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Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35.)

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Enhancing Motivation for Change in Substance Abuse Treatment.

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Chapter 6—From Preparation to Action: Getting Started

Strong commitment alone does not guarantee change. Unfortunately, enthusiasm does not make up for ineptness... Commitment without appropriate coping skills and activities can create a tenuous action plan... Anticipation of problems and pitfalls appears to be a solid problem-solving skill. DiClemente, 1991

At the end of the preparation stage, clients make a plan for change to guide them into the action stage. This chapter focuses on negotiating this specific change plan with clients. Changing any long-standing, habitual behavior requires preparation and planning. As your clients move from contemplating to actually implementing change in their lives, they are in an intermediate stage in which they increase their commitment to change by exploring, clarifying, and resolving their ambivalence and making a decision to act. In the transtheoretical model, this stage is known as preparation. Clients must see change as in their best interest before they can move into action. The negative consequences of ignoring the preparation stage can be a brief course of action followed by rapid return to substance use.

During the preparation stage, your tasks broaden. Where before you were using motivational strategies to increase readiness--the goals of the precontemplation and contemplation stages--now you will use these strategies to strengthen your client's commitment and help this person make a firm decision to change. Clients who are committed to change and who believe change is possible are prepared for action.

Clients and clinicians in the preparation stage are equipped with important knowledge from the personalized feedback of assessment information described in Chapter 4. The activities and strategies described in Chapter 5 were intended to solidify your client's commitment to change and set the stage for developing a plan for moving into action. Clients should now have a clearer picture of how their substance use affects many aspects of their lives, and they should have begun to recognize some of the consequences of continued use. In addition, many clients sense the hopeful possibilities inherent in the growing therapeutic alliance. If you have exercised the principles of motivational interviewing, your clients should recognize that they are in a safe environment for exploring their feelings and thoughts about change and that they are in control of the change process.

This chapter explains how and when to negotiate a change plan with the client and suggests ways to ensure a sound plan--by offering the client a menu of options, contracting for change, identifying and lowering barriers to action, enlisting social support, and helping the client anticipate what it will be like to participate in treatment.

Recognizing Readiness To Move Into Action

As clients proceed through the preparation stage, be alert for signs of their readiness to take action. Clients' recognition of important discrepancies in their lives is an uncomfortable state in which to remain for long; thus change should be initiated to decrease discomfort, or clients may retreat to using defenses such as minimizing or denying. Mere vocal fervor about change, however, is not necessarily a sign of determination to change. Clients who are vehement in declaring their readiness may be desperately trying to convince themselves, as well as you, of their commitment (DiClemente, 1991). The following are several confirming signs of readiness to act:

  • Decreased resistance. The client stops arguing, interrupting, denying, or objecting.
  • Fewer questions about the problem. The client seems to have enough information about his problem and stops asking questions.
  • Resolve. The client appears to have reached a resolution and may be more peaceful, calm, relaxed, unburdened, or settled. Sometimes this happens after the client has passed through a period of anguish or tearfulness.
  • Self-motivational statements. The client makes direct self-motivational statements reflecting openness to change ("I have to do something") and optimism ("I'm going to beat this").
  • More questions about change. The client asks what she could do about the problem, how people change once they decide to, and so forth.
  • Envisioning. The client begins to talk about how life might be after a change, to anticipate difficulties if a change were made, or to discuss the advantages of change.
  • Experimenting. If the client has had time between sessions, he may have begun experimenting with possible change approaches (e.g., going to an Alcoholics Anonymous [AA] meeting, reading a self-help book, stopping substance use for a few days) (Miller and Rollnick, 1991).

When you conclude that a client is becoming committed to change, determine what is needed next by asking a key question (see Chapter 5). You might say, "I can see you are ready for a change. How would you like to proceed?" If the client indicates that she wishes to pursue treatment with your help, you can begin negotiating a plan for change.

