quit using cocaine, marijuana, and alcohol with the support of intensive outpatient therapy. He has recently remarried and is considering pursuit of a career in healing ministries. As he approaches the six month marker of staying clean and sober, however, Nathan confides to his therapist that he has lain awake several nights in a cold sweat, using every ounce of his will to resist gut-wrenching urges to seek out some crack cocaine.
Viola just began her term of parole after serving time for possession of heroin. She got clean in prison by studying any available literature on treating drug addictions and promoting health and healing. By the end of her three years inside, she was co-leading workshops on healthy lifestyles for other inmates. Required to obtain drug therapy as a condition of her parole, Vi now reports to her therapist that she doesn’t see herself going back to using heroin, although she now drinks alcohol on occasion. However, she admits that moving back to her childhood home to care for her terminally ill, formerly abusive father after twelve years living out of state poses significant stresses, and she would appreciate some help with coping.
Each of these clients has taken important steps toward reducing the negative impacts of substance use on their lives. Each too faces new or continuing challenges that threaten to disrupt their progress and could potentially trigger a relapse into less healthy behaviors. Working with clients to develop their skills to prevent relapse is an integral component of therapy to address substance use disorders. The cases described above will be referred to again throughout this section to illustrate the establishment of relapse prevention and coping strategies.
This discussion of “relapse prevention” will employ broad definitions of both “relapse” and “prevention.” Relapse can refer both to a resumption of problematic substance use (however defined for a particular client), and also to recurrence of other maladaptive behaviors that have in the client’s past been associated with substance use as a coping strategy. For example, if Barry again started to withdraw from his family after recent attempts to mend fences, even if he is not drinking at present, he is relapsing into problematic behaviors that are tied into the impact of his own and his mother’s alcohol dependencies on his life. Prevention of relapse includes both warding off the resumption of problematic behaviors, and also building additional skills for coping with any episodes of substance use or related problems that do occur.
Therapists can help clients learn how to keep from falling back into old habits they are working hard to overcome by generating and implementing relapse prevention strategies. In this section, useful components of comprehensive relapse prevention strategies will be emphasized, with attention to the utility of embedding relapse prevention planning across the entire therapy process. Marlatt and Gordon (1985) present relapse prevention as a program by which individuals learn to manage their own behavior and change maladaptive habits by acquiring behavioral skills and cognitive strategies based on deliberate awareness and responsible decision making.
Marlatt (1985), one of the early proponents of relapse prevention strategies, underscores the crucial nature of the maintenance stage of the change process in determining long-term outcomes of treatment. While motivation, commitment, and action are all considered necessary components of changing problematic behavior, the gradual process of learning new coping strategies to replace former maladaptive coping mechanisms is essential in preventing and dealing with relapse. From this perspective, occasional mistakes or lapses in implementing therapy goals are to be expected, and can be viewed as opportunities for strengthening newly learned strategies rather than as indications of treatment failure.
Marlatt (1985) promotes relapse prevention training as a self-management program with goals of anticipating and coping with high-risk situations. Based on a social learning paradigm, relapse prevention efforts take an optimistic view of potential therapy outcomes, assuming that substance use disorders are characterized by behaviors that are learned and can be unlearned. In combination, efforts to increase self-efficacy and self-control are foundations for the maintenance of change in substance use behaviors.
Substantial research on relapse prevention has been conducted since the publication of Marlatt and Gordon’s germinal book. In a 1996 review of this literature, Carroll concluded that the evidence suggests that relapse prevention has greatest potential to reduce the severity of client relapses, to sustain the effects of treatment over time, and to be more effective with more severely impaired substance users. A meta-analytic review conducted by Irvin, Bowers, Dunn, and Wang (1999) further supported the general effectiveness of relapse prevention. The cognitive-behavioral relapse prevention model has been reconceptualized to facilitate extended research (Witkiewitz and Marlatt, 2004, 2007). In 2005 Marlatt and Donovan published a second edition of Relapse Prevention, updating the model and providing extensive empirical support. The second edition also includes chapters specific to relapse prevention with particular types of substance disorders, including separate chapters covering strategies for addressing alcohol problems, cigarette smoking, stimulant dependence, opioid dependence, cannabis related disorders, and club drugs, hallucinogens, inhalants, and steroids. Readers interested in addictive behaviors beyond disordered chemical substance use will also find chapters on eating disorders, gambling problems, sex offenders, and sexually risky behaviors. Witkiewitz and Marlatt (2007) edited a volume which comprehensively details relapse prevention techniques for a variety of client populations along with supporting evidence.
Tools clients generally need to develop in order to prevent relapse and maintain progress toward change include: dealing with factors that could trigger relapse, substituting healthy activities for formerly problematic behaviors, learning from relapse if and when it happens, and reinforcing successful relapse prevention efforts as they happen. In combination, these four objectives move the client toward the goals of mastery and confidence in their own relapse prevention skills. Individually, each objective can be approached in a course of therapy by employing methods selected to move clients from points at which they are presently struggling to points where they feel better able to cope.
Marlatt (1985) defines addictive behaviors as “compulsive habit pattern[s] in which the individual seeks a state of immediate gratification” (page 4). Throughout the substantial course of recovery from disordered substance use, individuals face moments of temptation to fall back on drugs or alcohol for an easy boost of mood or a quick escape from stressors. Factors that can trigger a relapse may be fleeting or pervasive, occasional or continual. While they are salient, they typically require the individual’s vigilant exertions to resist temptations to stray from therapy goals. Therapists can help strengthen clients’ skills for preventing relapse by paying attention to clients’ own most likely barriers to treatment goals and by guiding clients toward planning and practicing effective strategies for responding to such barriers.
The first step in dealing with barriers to progress is to clarify what kinds of situations, events, feelings, and thoughts have been associated with the client’s tendency to use substances inappropriately, and which of these will probably continue to prod the client to want to use again in spite of treatment goals. In much of the literature on treatment of substance use disorders, these factors are subdivided into urges, cravings, and triggers, with the advantage that such descriptive terminology helps clients sort out multiple factors contributing to their relatively undifferentiated experience.
