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Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2008. (Treatment Improvement Protocol (TIP) Series, No. 48.)

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Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery.

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Appendix C—Fidelity Checklists

Fidelity Checklist 1: General Underlying Principles

Adherent Behaviors

____ Respect is apparent when the counselor (1) shows respect for a variety of plans about how change can occur and (2) can accept differences between the ideal plan and the plan the client is willing to endorse. Counselors high in respect can negotiate with the client and avoid an authoritarian stance.

____ Understanding is apparent when counselors have a stance that is curious and patient and emphasizes drawing out clients' ideas rather than educating clients or giving opinions without being asked.

____ Accepting counselors accept that a client may choose not to change. They are invested in specific behavior changes, but they convey an understanding that the critical variables for change are within the client and cannot be imposed by others.

____ Strengths-based counselors focus on identifying, enhancing, and using the client's strengths as the foundation for the client's plan to create positive change. The counselor understands that the client must believe he or she is able to make a change to maintain motivation to make the change.

____ Commitment to follow up on the planned activities between sessions is elicited by the counselor by summarizing the client's stance on the issue, framing the next steps, asking the client whether the plan is acceptable, and making any necessary changes to the plan.

Nonadherent Behaviors

____ Low respect is evident when the counselor's stance is rigid and authoritarian and little effort is made to include the client's ideas about how change might be accomplished. It includes attempts to persuade clients about the need for change and occasions when clinicians confront clients with their point of view.

____ Low understanding is evident when the counselor neglects the task of eliciting the client's verbalizations about need for change. The counselor might convey cynicism about the client's desire for change or focus on giving information or educating the client.

____ Low accepting counselors convey a sense of urgency about the need for change. They have difficulty accepting that clients might choose to avoid or delay change or decide to proceed with change in an unconventional manner.

____ Low strengths-based counselors neglect to elicit and incorporate client strengths in the plan for change. Counselors base the plan for change on client weaknesses instead of strengths.

____ Low commitment to follow up on the planned activities is evident when the counselor assigns homework without eliciting and summarizing the client's stance on the issue and making any necessary changes to the plan.

Fidelity Checklist 2: Behavioral Techniques

Adherent Behaviors

____ Identifies specific behaviors that the client identifies as wanting to change. Helps the client identify what to do instead of what not to do. Understands the value of collaborating with the client to find alternative behaviors that are reinforcing to the client.

____ Helps the client set achievable goals for behavioral change. Helps the client to take big changes and break them down into smaller changes that can be more easily accomplished and maintained. Understands that the client will continue a behavior until there is good reason to believe that another behavior will be equally satisfying or reduce anxiety.

____ Helps the client find the support needed to plan for, initiate, and maintain behavioral changes. Helps the client find internal and environmental resources that will help him or her develop and maintain the motivation necessary to sustain behavioral changes.

____ Collaborates with the client on specific behavioral interventions (e.g., mild or moderate physical exercise, getting adequate rest, managing stress).

Nonadherent Behaviors

____ Neglects to identify specific behaviors for change. Focuses on what the client is feeling or thinking instead of identifying specific behaviors. Or, chooses to focus on changing a behavior the client does not identify as important to change. Does not understand the role of reinforcement in the role of behavior change.

____ Neglects to break big changes down into manageable goals. The counselor expects the client to take on more than the client feels able to take on. Or, the counselor expects the client to replace a reinforcing behavior with a behavior that is less reinforcing or is aversive.

____ Neglects to help the client find the support he or she needs to initiate and maintain behavioral changes. Does not understand the role of aversive experiences in causing clients to avoid making change.

____ Neglects to identify specific behavioral interventions. Instead offers other types of interventions (e.g., cognitive, affective).

Fidelity Checklist 3: Cognitive Interventions

Adherent Behaviors

____ Identifies automatic thoughts that are evoked by unpleasant events. Specifically, negative thoughts about self (e.g., worthlessness), the world (e.g., negative interpretation of experiences), and the future (e.g., expectation of failure).