Negotiating a Plan for Change

Creating a plan for change is a final step in readying your client to act. A solid plan for change enhances your client's self-efficacy and provides an opportunity to consider potential obstacles and the likely outcomes of each change strategy before embarking. Furthermore, nothing is more motivating than being well prepared--no matter what the situation, a well-prepared person is usually eager to get started. A sound change plan can be negotiated with your client by the following means:

  • Offering a menu of change options
  • Developing a behavior contract
  • Lowering barriers to action
  • Enlisting social support
  • Educating your client about treatment

Chapter 5 describes the process of exploring clients' goals as a way of enhancing commitment and envisioning change. The change plan can be thought of as a roadmap to realizing those goals. Some clients begin spontaneously suggesting or asking about specific things they can do to change. You can prompt others to make suggestions by asking key questions such as, "What do you think you will do about your drinking/drug use?" or "Now that you've come this far, I wonder what you plan to do?" (see Chapter 5 for a list of key questions).

Clients will create plans that reflect their individual concerns and goals. Most plans are not limited to stopping or moderating substance use, and ensuring success is the central focus of the plan. The plan can be very general or very specific, and short term or long term. Indeed, some clients may be able to commit only to a very limited plan, such as going home, thinking about change, and returning on a specific date to talk further. Even such a restricted and short-term plan can include specific steps for helping the client avoid high-risk situations as well as specific coping strategies for the interim.

Some clients' plans are very simple, such as stating only that they will enter outpatient treatment and attend an AA meeting every day. Other plans include details such as handling transportation to the treatment facility or arranging alternative ways to spend Friday nights. As discussed below, specific steps to overcome anticipated barriers to success are important components of many change plans. Some plans lay out a sequence of steps. For example, working mothers with children who must enter inpatient treatment may develop a sequenced plan for arranging for child care and training temporary replacements for their jobs before entering treatment.

Although the change plan is the client's, creating it is an interactive process between you and the client. One of your most important tasks is to ensure that the plan is feasible. When the client proposes a plan that seems unrealistic, too ambitious, or not ambitious enough, a process of negotiation should follow. The following areas are ordinarily part of interactive discussions and negotiations:

  • Intensity and amount of help needed--for example, the use of only self-help groups, enrolling in intensive outpatient treatment, or entering a 2-year therapeutic community
  • Timeframe--a short- rather than a long-term plan and a start date for the plan
  • Available social support--including who will be involved in treatment (e.g., family, Women for Sobriety, community group), where it will take place (at home, in the community), and when it will occur (after work, weekends, two evenings a week)
  • Sequence of subgoals and strategies or steps in the plan--for example, first to stop dealing marijuana, then stop smoking it; to call friends or family to tell them about the plan, then visit them; to learn relaxation techniques, then to use them when feeling stressed at work
  • How to address multiple problems--for example, how to deal with legal, financial, and health problems

Clients may ask you for information and advice about specific steps to incorporate in the plan. Provide accurate and specific facts, and always ask whether they understand them. Eliciting responses to such information by asking, "Does that surprise you?" or, "What do you think about it?" can also be helpful in the negotiation process.

How prescriptive should you be when clients ask what you think they should do? Providing your best advice is an important part of your role. It is also appropriate to provide your own views and opinions, although it is helpful to insert qualifiers and give clients permission to disagree.

Other techniques of motivational interviewing, such as developing discrepancy, empathizing, and avoiding argument, remain as useful during these negotiations as they are at all other stages of the change process. Guard against becoming overly focused on the negotiations and on the plan such that you forget to use these strategies. Acknowledge and affirm the client's effort in making the plan.