Cravings. Cravings are experienced as somatic pangs, like hunger, created by depletion in the body of a substance required in order to maintain homeostatic functioning. As an individual develops a tolerance for exposure to larger or more frequent doses of a psychoactive drug, the tissues and cells adapt their operations to the presence of the drug so that withdrawal of the drug creates imbalance in the system. Initial withdrawal of a heavily used substance is often associated with intense physical craving, but the experience of craving a favorite substance can continue or recur long after the substance has been completely flushed from bodily tissues. Cravings are thought to result from both conditioned learning and cognitive expectancy processes (Marlatt, 1985). Part of relapse prevention thus involves helping clients to anticipate, recognize, and react more adaptively to their cravings.
Urges. Urges are intense, pressing desires to consume a substance and to bring on, as quickly as possible, the immediate gratification the substance promises to provide. Like cravings, urges are compensatory responses a person makes when external cues trigger anticipation of the effects of substance use (Lewis, Dana, & Blevins, 2002). The impulsive nature of urges can lead to snap decisions to ignore long-term consequences of use. Strong urges can push a client down the slippery slope to a relapse, unless the client learns to prevent relapse by deliberately engaging in planned alternative behaviors. Nathan, for example, learned in therapy that when struck by urges to seek out cocaine, he found it helpful to write in his journal or practice relaxation and meditation techniques instead. When reporting the results of these techniques to his therapist, Nathan also came up with the idea of reminding himself in those difficult moments of the several painful results of past use that he had to face over many years of heavy drinking and smoking. He confided later that this turned out to be his most effective strategy for dealing with his intense urges.
Triggers. Triggers refer to situational factors that cue individuals with substance abuse histories into remembering the pleasurable aspects of drinking or taking drugs. By signaling the possibility of recreating that pleasurable state, triggers prompt the individual to use substances again. For the individual in recovery, classically conditioned triggers continue to operate, stimulating desires to resume use and paving the road to possible relapse. For Nathan, seeing a recent news report on crack cocaine use that included footage of silhouetted figures smoking a crack pipe triggered unexpected urges and cravings to use crack again, even after several months of abstinence. Jeannie, the client in the early recovery example, found that a strong trigger for her was spending time with her best friend on the patio where they used to get high.
In relapse prevention models, persons who misuse substances are presumed to exhibit maladaptive skills for coping with high-risk scenarios and with cues they have been conditioned to associate with substance use (Rawson, Obert, McCann, and Marinelli-Casey, 1993). Relapse prevention planning helps counter-condition individuals who have decided to quit disordered use of substances by extinguishing the old learned response and consciously replacing it with a new and incompatible one.
Changing conceptions of cravings, urges, and triggers as well as modifying behavioral reactions to them are gradual learning processes. Although clients cannot implement a relapse prevention strategy until they have taken action to modify their substance use and are in the stage of maintaining behavior change, they can begin to plan a strategy even as they are contemplating or preparing for action. Early in therapy, therapists can explain the rationale and procedures for planning how to prevent relapse to acquaint clients with the concept. They may focus on harm reduction. Then once clients agree they are ready for the next step, the therapist can structure a discussion of the personal triggers, urges, and cravings of which clients are already aware or coming to recognize. As clients list the factors that contribute to their own substance use behavior and describe how they have reacted to urges, cravings and triggers in the past, clients can be further encouraged to consider possible different responses to such factors in the future. Mindfulness training can be used to guide clients in allowing themselves to experience sensations, thoughts, and emotions linked to their own triggers without reacting automatically, instead learning to increase choice and control of behavioral responses (Bowen, Chawla, & Marlatt, 2011). Finally the therapist invites the client to monitor their experiences and practice these new response options when encountering triggers, cravings, or urges in present daily life, and to report back to the therapist about how these efforts are experienced.
In addition to talking about relapse promoting factors in individual sessions, clients can also be invited to explore related experiences in a group therapy context. With other clients sharing perspectives, clients can gain insight into experiences and barriers common to many recovering from substance use disorders, as well as into more rare or unique aspects of one’s own situation that will require individualized attention in planning relapse prevention strategies. Therapists can also suggest homework to keep clients involved in therapeutic planning or implementation in between sessions. Clients can try methods like generating or expanding lists of personal triggers to drink or use drugs, or they can use logs to monitor the occurrence of urges or cravings during the time between sessions. They may be willing to keep a journal, either by writing about barriers to goals as they are experienced, or by setting aside a regular time to record thoughts and feelings about the barriers the client identifies. The specific methods to promote identification of a client’s relapse triggers are best negotiated from the therapist’s observations and the client’s preferences.
Along with listing specific factors potentially promoting relapse, clients also need to sharpen their awareness of the situational contexts in which these relapse triggers are most likely to be salient as the client works toward initiating and maintaining change. For example, Viola’s return following years of incarceration to the community where she grew up, combined with her new caretaker role for a father who treated her poorly during childhood, will together present her with a variety of situations that strongly elicit her anger or sadness. If Viola already knows that feelings of anger and depression can tempt her to relapse, she will also need to clarify the aspects of her new circumstances that may bring up sad or mad feelings. Her therapist can better prepare her to confront these situations in a manner that prevents relapse by talking about and recording the particular events that Viola anticipates will be most stressful. The more the client can anticipate such situations and their potential impact, the better prepared the client can be to deal with them without giving in to temptations to relapse into old coping mechanisms associated with using drugs or alcohol.
Developing and practicing strategies for overcoming identified potential barriers to treatment goals is the crucial next step in helping clients prevent relapse. Often in the client’s past, cravings, urges, and triggers have been associated with problematic cognitions, emotions, and behaviors, which the client must now learn to manage in order to avoid relapse. Therapists can provide methods and clarify procedures by which clients can actively engage in deliberate change processes. Clients frequently benefit from a therapist’s guidance regarding identification and weighing of options, selection from among options, and implementation of new strategies through regular practice. Especially since many people who meet criteria for substance use disorders have over-learned expectations of immediate gratification, therapists also need to emphasize patience with the gradual, approximate nature of change. Therapists must pay attention to the client’s fluctuating motivations to comply with the relapse prevention plan or to remain committed to therapy goals. A therapist can reinforce the client’s commitment to decisions to avoid relapse by generating alternative perspectives and strategies to promote healthier coping activities.
