Clarify the Client's Goals

Help the client set goals that are as realistic and specific as possible and that address the concerns he or she described earlier about substance use. The client may set goals in multiple areas, not just substance use. He or she may work toward goals such as regaining custody of children, getting a job, becoming financially independent, leaving an abusive relationship, and returning to school. The client who sets several goals may need help deciding which to focus on first.

Early on, goals should be short term, measurable, and realistic so that clients can begin measuring success and feeling good about themselves as well as hopeful about the change.

If goals seem unreachable to you, discuss your concerns. Use OARS (Open questions, Affirmations, Reflective listening, and Summarization) to help clients clarify their goals, decide on which goal to focus first, and identify steps to achieving their goals. For example, if one goal is to get a job, you can start with an open question: “What do you think is the first step toward meeting this goal?” The goal is the vision, and the steps are the specific tasks that clients perform to meet the goal.

Setting goals is a joint process. The counselor and client work together, moving from general ideas and visions to specific goals. Seeing how the client sets goals and the types of goals he or she sets provides information on the client's sense of self-efficacy, level of commitment, and readiness for change. The more hopeful a client feels about the future, the more likely he or she is to achieve treatment goals.

Make identifying and clarifying treatment goals a client-driven process. Doing so is consistent with the principles of person-centered counseling and the spirit of motivational interviewing (MI). It is up to the client to decide what actions to take or treatment options to seek to address a substance use problem. Matching the client to the preferred substance use disorder (SUD) treatment options can help reduce alcohol consumption and improve drug-related outcomes (Friedrichs, Spies, Härter, & Buchholz, 2016). In a systematic review, brief motivational alcohol interventions for adolescents had significantly larger effects on alcohol consumption if they included goal-setting exercises (Tanner-Smith & Lipsey, 2015).

Your task is to help clients identify their preferred change goals and to enhance their decision making by teaching them about their treatment options. (See Chapter 3 for more information about and strategies for identifying change goals using MI.)

Remember that the client's preferred treatment goals may not match what you prefer. A client might choose a course of action with which you do not agree or that is not in line with the treatment agency's policies. A decision to reduce but not completely stop substance use, for example, may go against the agency's policy of zero tolerance for illicit substance use. Exhibit 6.2 offers some strategies for addressing these types of situations.

Box

EXHIBIT 6.2. When Treatment Goals Differ.

Figure

Sample Goals and Encourage Experimenting

You may need to help some clients sample or try out their goals before getting them to commit to long-term change. For instance, some clients benefit from experimenting with abstinence or cutting down their substance use for a short period. The following approaches to goal sampling may be helpful for clients who are not committed to abstinence as a change goal:

•

Sobriety sampling. This trial period of abstinence is commonly used with clients who (Boston Center for Treatment Development and Training [BCTDT], 2016):

-

Are not interested in abstinence as a treatment goal.

-

Express significant need or desire to address misuse but are not ready to commit to abstinence.

-

Have had many past unsuccessful attempts at moderate use.

A successful trial of sobriety sampling can enhance clients' commitment to a goal of abstinence. Even a 2-to-3-week period of abstinence before treatment can lead to positive client outcomes, including reductions in alcohol misuse (Gueorguieva et al., 2014). However, longer periods of trial abstinence may give clients more of an opportunity to experience the benefits of abstinence, like clearer thinking, a better ability to recognize substance use triggers, and more time to experience the positive feeling of living without substance use (BCTDT, 2016).

•

Tapering down. This approach has been widely used with people who smoke to reduce physical dependence and cravings before the quit date and is an option for some substances like alcohol or cannabis. This approach consists of setting increasingly lower daily and weekly limits on use of the substance while working toward a long-range goal of abstinence. The client keeps careful daily records of consumption and schedules sessions with the counselor as needed. Tapering off opioids, benzodiazepines, or multiple substances should be done under medical supervision.

•

Trial moderation. Trial moderation (i.e., clients try to reduce substance use with careful monitoring) may be the only acceptable goal for some clients who are in Precontemplation. Don't assume that clients will fail at moderation; however, if the moderation experiment fails after a reasonable effort, try to get clients to reconsider abstinence as a change goal. Clients can gain insight into their ability to reduce their substance use, and many will ultimately decide to abstain if they cannot reduce their use without negative consequences. Research indicates that clients whose goal is moderation have larger social networks of people who drink daily (Gueorguieva et al., 2014). Therefore, you should address clients' drinking social network as a potential barrier to moderation as a long-term goal.