Some clients have found the Change Plan Worksheet (see Figure 6-1) a useful tool in focusing their attention on the details of the plan. The following is a list of considerations for completing the worksheet (Miller et al., 1995c):

  • The changes I want to make are... Be specific. Include goals that are positive (wanting to increase, improve, do more of something), and not just negative goals (stop, avoid, or decrease a behavior).
  • My main goals for myself in making these changes are... What are the likely consequences of action or inaction? Which motivations for change are most compelling?
  • The first steps I plan to take in changing are... How can the desired change be accomplished? What are some specific, concrete first steps? When, where, and how will the steps be taken?
  • Some things that could interfere with my plan are... What specific events or problems could undermine the plan? What could go wrong? How will the client stick with the plan despite these particular problems or setbacks?
  • Other people could help me in changing in these ways... What specific things can another person do to help the client take the steps to change? How will the client arrange for such support?
  • I will know that my plan is working if... What will happen as a result of taking the different steps in the plan? What benefits can be expected?

Figure 6-1: Change Plan Worksheet.

Table

Figure 6-1: Change Plan Worksheet.

It can be helpful to estimate your client's readiness and self-efficacy for the changes that your client lists in the plan. For example, on a scale from 1 to 10 (1 = no confidence, 10 = most confidence), the client may rate himself as a "9" in regard to readiness for a making a particular change in behavior, but only as a "4" on self-efficacy. This could help you guide your client about where to start on the change plan.

Offering a Menu of Change Options

Researchers and clinicians working in the motivational framework find that one way to enhance motivation is to offer clients a choice from a variety of treatment alternatives. For example, a client who will not go to AA may go to a meeting of Rational Recovery or Women for Sobriety, if such groups are available. A client who will not consider abstinence may be more amenable to a "warm turkey" approach (Miller and Page, 1991), as described in Chapter 5. Encouraging clients to learn about treatment alternatives and to make informed choices enhances commitment to the change plan. Choices can be about treatment options or about other types of services.

No single approach to treating substance abuse works equally well for all clients. Determining what works best for whom and under what conditions can be a difficult undertaking. Evidence of treatment effectiveness is becoming increasingly specialized and, to some extent, more confusing, as more elements are added to evaluation formulas, including client characteristics, outcome measures, therapist qualities, treatment components, and quality of implementation.

Familiarity with the available treatment facilities in your community and with the relevant research literature pertaining to optimal choices for the types of clients you see is enormously helpful in providing your clients with appropriate options. It is also useful to know about the range of community resources in other service areas, such as food banks, job training programs, special programs for patients with coexisting disorders, and safe shelters for women in abusive relationships. A clinician who knows not only program names but also contact persons, program graduates, typical space availability, funding issues, eligibility criteria, and program rules and idiosyncrasies is an invaluable resource for clients. Additionally, knowledge about clients' resources, insurance coverage (or participation in some form of managed care), employment situation, parenting responsibilities, and other relevant factors is obviously crucial in considering alternatives. Information from an initial assessment is helpful, too, in establishing a list of possible treatment options and setting priorities.

Although you may have a wealth of knowledge about local resources, your program's administration has the final responsibility for developing liaisons with other agencies to ensure appropriate referrals for services and for keeping clinicians informed. In many places, a central agency compiles and regularly updates a comprehensive directory of community resources that contains information about services, costs, location, hours of operation, and eligibility criteria. Every program should have a manual of appropriate referral resources, with cross-references by program type, or should obtain current listings from local, State, or national sources (see Chapter 5 of TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [CSAT, 1997]). The Internet offers new possibilities for accessing information about community resources and for linking clients with programs and services. For example, in Washington, DC, a computer system linking criminal justice agencies with substance abuse treatment programs gives up-to-the-minute information about space availability and program changes. Workers in the justice system can set up intake appointments for clients online. Those in rural areas where resources are scarce may find the Internet especially valuable.

As you discuss treatment choices with clients, you can acquaint them with the concepts of levels of care, intensities of care, and appropriate fit. Do not, however, overwhelm them with a complicated description of all possibilities. Avoid professional jargon and technical terms for treatment types or philosophies. Limit options to several that are appropriate, and describe these, one at a time, in language that is understandable and relevant to individual concerns of clients. Explain what a particular treatment is intended to do, how it works, what is involved, and what clients can expect. Ask clients to postpone a decision about treatment until they understand all the options.