After clarifying potential barriers to treatment goals, the client and therapist expand the relapse prevention plan by specifying new ways of thinking about issues and concerns, new approaches for managing difficult emotions and disruptive behaviors, and new ways for the client to occupy time. Therapists can employ cognitive restructuring and emotional and behavioral management training to assist clients in replacing alcohol or other drug use as a coping mechanism with healthier alternatives. Engaging clients in new leisure activities and helping them develop occupational options is important in planning to prevent relapse. Rewarding abstinence from substance use, both total and partial, and also reinforcing alternatives to consumption of drugs or alcohol are empirically supported strategies for increasing motivation for change (Miller, 2006). Common factors in effective therapies include enhancing a client’s behavioral control skills and changing reinforcement contingencies to incentivize abstinence (Carroll and Roundsaville, 2006).
The therapist first encourages the client to identify typical thoughts the client entertains about personal substance use, about related stressors, and about coming to treatment. Then the therapist teaches the client to challenge and replace self-defeating thoughts with more productive cognitions. Extending the example of the client in early recovery from cannabis use disorder, Jeannie tells her therapist she thinks her friends are going to laugh at her or reject her when she tells them she recently quit smoking pot. She is also convinced it is no longer possible for her to have fun if she is not high. Jeannie says she still is not sure she wants to quit totally or forever; she says she is only abstaining for now to avoid further trouble.
Generating alternatives. Without invalidating Jeannie’s original comments, the therapist points out that there are probably other ways of thinking about her situation that are worth considering. While it is certainly possible that Jeannie’s friends might give her a hard time for not smoking with them anymore, it’s also plausible that at least some will be sympathetic with her situation and understand her choice. Some friends might even respect and admire Jeannie’s new stance. The therapist can introduce questions of what Jeannie thinks about friends who would reject her on such a basis; about what Jeannie would think of a friend who confided in her of a similar decision; and about how much Jeannie thinks it matters what other people think of her personal choices.
Regarding Jeannie’s doubts about why she is quitting and whether she can still enjoy herself, the therapist can offer the perspectives that it is Jeannie’s prerogative to decide what she wants, that it is possible to find activities that are satisfying even when she is not under the influence of marijuana, and that it could be interesting and even exciting to discover these possibilities.
Stopping self-defeating thoughts. Once the client agrees to try out new cognitions, the therapist can teach and reinforce thought stopping techniques. Clients learn to mentally catch themselves entertaining a self-defeating thought. Then they are instructed to practice consciously letting go of that thought and to deliberately replace it with a more affirming or realistic thought. The therapist can also instruct the client to pair a specific behavior with a mental exercise, such as the classic snap of a rubber band against the wrist, to serve as both a symbolic gesture and a visceral reminder of the cognitive modification. Continuing the earlier example, Jeannie decided instead of wearing a “tacky” rubber band around her wrist, she will move the clasp of her favorite necklace, which she wears every day, around her neck whenever she stops and replaces a self-defeating thought with the concepts 1) that she can meet her goal, and 2) that she wants to do it, first and foremost for herself.
It is crucial to emphasize that cognitive restructuring works best when the client believes the therapist understands and accepts the client’s starting cognitions, and when the client generates and chooses personally meaningful replacement messages and gestures. If the client feels either criticized or coerced by the therapist, the client is much less likely to take cognitive reframing seriously. Adding rhythmic repetition of the affirming replacement message(s) after the symbolic gesture is made along with stopping the irrational or maladaptive thoughts has potential to help clients remember, practice, and apply the newer, more positive cognitions outside of the therapy session. Furthermore, the therapist can enhance results by clearly explaining that lasting change in cognition will take time, especially since the client has had a long time already to establish the original self-defeating thoughts. By encouraging patience and regular practice, and by asking the client to reflect in therapy sessions on the efforts to reframe cognitions, the therapist teaches the client not only how to better regulate the content of the client’s own cognitions, but also to formulate realistic expectations of personal change. This of course means that the therapist must also be patient with the slow nature of change and the negotiation required for effective relapse prevention planning.
Limiting beliefs encountered in cognitive interventions. Two limiting beliefs commonly expressed by clients diagnosed with substance use disorders are worth further mention. Tendencies to externalize problems to sources outside of personal control or to maintain ambivalence (at best) about the existence of a problem or of the need to change are both cognitions that impede efforts to prevent relapse. When restructuring cognitions with a client, the therapist should work explicitly with the client’s attributions of both ability and responsibility for addressing problematic substance use and related barriers to treatment goals. Some clients may believe they could but do not want to make certain changes to maintain therapeutic gains. For example, some alcoholics in early remission believe they can still go to bars while choosing not to drink alcohol. Such clients may prove reluctant to discuss risks or shoulder responsibilities for the possibility of relapse under such circumstances. Some may turn out to be capable of doing so; for others the temptation to resume problematic drinking turns out to be too great. Other clients are willing to accept responsibility but are unconvinced of their ability to bring about desired outcomes.
Take the extended example of Barry, whose depression intensifies despite months of newfound sobriety. Barry commits to removing all alcohol from his home and driving past all liquor stores without stopping, but still is not sure that at the end of each day he can make himself leave the grocery store where he works without buying a bottle off the shelf. In each case, the therapist can help the client clarify, challenge, and balance beliefs about the extent to which the client possesses and takes control of factors that can influence the client’s progress.