____ Collaborates with the client to determine whether the client's negative thinking is inaccurate.

____ Elicits from the client the link between negative thoughts and increased feelings of depression and less functional behaviors. Increases client's objectivity about his or her thoughts and helps the client differentiate between unrealistic and realistic meanings of events.

____ Uses cognitive techniques such as searching for alternative explanations or assessing for negative self-talk, and offers reasonable responses to decrease the client's distress.

____ Discusses homework, including understanding obstacles to completing homework.

Nonadherent Behaviors

____ Focuses on feelings or behaviors instead of identifying automatic thoughts, or identifies automatic thoughts that are not connected to the unpleasant event or feeling.

____ Tells the client that his or her negative thinking is inaccurate instead of collaborating with the client to come to this conclusion.

____ Tells the client about the link between negative thoughts and increased feelings of depression/less functional behaviors, instead of eliciting an understanding of the link from the client. Does not increase the client's objectivity about his or her thoughts, and does not help the client differentiate between unrealistic and realistic meanings of events.

____ Uses techniques other than cognitive techniques (e.g., affective techniques).

____ Assigns homework but does not review it.

Fidelity Checklist 4: Beliefs Interventions

Adherent Behaviors

____ Listens carefully to identify the underlying meaning of what the client is saying.

____ Elicits the meaning the client attaches to negative events.

____ Identifies core beliefs (e.g., extreme, negative, categorical, absolute, and judgmental meanings areattached to negative events) that lead to the conclusion that the client can't take care of the problem.

____ Facilitates the client's objective assessment of his or her core beliefs.

____ Elicits from the client alternative beliefs or solutions.

____ Elicits from the client the link between the client's behavior and feelings and the client's underlyingbeliefs about self.

____ Elicits from the client possible experiments with new solutions to the problem and ways to test out beliefs.

____ Discusses homework, including understanding obstacles to completing homework.

Nonadherent Behaviors

____ Does not identify the underlying meaning of what the client is saying.

____ Tells the client how to interpret negative events.

____ Does not identify the core beliefs leading to the client's conclusion that the client won't be able to take Care of the problem.

____ Tells the client that his or her core beliefs are irrational.

____ Tells the client what the client should believe.

____ Tells the client that the client's behavior and feelings are linked to underlying beliefs about self instead of eliciting this from the client.

____ Tells the client what experiments or new solutions to the problem to test out.

____ Assigns homework but does not review it.

Fidelity Checklist 5: Affective Interventions

Adherent Behaviors

____ Identifies the feelings that the client finds too painful, overwhelming, or unmanageable to express.

____ Conceptualizes the client's behaviors (e.g., avoidance, controlling, substance use, difficulty asking for help) as arising from the need to avoid these feelings.

____ Assists the client in creating a safe enough environment in the counseling session to explore these feelings without having to resort to the use of defenses (e.g., isolating, projecting, drinking).

____ Addresses defenses when the client feels comfortable enough to examine them without needing to become more defensive.

____ Works at the client's pace toward the goal of helping the client become comfortable with expressing the feelings that are being avoided.

____ Demonstrates the ability to help the client pull back from intense feelings and helps the client experience and resolve grief.

Nonadherent Behaviors

____ Does not identify the feelings that the client finds too painful, overwhelming, or unmanageable to express.

____ Conceptualizes the client's behaviors (e.g., avoidance, controlling, substance use, difficulty asking for help) as arising from reasons other than the need to avoid these feelings.

____ Rather than facilitate the client's creation of a safe place to explore these feelings, takes responsibility for creating this environment without regard for the client's concerns.

____ Addresses defenses at times when the client is not comfortable enough to examine them.

____ Works toward a different goal than the goal of helping the client become comfortable with experiencing the feelings that are being avoided.

____ Does not appear to know how to help the client pull back from intense feelings or experience and resolve grief.

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