As each option is discussed, ask clients if they have questions and ask for their opinions about how they would handle each alternative. Although the goal is to choose the right approach initially, some clients may choose an option that you believe is inappropriate. Offer advice based on your clinical experience and knowledge of the research. You are searching for change strategies with which to begin, and, ideally, the client will view some appropriate options positively.

Treatment Options and Resources

In our alcohol treatment program, I found that having lists of both community resources and diverse treatment modules enables case managers to engage clients, offer individualized programming, and meet clients' multiple needs. The following are some options we offer our clients:

  • Values clarification/decisionmaking
  • Social skills training (assertiveness, communication)
  • Anxiety management/relaxation
  • Anger management
  • Marital and family therapy
  • Adjunctive medication (disulfiram [Antabuse], naltrexone [ReVia])
  • Problem-solving group
  • Intensive group therapy
  • Halfway houses
  • Support groups (AA, Narcotics Anonymous [NA], Rational Recovery, Women for Sobriety)
  • Social services (child care, vocational rehabilitation, food, shelter)
  • Medical care
  • Transportation
  • Legal services
  • Psychiatric services
  • Academic and technical schools

While you are exploring treatment options with a client, also review the concept of change as a wheel or cyclical process (see Chapter 1). Each person moves through the stages of change--forward or backward--over a substantial period of time (Prochaska and DiClemente, 1984; Prochaska et al., 1992b). This cycling sometimes takes the form of an upward spiral, with gradual improvement in the spacing, length, and severity of periods of problematic behavior (Miller, 1996). Because most people typically move around the cycle several times before exiting into stable recovery, let clients know that they should not become discouraged if their first treatment option does not work. Point out that, with all the possibilities, they are certain to find some form of treatment that will work. Reassure them that you are willing to work with them until they find the right choice.

Clients sometimes resist the idea that change is a cyclical process and prefer to view change as "all or nothing." The resistance may stem from fear that acknowledging the possibility of a lapse represents giving oneself permission to actually have one. It is of the utmost importance to convey to your clients that they can return to see you no matter what, even after a slip.

You also should be sensitive to the client who resists an idea you have found motivational for others. In this case, you might say, "It sounds like this issue is really important to you. Tell me more about that," or "It sounds like you would not want to go through that again, and I can understand why, at this point, you would not want to talk about those things. So, to help you with this, let me know how I can help you avoid the things that led to recurrence in the past, while at the same time help you avoid discussing the things that you do not think are helpful." The hope is that in discussing previous returns to problem behavior (while conveying your agreement with the client's wish that it not happen) you can "ease" into the possibility of recurrence and how to handle it.

Clinicians are accustomed to the idea that treatment success means completing a formal program and, conversely, dropping out means treatment failure. However, research has shown that a significant number of clients stop treatment because they do not need further help and can implement change on their own (DiClemente and Scott, 1997). Often, they only need assistance in maximizing their readiness to change and enhancing their motivation. No further aid is wanted--no negotiating, no plan, no contract--just encouragement and reassurance that they can return if they need more help. The danger is that some clients, such as those with a long history of excessive and relatively uninterrupted substance use, may take this opportunity to run away from treatment. When these clients suggest trying to change on their own, discuss your concerns about their leaving prematurely.

Several programs offer time-limited check-in modules to prepare clients for change. For example, a treatment program in Austin, Texas, periodically offers a 2-hour group for people who smoke. The program contains educational and motivational components as well as some elements of self-help through group support. Although participants are told how to access treatment if necessary, the group is designed to help participants initiate self-change. Research suggests that some people can change substance-dependent behaviors on their own without treatment (DiClemente and Prochaska, 1985; Klingemann, 1991; Sobell et al., 1993b; Tuchfield, 1981).