As the therapist and client together plan ways for the client to prevent relapse, the client learns to first recognize thoughts that interfere with making healthy decisions. Next the client develops alternative beliefs to counter self-defeating cognitions, and then is challenged to deliberately notice and replace maladaptive thoughts with more productive ones. As the client practices and refines these cognitive restructuring skills, the client wields new tools for resisting relapse. The client comes to believe 1) that there are options besides drinking or using drugs for eliciting pleasure and satisfaction from daily life, 2) that these options are in many ways preferable to former substance use behaviors given their relative consequences, 3) that the client is capable and deserving of these more beneficial options, and 4) that the client is willing to undertake the responsibility for making the effort to establish and reach personal goals.
Helping clients learn to manage difficult affect is essential in preventing relapse. In addition to self-sabotaging thoughts, limited skills for coping with negative affect – especially intense anger, sadness, or anxiety – frequently pose complications for clients recovering from substance use disorders. In many cases, clients were using drugs or alcohol as their primary mechanism to blunt difficult emotions or blot out guilt for affect-induced behaviors. After a client takes steps to reduce or abstain from substance use, strong feelings often emerge. A good example is Ricardo, who told his therapy group about a recent incident in which Ricardo’s son was surprised to see his father crying for the first time, and curious about why. Ricardo told the group he had explained to his son that, “It’s okay. It’s just that Daddy is starting to have feelings again.” Unless the client develops effective new strategies for coping with rage, depression, disappointment or fear, the risk is high for relapse to substance abuse as a means of shutting off such bad feelings.
A client’s relapse prevention plan should thus include steps for helping clients learn to manage their own inevitable negative affect. Affect management training refers to techniques by which therapists teach clients first how to recognize, acknowledge and accept their emotions, and then to make informed and wise choices about how to act on their feelings, taking appropriate responsibility for the outcomes. Anger management is one well-known specific form of affect management training, both because anger issues are evident among many individuals mandated to obtain treatment for a substance-related or addictive disorder, and relatedly because the term has caught the attention of the popular media. However, all forms of negative affect can be exceedingly hard to experience and manage.
Identifying affective themes. While a client’s perceptions of past, present, and future can each be associated with a range of difficult emotions, often a client will exhibit some characterological affect (Teyber, 2010). For Barry, profound sorrow is prevalent; for Viola, the predominant affect is anger. In Nathan’s case, guilt over past transgressions and mistakes is a recurrent theme. The therapist begins training the client to better manage affect by starting with the characteristic affective theme evident in the client’s presentation, with the therapist’s understanding that other forms of affect with which the client also has trouble coping are sure to surface once the primary affect is addressed.
Distinguishing alternatives for expressing emotions. To incorporate affect management training into a client’s relapse prevention plan, a therapist first points out the evident affective theme and the apparent or likely difficulty of managing volatile emotions. Once the client agrees, the therapist then helps the client distinguish between “having a feeling” and “acting on the feeling.” The therapist validates the client’s feeling and the client’s right to feel it. The therapist also helps the client explore and understand the reasons for the feeling and the ways the client has coped with the feeling in the past. This analysis of coping may yield discussion of feelings that trigger the client’s urge to use substances, of emotions about the consequences of the client’s substance use, and of feelings about the process of change. The therapist communicates the messages that emotions themselves are neither wrong nor right, they are simply but inevitably what a person feels in reaction to a thought or an event. However, there are good and bad ways for people to act out or express their emotions, and examining different possible reactions and their probable consequences can help clients make better choices about how to manage their own feelings.
The client is invited to discuss these ideas and to consider both effective and less effective options for expressing emotion. The therapist further encourages discussion of the probable consequences of choosing to express feelings one way compared to another. Role-play exercises can be used for the therapist to model and the client to practice new forms of affective expression, with minimal interpersonal risk to the client. Relaxation, mindful meditation, and stress management techniques may be used to help the client identify alternative responses to strong emotion. Through these activities in session, the client learns to isolate the experience of affect from a behavioral response. In addition, the client begins to consciously generate options to an identified emotion, rather than acting according to a familiar, automatic impulse.
The therapist also asks the client to name specific situations and general contexts in which the client anticipates being confronted with negative emotions. Journaling or logging homework often helps clients focus in on people, events, memories, times of day and the like that pose particular challenges or threats to the client’s therapy goals. The therapist can guide the client in session toward deciding how the client plans to respond to those challenges. With an articulated plan, the client should become better able to consider and eventually employ new strategies for managing intense affect in the heat of such a moment.
Implementing new affect management skills. When the client is ready, steps can be taken to transfer these behavioral strategies for managing affect beyond the therapy session. Before discussing these steps, however, it is crucial for the therapist to remember to continue assessing and validating the client’s experience of emotions as they are learning to behaviorally manage them. Understandably, some clients interpret the goal of affect management as eliminating negative affect. Even clients who endorse the distinction between the experience of emotion and a response to that emotion can be sideswiped by unanticipated feelings when methods that seemed clear in a therapy session turn out to be harder to implement than the client hoped or expected. Less than ideal outcomes can yank to the surface old impulses to escape bad feelings with drugs or alcohol. Clients typically need the therapist’s continuing help and support as they learn to tolerate and manage their emotional reactions to ongoing issues and changing circumstances.
As new concepts and skills for managing the client’s affect are developed in therapy sessions, the client and therapist further address the client’s readiness to implement changes outside of the session. The therapist can ask if the client has noticed any differences in how the client has been feeling and how the client has been acting on those feelings. The therapist should also inquire about any consequences the client has encountered in response to new forms of expression with which the client is experimenting. If the client is not reporting any changes, the therapist can suggest more directive homework. The client can be asked to try a specific strategy when the client experiences negative affect, and then to notice the results and discuss the experiment in the next therapy session. For willing clients, it will probably be useful to keep a journal to record impressions or a behavioral log of occurrences.
Clients often need guidance to structure their efforts to be meaningful without being overwhelming. Building on earlier planning efforts, the therapist can help the client select one particular type of affect eliciting stimulus with which to practice managing responses. Preferably, the situation, person, or issue selected should be one the client is likely to encounter but not one of highest stakes to the client. By beginning with salient but less threatening stimuli, the client can practice and achieve some success or at least meaningful insights that will reinforce willingness to make additional efforts to try new management strategies in increasingly challenging contexts. The therapist can help the client make informed choices about where to focus efforts, what new approaches to try, how to interpret outcomes, and next steps to successively approximate affect management goals.