Elicit Change Strategies From the Client

Work with clients to develop a change plan by eliciting their own ideas about what will work for them. This approach is a particularly helpful if clients have made past attempts to address substance use behaviors or have been in treatment before. For example, you might begin with a reflection of commitment talk and follow with an open question: “You clearly think that giving up cocaine is the best thing for you right now. What steps do you think you can take to reach this goal?”

Help clients create plans to match their concerns and goals. Plans will differ among clients:

•

The plan can be very general or very specific and can be short term or long term.

•

Some clients can commit only to a very limited plan, like going home, thinking about change, and returning on a specific date to talk further. Even a small, short-term plan like this can include specific steps for helping clients avoid high-risk situations as well as identifying specific coping strategies.

•

Some plans are very simple, such as stating only that clients will enter outpatient treatment and attend an Alcoholics Anonymous (AA) meeting every day.

•

Other plans include details (e.g., transportation to treatment, new ways to spend weekends).

•

Many plans include specific steps to overcome anticipated barriers to success (Exhibit 6.3). 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.

Box

EXHIBIT 6.3. Change Plan Worksheet.

Figure

Create a change plan using a joint process in which you and the client work together. One of your most important tasks is to ensure that the plan is realistic and can be carried out. When the client offers a plan that seems unrealistic, too ambitious, or not ambitious enough, use shared decision making to rework the plan. The following areas are often part of such discussions:

•

Intensity and amount of help needed. Encourage participation in community-based recovery support groups (e.g., AA, Narcotics Anonymous [NA], SMART Recovery, Women for Sobriety), enrolling in intensive outpatient treatment (IOP), or entering a 2-year therapeutic community.

•

Timeframe. Choose a short-term rather than a long-term plan and a start date for the plan.

•

Available social support. Discuss who will be involved in treatment (e.g., family, Women for Sobriety members, community members), where it will take place (e.g., at home, in the community), and when it will occur (e.g., after work, weekends, twice a week).

•

The order of subgoals and strategies or steps in the plan. For example:

1.

Stop dealing marijuana.

2.

Stop smoking marijuana.

3.

Call friends or family to tell them about the plan.

4.

Visit friends or family who know about the plan.

5.

Learn relaxation techniques.

6.

Use relaxation techniques when feeling stressed at work.

•

Ways to address multiple problems. Consider legal, financial, and health problems, among others.

Clients may ask you for information and advice about specific steps to add to the plan. You should:

•

Ask permission to offer advice.

•

Use the Elicit-Provide-Elicit (EPE) approach to keep the client in the center of the conversation (see the section “Developing discrepancy: A values conversation” in Chapter 3).

•

Provide accurate and specific facts, and always ask whether they understand them.

•

Elicit responses to such information by asking, “What do you think about this?”

The last step in EPE is key to completing the information exchange between you and the client.

How specific 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 share your own views and opinions, although it is helpful to “soften” your statements and give clients permission to disagree. For example, you might soften your suggestion by saying, “This may or may not work for you, but a lot of people find it helpful to go to NA meetings to meet others who are trying to stay away from cocaine.” Other techniques of MI, such as developing discrepancy, empathizing, and avoiding arguments, also are useful during this process.

The Change Plan Worksheet in Exhibit 6.3 helps clients focus their attention on the details of the plan, increase commitment to change, enlist social support, and troubleshoot potential roadblocks to change.

Use the Importance and Confidence Rulers in Exhibit 3.9 and Exhibit 3.10 to determine the client's readiness and self-efficacy about each change goal. These tools can help you and the client determine which goals to address first and which strategies to begin with. Ideally, the top goal will be one with higher ratings on both importance and confidence. If the client rates one goal as high in importance and low in confidence, focus on exploring self-efficacy and evoking confidence talk to prepare the client for taking action.

Offer a Menu of Change Options

Enhance clients' motivation to take action by offering them a variety of treatment choices.

Choices can be about treatment options or about other types of services. For example, clients who will not go to AA meetings might be willing to go to a Rational Recovery, SMART Recovery, or Women for Sobriety group; clients who will not consider abstinence might be willing to decrease their consumption. Encourage clients to learn about their options and make informed choices to enhance their commitment to the change plan.

Box

EXPERT COMMENT: TREATMENT OPTIONS AND RESOURCES.

Know your community's treatment facilities and resources. This helps you provide clients with suitable options and makes you an invaluable resource for clients. Offer clients information on:

•

Specific contact people.

•

Program graduates.

•

Typical space availability.

•

Funding issues.

•

Eligibility criteria.