Developing a Behavior Contract

A written or oral contract is a useful tool for helping clients start on their change plans. A contract is a formal agreement between two parties. Literate clients may choose to make a signed statement at the bottom of the Change Plan Worksheet or may prefer a separate document. Explain to literate clients that other people have found contracts useful at this stage and invite them to try writing one. The act of composing and signing a contract can be a small but important ceremony of commitment. Avoid writing the contract for clients and encourage them to use their own words. With some, a handshake is an adequate substitute for a written contract, particularly with the client who lacks literacy.

Establishing a contract raises issues for fruitful discussion about your client's reasons for desiring change. Whom is the contract with? What parties does it involve? Some contracts include the clinician as a party in the contract, specifying the clinician's functions and responsibilities. Other clients regard the contract as a promise to themselves, to a spouse, or to other family members.

Contracts are often used in treatment programs that employ behavioral techniques. For many clinicians, contracts mean contingencies--rewards and punishments--and programs often build contingencies into the structure of their programs. For example, in many methadone maintenance programs, take-home medications are contingent on substance-free urine screens. Rewards or incentives have been shown to be highly effective reinforcers of abstinence. In a treatment program study of 40 cocaine-dependent adults (Higgins et al., 1994b), one group received vouchers exchangeable for retail items contingent on submitting cocaine-free urine specimens during weeks 1 through 12 of treatment. The other group received no vouchers. Seventy-five percent of the voucher group completed 24 weeks of treatment, compared with 40 percent of the control group, and the duration of continuous cocaine abstinence in the voucher group was nearly twice as long as that of the control group (11.7 weeks versus 6 weeks). See Chapter 7 for more discussion of incentives.

In developing a contract, the client may decide to include contingencies, especially rewards or positive incentives. Rewards can be highly individual. Enjoyable activities, favorite foods, desired objects, or rituals and ceremonies can all be powerful objective markers of change and reinforcers of commitment. Rewards can be tied to duration of abstinence, to anniversaries of the quit date, or to achievement of subgoals. One client might plan to spend the afternoon at a baseball game with his son to celebrate a month of abstinence. Another might buy a pair of red shoes after attending her 50th AA meeting. Still another might light a candle at church, and another might hike to the top of a nearby mountain to mark an improvement in energy and health.

Lowering Barriers to Action

Identifying barriers to action is an important part of the change plan. As clients decide what options are best for them, ask whether they anticipate any problems with those options or any obstacles to following the plan and achieving their goals: What could go wrong? What has gone wrong in past attempts to change? As mentioned earlier, certain clients resist the idea that something could go wrong. Here, it is better to get the information by asking about what has gone wrong in the past. It is sometimes easier to discuss past difficulties than to acknowledge the possibility of difficulties in the future.

One common barrier to action involves referring your client to another treatment program or other services following initial consultation or evaluation. When you refer clients, make sure they have all the necessary information about how to get to the program, whom and when to telephone, and what to expect during the call (e.g., what type of personal information might be requested). Giving your client "insider information" also reduces the client's anxiety and eases the way. For example, you may know that the receptionist at the program is a friendly person, or that many people get lost by entering the building on the wrong side, or that a nearby lunch counter serves good food. One inpatient program takes clients on field trips to the outpatient aftercare site before discharge to ensure a smooth transition.

Research has shown that giving the client a name and telephone number on a piece of paper is far less effective than more personalized referral methods (Miller, 1985b). Consider helping your client make the telephone call to set up the intake appointment at the chosen program. Some clients may want to make the phone call from your office, whereas others might wish to call the program from home and call you later to inform you that they made an appointment. Still others prefer to think things over first and make the call from your office at the next session. Let your clients know that you are interested in knowing how everything goes.

Anticipating problems

As suggested in the Change Plan Worksheet, one question to ask clients is, "If down the line the plan fails, what do you envision might be the cause?" Clients can predict some barriers better than you can, and it is important to allow them to identify and articulate these problems. Do not try to anticipate everything that could go wrong; focus on events or situations that are likely to be problematic and build alternatives and solutions into the plan.