As the client learns to substitute productive thoughts for former self-defeating cognitions, and to generate healthier responses to difficult emotions, the need to develop alternative vocational, education, or leisure activities emerges. To promote treatment goals, the client must not only reduce reliance on old habits of coping, amusement, or involvement; the client also needs to replace habitual activities with other intrinsically satisfying means of occupying the client’s time. Clients who have been using drugs or alcohol to entertain themselves, to keep busy, or to deal with (or avoid dealing with) issues will have to establish new activities as part of their relapse prevention plans.
The activities in which a client engages are intricately tied into the client’s thoughts and feelings. Again recalling earlier examples: Barry’s days have for decades revolved around procuring liquor for his fifth-per-episode binges, alternating with time spent sneaking into the garage to consume and store his supply. Although he claims he never drank at work, Barry does admit that much of his time at work and home was occupied, when he was not drinking, with severe hangovers compounded by brutal self-recrimination. Since he has been sober, he has vastly more time on his hands with which he would like to concentrate on improving family relationships. However, distressed by the barrage of depressing memories now crowding his existence, Barry voices doubts that he is capable of engaging in the activities he deems necessary to connect with his wife and son.
Nathan, for another example, sold drugs for years before his most recent arrest, his new wife, and his renewed faith all convinced him to clean up his act. As he worked with his therapist to identify new income-generating options, Nathan flirted with the idea of entering the ministry to share what he has learned and to help others in need. However, he feared that other people would not take him seriously or believe his sincerity considering his criminal past. Meanwhile, as he weighed the strength of his newly inspired convictions against his anticipated vows of education and relative poverty, he could not help missing the quick money he made selling drugs. Furthermore, his current construction job is physically taxing, not to mention boring.
To prevent relapse for both Barry and Nathan, their therapists can direct these clients’ attentions toward choosing productive activities and building involvement in those occupations, be they leisure or vocational. The development and subsequent revisions of a client’s relapse prevention plan can usefully include discussions about how the client has been spending time along with alternative activities in which the client would like to participate. These alternatives may reflect interests the client has never pursued, former activities the client has given up to engage in substance use, and new options the client has never considered.
From the list of activities generated in this discussion, the therapist asks the client to prioritize and then select a highly ranked activity for concentrated focus. The therapist explains that other activities on the list will receive attention later, once the client has begun to achieve progress toward the initially selected priority activity. When the client is ready to commit to a particular pursuit, the therapist guides the specification of a target goal and helps break the goal down into attainable steps. The therapist will need to adapt the emphasis depending on the client’s particular difficulties with the approach. Some clients, like Barry, will have trouble identifying alternative activities or setting priorities. Others, like Nathan, are able to articulate clear goals, but have little understanding of how to formulate a workable plan to move from where they are to where they want to be. The therapist can utilize psychoeducational and motivational strategies as needed to flesh out options, rankings, goals, and objectives for enhancing the client’s vocational and avocational activities, thus reducing the risk of relapse.
After the therapy dyad has negotiated activity goals and objectives, the therapist assists in putting the plan into action, step by step. The therapist is advised to recall the four components of fostering a client’s efficacy expectations, detailed already in Planning Treatment to Enhance Self-efficacy and Motivation. Objectives aimed toward developing new client activities to replace potentially destructive behaviors should be carefully implemented by accounting for the client’s performance accomplishments, emotional arousal, and exposure to vicarious successes and failures. The therapist also selectively offers verbal persuasion to support the client’s efforts at attempting objectives that both agree are reasonably within the client’s grasp.
The therapist’s persuasive efforts are most needed when the client’s confidence or commitment to relapse prevention activities starts to waver. Often after acknowledging the value of an objective or indicating willingness to take a step toward occupational goals, a client’s ambivalence resurfaces. For example, now on parole, Viola has expressed excitement about enrolling in university coursework during early conversations with her therapist about relapse prevention activities. However when the time came to comb through the schedule of courses and complete admissions forms, Vi questioned her own interest in hassling with such complicated, time-consuming paperwork when she had other necessary things to do. In addition, she complained to her therapist that earning a degree would take more time than she was able to give at her age.
Viola’s therapist employed persuasion at this point, not to try to convince Vi that she really did want to commit four or more years to achieve a bachelor’s degree, but rather to take the extra step of reconsidering her relapse prevention plan before abandoning this objective. Viola’s therapist told her:
Last week I heard the part of you that felt inspired to pursue your studies and expand your career options, and now this week I also clearly hear your doubts and concerns about whether that goal is feasible. If we pay attention to both competing sides of this issue, it looks to me like it’s worth talking more in here about the pros and cons of school versus giving up on the idea of school, so that whatever you decide, you’ll be satisfied that you thought it through carefully.
Viola agreed to further discussion, and ended up deciding that she did want to take some courses, but not immediately, while her dying father’s care required so much of her time and attention. Vi and her therapist revised her relapse prevention plan to include one hour per week, subdivided as necessary and convenient, to study the university catalog for interesting courses while postponing plans to enroll.
Vocational counseling becomes an essential part of many relapse prevention plans as clients seek to determine what to do with their time and energy once they limit investment in excessive substance use. Categories of goals that may be relevant include: addressing problems that have arisen at a current job setting due to the client’s substance use, pursuing educational or career goals that have been sidetracked or underdeveloped because of the client’s substance use, and coping with occupational stressors without resorting to excessive use of psychoactive chemicals. Related vocational counseling applications are discussed more extensively in Chapter 9 of Glidden-Tracey (2005).
In summary, over the course of addictions therapy, a therapist can help clients develop skills to avoid relapse by learning to substitute positive cognitions, emotions, and behaviors for former drug associated tendencies. As the therapist supports the client in the gradual process of strengthening these skills, the client will typically experience some gratification that further reinforces the client’s commitment to avoiding relapse and replacing substance use with newly valued alternatives.