•

Program rules and characteristics.

•

Community resources in other service areas, such as:

-

Food banks

-

Job training programs

-

Special programs for clients with co-occurring medical and mental disorders

-

Safe shelters for clients experiencing intimate partner violence

In addition, knowledge about clients' resources, insurance coverage, job situation, parenting responsibilities, and other factors is crucial in considering options. Initial assessment information also helps establish treatment options and priorities.

When discussing treatment options with clients, be sure to:

•

Provide basic information in simple language about levels, intensities, and appropriateness of care.

•

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 matches clients' concerns.

•

Describe the purpose of a particular treatment, how it works, and what clients can expect.

•

Ask clients to wait to make a decision about treatment until they understand all the options.

•

Ask clients if they have questions, and ask their opinions about how to handle each option.

•

Review the concept of the SOC; note that it is common for people to go through the stages several times as they move closer to maintaining substance use behavior change and stable recovery.

•

Remind clients that not completing a treatment program and returning to substance use are not failures, but opportunities to reevaluate which change strategies are working or not working.

•

Point out that, with all the options, they are certain to find some form of treatment that will work.

•

Reassure clients that you are willing to work with them until they find the right choice.

Exhibit 6.4 provides a change-planning strategy for situations with many possible change options.

Box

EXHIBIT 6.4. Mapping a Path for Change When There Are Multiple Options.

Negotiate a Behavioral Contract

Develop a written or oral contract to help clients start working on their change plans. A contract is a formal agreement between two parties. Clients may choose to make a signed statement at the bottom of the Change Plan Worksheet or may prefer a separate document. Be sure to:

•

Explain that others have found contracts useful at this stage, and invite them to try writing one.

•

Avoid writing contracts for clients. Composing and signing it is a small but important ritual of “going public” that can enhance commitment (Connors, DiClemente, Velasquez, & Donovan, 2013).

•

Encourage clients to use their own words.

•

Be flexible. With some clients, a handshake is a good substitute for a written contract, particularly with clients who have challenges with reading and writing or whose first language is not English.

Establishing a contract raises issues for discussion about the client's reasons for change. What parties does the contract involve? Some contracts include the counselor as a party in the contract, specifying the counselor'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, such as contingency management (CM). For many counselors, contracts mean contingencies (i.e., rewards and consequences), 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 urinalyses. Rewards or incentives have been shown to be highly effective external reinforcers. For instance, CM rewards are effective in reducing use and misuse of a range of substances including alcohol, tobacco, cannabis, and stimulants, as well as polysubstance use (Ainscough, McNeill, Strang, Calder, & Brose, 2017; Litt, Kadden, & Petry, 2013; Sayegh, Huey, Zara, & Jhaveri, 2017).

Clients may decide to include contingencies, especially rewards or positive incentives, in the contract. Rewards can:

•

Be highly individual.

•

Include enjoyable activities, favorite foods, desired objects, or rituals and ceremonies, all of which can be powerful objective markers of change and reinforcers of commitment.

•

Be tied to length of abstinence, quit-date anniversaries, or achievement of subgoals. For instance:

-

A client may plan an afternoon at a baseball game with her son to celebrate a month of abstinence.

-

One client might go out to dinner with friends after attending his 50th AA meeting.

-

Another client may light a candle at church.

-

Still another client might hike to the top of a nearby mountain to mark an improvement in energy and health.

Explore and Lower Barriers to Action

One category in the Change Plan Worksheet in Exhibit 6.3 addresses possible obstacles to change and ways to handle them. Identifying barriers to action is an important part of the change plan. Potential roadblocks to taking action on change goals might include:

•

A lack of non-substance-using social supports.

•

Unsupportive family members.

•

Co-occurring medical or mental disorders.

•

Distressing side effects from medication-assisted treatment or psychiatric medications.

•

Physical cravings or withdrawal symptoms.

•

Legal issues, money-related problems, or both.

•

Lack of child care.

•

Transportation issues.

•

A lack of cultural responsiveness of some agencies, programs, or services.

Clients can predict some barriers better than you can, so allow them to identify and discuss possible problems. Specifically:

•

Do not try to predict everything that could go wrong.

•

Focus on events or situations that are likely to be problematic.

•

Build alternatives and solutions into the plan.

•

Before offering advice, explore clients' ideas about how they might handle issues as they arise.

•

Explore the ways clients may have overcome these or similar barriers in the past. This is a way to open a conversation about their strengths and coping skills.