Some problems may be clear from the outset. A highly motivated client sitting in your office may plan to attend an outpatient treatment program 50 miles away three times a week, even though such a plan involves both bus and train schedules and late-night travel. Referral to a less distant program may be the solution, although helping the client make some telephone calls to the program could identify a participant willing to provide a ride.

Recognizing barriers to action

Barriers to action are frequently encountered and should be discussed, if only briefly, when the change plan is being negotiated. Consider specific strategies and coping behaviors, and help clients explore what works best for them. Potential barriers exist in several areas.

Family relations can be critical barriers to initiating and maintaining action. A client's changed behavior may throw family relationships off balance, and problems that were suppressed as long as family dynamics centered on the substance use behavior may begin to surface. For example, the client may want to take back control. A wife who has made all family decisions by herself for a long time may react negatively to sharing power. A teenager who is used to coming and going unnoticed may rebel over a new curfew. Some family members may have deep resentment and criticism about the client's past behavior that they cannot wait any longer to express.

Such family disruptions and crises can contribute to a return to substance use, and clients can anticipate and learn specific strategies and coping behaviors to avoid such an outcome. Some clients may decide to institute a family meeting at a certain time each week for discussing problems and averting crises; the first one can be scheduled in your office. Some families benefit from more formal family therapy, which can be incorporated into the change plan. Other clients may identify a respected older person, such as a grandfather or friend, who would be willing and capable of acting as an arbiter in family disagreements. Also, people in recovery attend frequent meetings, which decreases the time they have available for family. Clients may consider attending meetings during the lunch hour or at other times that do not reduce family time. Sometimes, fellow attendees in AA and Narcotics Anonymous groups provide unsound advice that is not in the family's best interest. Another important issue is the rebonding of a relationship or a marriage. Usually the male client is eager to return to a sexual relationship, and the female is cautious because of the past pain and mistrust. The male then reacts to the tension that develops from not having a commitment for sexual activity from his partner. In some cases, sexual behavior is used as a device to control the recovering person, and when the expectations of the recovering person are not met, tension builds.

Health problems present obstacles to recovery for many clients with serious physical or mental health disorders. Some become sick after entering treatment; others have chronic conditions that require monitoring and treatment and can produce periodic health crises (e.g., HIV/AIDS, diabetes, hypertension). Clients may be in chronic pain from injuries or self-neglect (e.g., back pain, dental problems). Abstinence sometimes reveals underlying mental illnesses, such as depressive or psychotic disorders (see TIP 9, Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse [CSAT, 1994b]; and TIP 29, Substance Abuse Treatment for People With Physical and Cognitive Disabilities [CSAT, 1998a]). Medications taken for physical and mental health problems may cause distressing side effects.

All of these conditions and situations can increase the risk of returning to substance use. Although some of these problems cannot be anticipated, clients may have to build health supports and improvements into the plan. Some clients, especially those with strong concerns about their health, may wish to include a schedule for physical and dental checkups or arrangements with specific physicians and clinics for ongoing care of chronic problems. Subgoals for acquiring medical care may involve applying for entitlement programs or checking insurance coverage. A depressed client, for example, may plan to see a mental health worker for an evaluation if she is still feeling depressed after 30 days of abstinence, or she may decide to see one sooner if her symptoms increase the risk of returning to substance use. It should be reemphasized that some clients (e.g., those with coexisting disorders) need more intensive services.

System problems in the treatment program itself can be obstacles to immediate and sustained recovery. For example, many facilities have long waiting lists. Some programs require a great deal of paperwork to enter, which may put off clients with poor literacy skills. Clients with outstanding legal problems are not accepted in some programs. Financial support that clients counted on for treatment may disappear. For instance, a mother whose treatment is covered by Medicaid may lose her eligibility when she takes a higher paying job. Some highly motivated clients encounter significant language barriers at local programs if they do not speak English well. Clients with coexisting disorders who are on psychoactive medications may not be welcome at some AA groups.