In spite of valiant efforts and best intentions, clients sometimes relapse anyway. The literature cites many indicators of the likelihood that the majority of people treated for substance use disorders will engage in some substance use or misuse following treatment (Tucker & King, 1999). Especially in early recovery or at times of stress or crisis, clients continue to encounter strong ambivalence about changing addictive behavior. Urges and cravings to again experience substance-induced pleasure can become excruciating, thus exaggerating the relief the substance promises to provide. Even when the urges subside and the client has successfully resisted the temptation to relapse, additional cravings frequently follow within days or hours. For clients whose desire to use substances fades over time, the risk of relapse remains high as long as other problems remain salient but the client has few or poorly established coping skills aside from escape through substance use.
To work effectively with the high probability of relapse during addictions therapy, therapists are advised to accept the likelihood of relapse, to address negative thoughts and feelings about relapse, and to utilize client relapses as windows of opportunity to further therapeutic change. This section will outline means of building these interventions into plans for preventing client relapse. Emphasis is placed not only on the impact of relapse on the client’s recovery process, but also on the therapist and the interpersonal therapy process.
By acknowledging up front that relapse can happen, a therapist presents the client with a realistic picture of the recovery process. Early in the development of a client’s relapse prevention plan, the therapist explains that although the potential long term benefits of addiction therapy are highly worthwhile, the pull of old habits is likely to be strong and hard to resist at times. The therapist offers viable hope of progress and eventual success through the therapy collaboration, but also informs the client that some frustrations, setbacks, and possibly episodes of relapse are inevitable along the way. The therapist lets the client know that anticipating these eventualities will allow the client to be better prepared to deal with them if they occur. Furthermore, the therapist invites the client to specify – as part of the relapse prevention plan – objectives and strategies for coping with both potential and actual incidences of relapse. The therapist assures the client that if relapse happens to occur, it can be used in therapy as a chance to learn more about personal strengths, limitations, and needs.
To maximize client involvement, the therapist needs to take steps beyond simply stating this acknowledgment to the client. The therapist should further inquire about the client’s reaction to the perspective on relapse just described. Sincere consideration of any miscomprehensions, disagreements, or doubts will facilitate the elaboration of a plan that is most personally relevant to the client.
Note the importance of the therapist also accepting the probability of client relapse. The helping professions are rife with unfair sentiment that therapy for disordered substance use is largely fruitless because such clients cannot or do not want to change. Some other professionals who reject this pessimistic outlook and believe that relapse does not equal failure of treatment still may encounter their own feelings of disillusionment when a client succumbs to temptations to fall back into old behaviors. Therapists need to be aware of their own attitudes and feelings about client relapse, and to carefully pick and choose how to utilize as therapeutic tools their own reactions to the sensitive issue of relapse. Supervision can assist newer or struggling therapists in working through their own resistances and in working effectively with the difficult dynamic of client relapse.
By encouraging the client to report relapse incidents or other considerations of acting counter to therapy goals, the stage can be set for using therapy sessions to promote learning from setbacks as well as from successes. The therapist reassures the client that:
If you choose to share a relapse experience with me, I won’t think it means you’ve failed, nor will I think any less of you. What I will do is help you understand what happened and to explore what the experience teaches you so we can use that awareness to strengthen your skills to prevent future relapses.
The therapist may also ask for or reassert the client’s permission to inquire at each session about any recent substance use.
Once the possibility of relapse is admitted and an agreement to examine any relapse episodes is in place, the therapist remains attentive for emerging needs to address negative thoughts and feelings about relapse as they arise.
The client’s perspective. From the client’s perspective, anticipatory feelings range from excessive fears to arrogant overconfidence about abilities to resist relapse. When the therapist hears extreme or unrealistic anticipations of relapse potential, the therapist intervenes by reflecting back what the therapist is hearing and by challenging the client to explore those thoughts and feelings in greater depth. Regarding a relapse that has already occurred, clients may feel anything from intense guilt and shame to relief or resignation associated with resuming substance use.
While some clients openly acknowledge a relapse, other clients who have agreed in advance to report a relapse still hesitate to confide about an incident once it has actually occurred. An attentive therapist can often detect changes in client mood or attitude that hint that something has happened. Being careful not to assume a relapse has in fact occurred, the therapist can notice aloud the difference in the client’s presentation and express curiosity, inviting the client to elaborate on its meaning.
The therapist who regularly checks in with the client to inquire about any substance use since the last therapy session provides a context in which a client who is reluctant to bring up the topic can be prompted to share information. Also, such inquiry during each session gives the therapist a baseline against which a client’s atypical response more clearly signals the need for greater investigation. As the therapist explores client material that appears vague, evasive, unusually emotion-laden or cryptic, it is important to remember that pushing clients to admit relapses they have not yet acknowledged rarely helps. Using open questions that avoid presumptive wording is more likely to elicit relevant content from the client.
When a client reports a relapse, either by self initiation or in response to the therapist’s exploration, the therapist first offers support by reiterating unconditional acceptance of the client along with curiosity about what can be learned from the incident. Then the therapist asks both about what happened and how the client is feeling about it. Empathic listening will help the therapist maintain rapport at such difficult times, and also help assess how the client is actually reacting to the relapse. Relapse prevention planning continues from this point to incorporate analysis of the relapse experience and to apply findings toward treatment objectives. Analysis of the lessons learned from a relapse is most useful when the therapist can get an accurate reading of the client’s emotional state following relapse.
Whatever feelings the client expresses, the therapist both validates that affect and encourages the client to generate or review options for acting on that feeling. A shame-ridden client can be reminded that while his feelings are understandable painful, it is important not to lose sight of progress he has already made, as well as the remaining potential for additional progress. The client wrapped up in anger that she bothered to try therapy when this relapse proves she was just setting herself up for yet another failure can be prodded to recall reasons for seeking and attending therapy prior to this relapse. If the client indicates indifference to the occurrence of a relapse, the therapist can acknowledge that sentiment at face value, but also ask the client to remember and comment on stated treatment goals and rationale. In each case, the therapist will probably suggest a review of the treatment plan, especially the provisions for relapse prevention. The therapist further determines with the client whether some revision of the plan is needed based on incoming information.