Some problems are evident immediately. For instance, a highly motivated client may plan to attend an IOP treatment program 50 miles away 3 times a week, even though this requires bus and train rides and late-night travel. Explore the pros and cons of this part of the change plan with the client, and brainstorm alternative solutions, like finding a program closer to home or a family member, case manager, peer support specialist, or program volunteer who can drive the client to the program. Remember, the change plan should include strategies that are accessible, acceptable, and appropriate for each client.

You may need to refer clients to another treatment program or other services following initial consultation or evaluation, but this too is another common barrier to action. When you refer clients:

•

Ensure they have information about how to get to the program, whom and when to telephone, and what to expect on the call (e.g., what type of personal information may be requested).

•

Give them any “insider information” you have about the program or provider, which can reduce clients' anxiety and makes the process easier. 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 diner serves good food.

•

Use active linkage and referral interventions, which enhance client engagement and retention in SUD treatment and ancillary services and improve outcomes (Rapp, Van Den Noortgate, Broekaert, & Vanderplasschen, 2014). Strategies for active referral procedures include:

-

Helping the 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; others might wish to call from home and call you later to tell you that they made an appointment. Some clients prefer to think things over first and make the call from your office at the next session.

-

Following up with clients and the program, if possible and with client permission, to ensure that clients are connected to the new service.

-

Offering a “warm handoff,” if possible, which involves introducing clients to the new provider.

-

Linking clients to a case manager, peer recovery support specialist, program alumnus, or community-based recovery support group volunteer to act as a liaison and actively engage clients in treatment programs; social, legal, or employment services; or community-based recovery support programs.

Enlist Social Support

Help clients enlist social support and build or enhance social networks that support recovery from SUDs. Positive social support for substance use behavior change is an important factor in clients' initiating and sustaining behavior change (Black & Chung, 2014; Fergie et al., 2018; Rhoades et al., 2018).

As a counselor, you are a central support for clients, but you cannot provide all the support they need. In general, a supportive person is someone who will listen and not be judgmental. This supportive person should have a helpful and encouraging attitude toward clients. Ideally, this person does not use or misuse substances and understands the processes of addiction and change. The Change Plan Worksheet (Exhibit 6.3) includes space for listing supportive individuals and describing how they can help. As discussed in Chapter 4, concerned significant others can offer support by learning some MI skills (e.g., offering simple reflective listening responses, becoming effective partners in change).

Encourage clients to include social support strategies in their change plans. These include:

•

Engaging in activities with friends that don't involve substance use. Social support often entails participating in non-substance use activities, so close friends with whom clients have a history of shared interests other than substance use are good candidates for this helpful role. Members of social groups who drink and use drugs are not likely to offer the support clients need in recovery.

•

Repairing or resuming connections with supportive family members and significant others. Clients can find supportive people among their family members and close friends as well as in faith-based and spiritual organizations, 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.

•

Participating in AA or other recovery support groups. Recovery groups provide clients with social support for behavior change, positive role models of recovery, recovering friendship networks, and hope that recovery is possible. Research confirms that participation in AA is associated with positive alcohol-related, psychological, and social outcomes (Humphreys, Blodgett, & Wagner, 2014).

•

Connecting with addiction-focused peer support. Peer recovery support specialists can be recovery role models and an important source of social support for clients. Client participation in peer recovery support services with a peer specialist leads to positive social support and improved substance use outcomes, including decreased alcohol use and hospitalizations as well as better adherence to treatment goals after discharge (Bassuk, Hanson, Greene, Richard, & Laudet, 2016). Oxford Houses and similar sober living housing options have built-in social support systems.

•

Connecting clients with a case manager. For some clients, especially those with chronic medical or serious mental illness, case management teams provide a sense of safety, structure, and support. A case manager can also actively link clients to community-based social services, federal and state financial assistance, and other ancillary services that support clients' recovery efforts.

When helping clients enlist social support, be particularly alert for clients who have limited social skills or social networks. Some clients may have to learn social skills and ways to structure leisure time. Add social skill-building steps into the change plan. Some clients may not be connected to any social network that is not organized around substance use. Furthermore, addiction may have so narrowed their focus to the point where they have trouble recalling activities that once held their interest or appealed to them. However, most people have unfulfilled desires 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 still another to take a creative writing class. Planning for change can be a particularly productive time for clients to reconnect with this desire to find fulfilling activities, and seeking such activities provides opportunities for making new friends.

Clients with a carefully drafted change plan, knowledge of both high-risk situations and potential barriers to getting started, and a group of supportive friends, family members, or recovery supports should be fully prepared and ready to move into the Action stage.