Second thoughts and doubts occur to even the most highly motivated clients with carefully considered change plans. It is not uncommon to have an attack of regret or "cold feet." An expression used by AA members is "to come off the pink cloud." Second thoughts may emerge as soon as the client leaves your office--or several weeks into the change plan. Normalize this experience for clients and, at the same time, make specific plans for dealing with it. It is an important task to help clients overcome their doubts. You can insist that your client call you as soon as second thoughts arise or discuss other strategies such as attending extra AA meetings or calling a trusted support person (see below). Some clients keep a supply of disulfiram to use when they feel overwhelmed by urges and cravings.

Enlisting Social Support

Social support is an important influence on whether change happens and whether it is maintained (Sobell et al., 1993b). It is not sufficient to think of social support in terms of amount or even quality. When treating substance abuse, question whether the client's social support system is supporting continued substance use. For example, within Project MATCH, treatment outcomes were predictable from the extent to which the client's social network supported continued drinking or sobriety (Project MATCH Research Group, 1997a, 1997b). Those with good social support for sobriety fared better overall. Those whose social networks at intake supported continued drinking tended to have less abstinence at followup, with an important exception. These clients did much better if their treatment helped them get engaged in AA. In essence, AA provided them with a new social network supportive of sobriety (Project MATCH Research Group, 1997b). When your client has few or no significant others who are encouraging sobriety, it is important to help your client build a new social structure that will support the effort to change.

As a clinician, you are a central support for your clients, but you cannot provide all the support they need. In general, a supportive person is someone who will listen and not be overly judgmental (or who will at least withhold judgment). This supportive person should have a helpful and encouraging attitude toward the client, rather than being critical or nagging. Ideally, this person does not use or misuse substances and understands the processes of substance dependency and change. The Change Plan Worksheet (given in Figure 6-1) includes space for listing supportive persons and describing how they can help. As discussed in Chapter 4, concerned significant others can learn the skills and techniques of motivational interviewing and become effective partners in change.

Because social support often entails taking part with the client in activities that are alternatives to substance use, close friends with whom the client has a history of shared interests other than substance use are good candidates for this helpful role. Of course, members of social groups organized around drinking and drug use are not likely to offer the kind of support your client needs during recovery.

In addition to repairing or resuming ties with helpful family members and significant others, clients can find supportive people in, for example, churches, recreational centers, and community volunteer organizations. To make these connections, encourage clients to explore and discuss a time in their lives before substance use became a central focus. Ask them what gave meaning to their lives at that time.

Clients may find supportive new friends in such prosocial organizations as mentoring groups modeled after Big Brothers and Big Sisters. Fellow members of AA and other self-help groups are important supports in the lives of many recovering clients. Oxford Houses and similar treatment-housing options have built-in social support systems. For some clients, especially those with chronic physical problems or severe mental illness, case management teams provide a sense of safety, structure, and support.

When helping clients to enlist social support, be particularly alert for those who have poor social skills or scant social networks. Some clients may have to learn social skills and ways to structure leisure time, and such small steps can be incorporated into the change plan. Some clients may not be connected to any social unit that is not organized around substance use. Furthermore, substance dependency may have so narrowed their focus that they have trouble recalling activities that once held their interest or appealed to them. However, most people harbor secret, unfulfilled wishes to pursue an activity at some time in their lives. Ask about these wishes. One client may want to learn ballroom dancing, another to learn a martial art or take a creative writing class. Planning for change can be a particularly fertile time for clients to reconnect with such lost hopes, and pursuing such activities provides opportunities for making new friends.