The therapist’s perspective. In addition to helping the client address feelings about a relapse and its impact on treatment motivations, therapists also experience their own strong affect at points of client relapse. It is one thing to anticipate the possibility of client relapse, but a report of the actual event can send a therapist reeling with intense emotion. Among the feelings the therapist may need to deal with are feelings of responsibility for the relapse, guilt for not doing enough to prevent it, anger or disgust with the turn of events, or sadness or fear regarding consequences the client now faces. Such emotions on the therapist’s part can be as hard to experience and as influential on the therapy process as the client’s reactions to relapse.
The therapist should not try to ignore or deny these feelings, but must also consider what it would be like for the client to hear about the therapist’s reactions to a relapse and what the client is likely to do with that information. The therapist chooses to share those thoughts and feelings that the therapist has justifiable reason to believe will be therapeutic. This means that any frustration or disappointment the therapist reveals should be closely linked with the therapist’s continuing hope and support for the client’s ongoing progress. Such messages are often also combined with challenges to the client. Explicitly or otherwise, many clients will want to know what the therapist truly thinks of the client. Thus at the critical juncture following a recent relapse, the therapist’s ability to offer honest critique paired with sincere faith in the client’s potential is paramount.
Personal feelings about the client’s relapse that the therapist cannot justify telling the client should be kept private. These may still be useful as sources or tests of a therapist’s hypotheses. Such feelings can potentially also become problematic if they interfere with rapport in session, with the therapist’s ability to offer support and hope, or with the therapist’s well-being outside of session. Confidential consultation with a trusted supervisor or colleague may be useful or even necessary for a therapist burdened by negative feelings toward a client relapse that the therapist cannot quite put to therapeutic use.
By fairly addressing negative affect and disruptive cognitions as they arise in session, therapists guide clients toward accepting the reality of personal experience. Just as importantly, examining relapse episodes moves the therapy process toward using the experience to gauge the barriers and assets weighing against and for the client’s recovery. The therapy dyad admits the downside of relapse, but in equal measure acknowledges the opportunities for learning and growth presented by the relapse episode.
Exploring a relapse creates chances to strengthen the clients’ understanding of the processes of relapse and recovery. Furthermore, the therapist can seize opportunities to reassess and reassert the client’s goals in therapy. The therapist asks the client what factors led up to the relapse and how this episode was similar to and different from other times the client has run into problems with drugs or alcohol. Clients are encouraged to articulate what they know now that they did not know before about personal vulnerability or resistance to relapse. Therapist and client together consider what they like and dislike about the way the relapse has been handled, and the therapist invites the client to talk about what the client can do differently in the future to better ward off another relapse, or to minimize its negative impact.
This kind of discussion can be punctuated with a review of the client’s extant relapse prevention plan. Insights gleaned from conversational analysis of the relapse lessons are then underscored by building them into a revision of the client’s plan. The therapist can write these revisions in a format that can be offered to the client, with a copy maintained in the therapist’s records, to be consulted later by each as needed.
Thus relapse prevention planning continues in the face of a client relapse. Instead of assuming treatment failure or using a slip as an excuse to give up, the therapy dyad can investigate the lessons inherent in the experience of relapse. Directly addressing relapse incidents teaches clients to better recognize and manage factors that could threaten their progress in therapy and recovery.
Therapists reinforce clients’ efforts to prevent relapse by emphasizing progress and rewarding client success. In addition to expressing praise, admiration, and appreciation of steps the client takes toward established goals, the therapist also instructs clients on how to reinforce their own skills at relapse prevention. The therapist accomplishes this through a combination of treatment planning, implementation, and outcome evaluation tasks.
First, the therapist helps build evaluation and reinforcement into the client’s relapse prevention plan. When clients identify strategies for avoiding barriers to treatment goals, or choose new activities to substitute for substance use, therapists ask clients how they can reward themselves for attempts to implement these alternatives. Therapists also prompt clients to consider ways they can reinforce themselves for successes in meeting treatment goals or in resisting temptations to relapse.
For clients who in the past have used alcohol and other drugs to reward themselves, finding equally satisfying reinforcers is no simple task. As already noted, psychoactive chemicals have strong, inherently gratifying properties, and can furthermore blunt the brain’s response to otherwise pleasurable stimuli. Therefore it is often hard for clients who have excessively used alcohol or other drugs to identify and experience other reinforcers.
Therapists may thus need to generate ideas with clients about types of reinforcers both available and meaningful to the clients. Once a therapy dyad has developed a list of plausible ways for the client to reward progress, the therapist gives the client the list (retaining a copy for the therapist’s file) and suggests that the client reread the list and apply a suitable option whenever the client notices indications of progress.
Some clients will also need help with evaluating progress that deserves reinforcement. The therapist can ask, “How will you know, outside of our sessions, when you have taken a step that’s worth a reward?” For clients who have trouble answering this question, the therapist steers the conversation toward objectives specified in the treatment plan to highlight desirable outcomes. In terms of self-evaluation criteria, clients can be encouraged, especially in the early phases, to apply reinforcement for genuine efforts, partial successes, and small but still salient indicators of change. Therapists can implement cognitive restructuring and behavioral management of affect in facilitating discussions of client self-evaluation and reward.
As clients learn the concept of self-reinforcement, they also benefit from guidance in recognizing and responding to positive outcomes of their change processes. A client who grasps the idea of rewarding progress may still lack motivation or understanding of how to make it work for her personally. Jeannie, the client with three weeks abstinent from marijuana, initially scoffed at the suggestion that she had made a good choice that merited some reward by deciding not to attend a party in the past week where she knew marijuana would be offered to her. “All I did was stay home, bored out of my skull and feeling sorry for myself. And I’m not sure I’d make the same choice if another opportunity comes up this weekend,” she complained to her therapist. “You call that progress?” Her therapist admitted she could empathize with Jeannie’s frustration, but also pointed out that the episode proved Jeannie was capable of exerting more control over her substance use and over staying out of trouble that she had expected. In addition, the boredom and self-pity she had encountered could be viewed in the more positive light as good indicators of the importance of finding alternative means of fun for Jeannie on those weekends that she does choose not to smoke pot. Reframed in this way, Jeannie came to see some advantages to the outcome of her choices, even if they were not entirely satisfactory. Along with recognizing desirable outcomes, clients can learn to find something desirable in many outcomes of their efforts, even the less obviously positive ones.
Clients addressing substance use disorders also need to practice responding in a reinforcing manner to indicators of their progress. If clients minimize or devalue steps they have taken, the therapist can encourage application of a different client response that supports relapse prevention efforts in a realistic context. For example, Barry notes that he is feeling physically healthier since he stopped drinking, but he also tells his therapist, “Not that it matters when I’m either depressed or just numb all the time.” His therapist reflects the disillusionment she hears from Barry, but she also points out that it is worth something that his headaches and stomach problems have abated, his hands are steadier, and his thoughts clearer. She asks him, “How about telling yourself that it is nice to feel healthier even though you realize there are still important emotional concerns to work on?” The therapist invites Barry to talk about how he could make some time in his sessions or in his daily routine to appreciate the physical improvements he is noticing.
Some clients like Barry have difficulty applying self-reinforcement. Aside from the gratifying effects of using psychoactive chemicals, they may have limited experience and few skills at responses that promote positive outcomes. The therapist can help clients learn to reinforce their own relapse prevention efforts by reflecting and interpreting signs of progress toward treatment objectives, and by prodding clients to think through how they can choose to react to situations in which a potential relapse was prevented or managed. Clients who are not convinced of their need or ability to reinforce themselves can be asked to experiment with new options for purposes of comparison. The therapist can recommend that the client try to act “as if” if outcomes of their relapse prevention efforts are positive or worthwhile. Sometimes such experiments or exercises will surprise the client with the result that the new responses to recovery efforts and outcomes actually make the client feel better, stronger, or more competent. Gradually, recognizing and responding to positive outcomes of relapse prevention efforts become their own reward.
From the therapist’s perspective, it can be enormously gratifying to hear the client’s report of new behaviors and to see the client demonstrating expanded skills at preventing relapse and promoting progress. These are times when it is easy to help reinforce client initiatives, and the client will be wonderfully responsive to therapist feedback. There are moments of doubt and frustration for the therapist, too, when clients are not changing as much or as fast as the therapist had anticipated, or when the client does not acknowledge or maintain new behaviors that the therapist sees as signs or positive change. Thus the therapist will need to stay attentive both for indications of small but still meaningful successes, and to find ways to productively discuss these with clients. A therapist’s own frustration can serve as a signal that something is occurring in session that needs to be discussed.
If therapists decide to reveal their own feelings to their clients, it is strongly recommended that the therapist’s expression of frustration be solidly paired with expressions of hope that sharing impressions will lead to reactivated momentum in therapy, along with genuine interest in the client’s reactions to what is occurring in session in that moment. For example:
I’m starting to feel like a cheerleader, like I’m trying to get you to admit that what you did is an important step, but the message I’m getting is that you don’t see it as any big deal. Let’s talk some more about what it means that we’re looking at this so differently. What is your reaction to me saying this?
You’re telling me you don’t think it’s worth trying anymore since this just feels too hard. I have to admit, that is hard for me to hear, but I’m also hoping that if we keep talking about it some more we can find ways to make this worth your while. Are you willing to talk some more with me about what is working and what’s not and what we can do differently in here?
In essence, getting the client to stay involved in the therapy process and to keep coming to sessions until the work is satisfactorily completed is in itself a positive outcome and a step toward preventing relapse. As these moments occur in session, the therapist is in a position to provide immediate reinforcement to the client’s engagement in continuing to sort out the advantages and difficulties of working to prevent relapse. In other words, when the client accepts the therapist’s invitation to keep talking about what progress means and how to make it happen, in addition to the client’s report of what the client is doing outside of session, steps toward relapse prevention are occurring directly in session. The therapist can acknowledge and praise all these client behaviors as they happen, thus utilizing the immediacy of the therapy interaction:
Just the fact that you’re telling me this is new. I want you to know I appreciate your willingness to explore this even though I know some aspects of this discussion aren’t easy for either one of us. The fact that we can talk about it, even though it is hard, is part of what seems important about it, at least from my vantage point. So I hope we can stick with it.
As the therapist and client together reinforce the relapse prevention strategies, which the client is learning to implement, clients are likely to experience increasing success and satisfaction. As objectives are met, therapists can further develop clients’ relapse prevention skills by expanding treatment goals to build on client successes. Earlier this section described the idea of using a relapse episode as a window of opportunity to clarify the client’s abilities and limitations to deal with temptations to drink, take drugs, or engage in related problem behaviors. Episodes of client success at deflecting a relapse also provide parallel opportunities. When the client has met a relapse prevention objective or demonstrated a new skill at coping with a potential problem, the time is ripe for reviewing goals, articulating accomplishments, and clarifying new priorities and next steps. This process of revising the relapse prevention plan can itself be rewarding as the therapist encourages the client to use what the client has already learned in taking strides toward further skill development.
The changes a client begins to make through addictions therapy need to be planfully maintained and reinforced to prevent client relapse into formerly problematic substance use and related habits. Therapists can facilitate beneficial outcomes of treatment and help clients learn skills for preventing relapse by teaching clients (a) to cope effectively with urges, cravings, and triggers, (b) to substitute healthier cognitive, affective and behavioral strategies in place of old habits, (c) to realistically address the possibility and actuality of a relapse during the recovery process, and (d) to productively reinforce ongoing relapse prevention efforts. By gradually learning the logic and implementation of relapse prevention strategies, clients can expand their ranges of options and their senses of control over decisions they make regarding substance use, coping mechanisms, and productive activity.
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