Finally, in helping clients enlist social support, avoid the stereotype of the self-sufficient loner. Although early views of people with substance dependency characterized them as cut off from primary relationships and living a kind of "alley cat" existence, accumulating evidence from several countries indicates that most are closely tied to their families (Stanton, 1997). In fact, their rates of contact with family members--especially mothers--are often much higher than rates for adults with no substance use problems. In addition to presenting evidence of these close ties and of the effectiveness of family support, Stanton provides a valuable overview of seven approaches to engaging clients in treatment by enlisting the support of family members and significant others. Describing these methods is beyond the scope of this TIP; however, this review is a valuable reminder that stereotypes such as the loner are significant barriers to effective treatment (Stanton, 1997).

Educating Your Client About Treatment

To ensure a smooth transition into treatment, elicit and explore your clients' expectations to search for any misunderstandings or misinformation they may have. This step is called role induction, which is the process of educating clients about treatment and preparing them to participate fully and obtain what they need. Ask them to anticipate what feelings they might have when they attend group therapy or a self-help meeting. Role induction brings the expectations of the client in line with the realities of treatment and reduces the probability of surprises. Research consistently demonstrates that retention in treatment has a strong positive relation with a client's expectancy and that role induction prevents early dropout (Zweben and Li, 1981).

If you refer clients to another program, review with them what you know of its philosophy, structure, and rules, as well as any idiosyncrasies with which you may be familiar. Available videotapes can give clients some sense of what individual and group therapy is like, or what to expect when attending an AA or other 12-Step meeting. Most programs also conduct their own role induction. For example, at intake clients are given a list of their rights and responsibilities, including rules about involuntary discharge, and have an opportunity to discuss the list.

When providing information about a program, be sure to check with your client that nothing you have described will disrupt the change plan. Some aspects of the program, such as cost, a requirement to bring a significant other to certain meetings, or location, could cause clients to believe that the program will not work for them. They may be reluctant to bring up the issue after progressing so far in the change plan. Such reactions should be explored, especially in terms of recurrent ambivalence. Often they involve a misunderstanding about the program.

Another important aspect of role induction is educating clients about what to expect in terms of physical withdrawal from substances. The symptoms--or rebound reaction--can range from minimal to extremely difficult and prolonged. Accurate information helps give clients a sense of control, although many reactions are subjective and difficult to anticipate. Nevertheless, it is important to tell your clients that certain physical and psychological reactions to stopping substance use are normal and relatively predictable. For example, many former heroin users report that the fourth day of abstinence is the most difficult. Clients may have a strong and visceral reaction to the sight of needles. A television commercial that shows a white powdered detergent may produce urgent cravings. Protracted and unexpected withdrawal syndromes can occur as long as 30 days after last use of some substances, such as benzodiazepines and cocaine. Some clients have such vivid dreams of using substances that they awaken believing they have actually returned to substance use, with all the accompanying fears and confusion. During the first weeks of abstinence, some clients report feeling as if they are going crazy. Knowing what to expect, then, will provide them needed reassurance.

Initiating the Plan

Many change plans have a specific start date. Some clients like to mark this new beginning with a ritual that not only looks forward but also symbolically leaves old behaviors behind. For example, some may burn or ritually dispose of substance paraphernalia, cigarettes, beer mugs, or liquor. Depending on whether clients plan to continue regular treatment sessions with you, follow up on a referral, or initiate self-change, decide with them whether and how often they will check in with you. Alternatively, if they do not expect to continue in counseling with you, you may arrange to call them periodically to show your support and continuing interest.

Whatever the arrangements, all clients should leave your office with the understanding that they can return or call for additional encouragement and support, or renegotiate the change plan. Many programs have agreements about communicating with other facilities or services to which they refer clients in order to ascertain whether the transition is completed satisfactorily. If not, you should have a protocol for contacting clients who do not follow through on the referral and inviting them back for further help.

Clients with a carefully drafted change plan, a knowledge of both risky situations and potential barriers to getting started, and a group of supportive friends or concerned relatives should be fully prepared and ready to move into action.

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