Developing a Coping Plan

You can conduct functional analyses and develop coping strategies for every treatment goal. This approach addresses many factors that influence the well-being of the client trying to cope with recovery.

Developing a coping plan is a way of anticipating problems before they arise and of recognizing the need for a repertoire of alternative strategies (see Figure 7-2). A list of coping strategies that others have found successful can be particularly useful in developing a plan and in brainstorming ways to deal with anticipated barriers to change.

One way to help your client learn how to develop coping strategies is to conduct a functional analysis on a pleasurable activity. The process of developing a coping plan provides an opportunity for positive reinforcement.

You can use the activity to boost a client's self-esteem by saying, "What can we learn about where you are in recovery from your actions? For example, when you went to the trigger location and didn't use alcohol, how did you do it?" You can point out that something must have changed if the client can now go into a bar or restaurant and not drink.

However, explore the motivation for going to the bar and ascertain whether there is a good reason or whether the behavior is reckless. A client who has developed sound coping strategies should be conscious of the danger, but not reckless.

Occasionally, you may find that your clients have not pursued the new activities you have suggested. In these situations, strategies similar to those suggested earlier for a missed appointment may help strengthen coping strategies. Reevaluate the plan and modify it as necessary. Ask your client to rehearse coping strategies while in a counseling session and then try to implement the strategy in the real environment.

Ensuring Family and Social Support

Clients are embedded in a social network that can be either constructive or destructive. One task for you and your client is to determine which social relationships are supportive and which are risky.

Substance-free family and friends can be especially helpful in stabilizing change because they can monitor the client and model and reinforce new behavior. They can keep track of the client's whereabouts and activities, involve the client in new social and recreational activities, and be a source of emotional and financial support. Other types of support are instrumental (e.g., babysitting, carpooling), romantic, spiritual, and communal (i.e., belonging to a particular group or community).

Sources of support, however, also can be stressors--for example, if a female client has family members who both depend on her and support her. Support can have costs that sometimes leave your client feeling, "Now I owe you." Help the client pinpoint the reasons for using or not using different sources of support. Ask clients the following questions:

What kinds of support do you want?
What sources of support do you have?
What holes are there in your network of support?

By identifying the array of support sources your client has available, you can help determine any gaps in the support system. At the same time, caution the client not to rely too heavily on any one source of support. Next, you can help the client develop an early warning system with a partner or significant other; this person can learn to recognize the triggers and signs that your client is returning to substance use and can intervene effectively (Meyers and Smith, 1997). In a 12-Step program, the sponsor fills this role.

Try to ascertain what clients are willing to change in their lives. How your clients want to make changes and what timing is appropriate are of particular concern. In many communities, although it can be dangerous to interact with active users in terms of triggers and ready access, for some clients it is just as dangerous to cut ties with their substance-using social network.

Sometimes, heroin users will welcome a member of the group who has stopped using back into the network. Clients who use substances have to be innovative in coming up with solutions to unique problems. Clients surrounded by substance-using friends may have to have acceptable reasons to offer as to why they are not currently using substances--for example, the client's wife is pregnant and can't use, or the client must submit drug-free urine regularly to keep a job.

Your clients also need help in figuring out how to handle drug suppliers. Assist them in describing the nature of these relationships and the level of emotional support provided. Some clients do not really know the meaning of friendship--what they can expect or count on for support as well as their reciprocal responsibilities.

Use motivational interviewing techniques to develop discrepancies, find out what clients intend and are willing to do to decrease perceived discrepancies, and introduce the concept of setting boundaries. The case studies in Figures 7-3,7-4, and 7-5 depict different support scenarios you and your clients may encounter.

Involving a spouse or significant other in the treatment process also provides an opportunity for a firsthand understanding of the client's problems. The significant other can offer valuable input and feedback in the development and implementation of treatment goals. Additionally, the client and the significant other can work collaboratively on issues that might stand in the way of attainment of treatment goals.

Project MATCH, a multisite clinical trial of patient-treatment matching sponsored by the National Institute on Alcohol Abuse and Alcoholism, included motivation enhancement therapy (Miller et al., 1992). In this trial, the greatest number of subjects chose spousal support as the maintenance factor most helpful in maintaining their resolution to change. This finding is consistent with those of treatment studies and natural recovery studies that family environment is one of the most notable factors associated with positive outcomes (Azrin et al., 1982; Sobell et al., 1993b).

Finally, some therapists model social behaviors in public for their clients as part of therapy. Examples would include modeling the behavior and skills required for everyday activities, such as opening a bank account or going grocery shopping. Some theoreticians argue that providing realistic in vivo guidance is preferable to rehearsed and stilted play-acting in the office.

Whether or not you choose to provide this type of "help" depends, of course, on your therapeutic orientation, guidelines, program policies, and awareness of the client's cultural mores. Before undertaking such a strategy you should carefully think through it, weighing the benefits versus the potential harm and discussing the plan with your supervisor. For example, going out with a client can be easily misinterpreted by the client as an act of friendship or even intimacy rather than therapy. This can lead to boundary and therapeutic relationship problems that can put both you and your client in awkward situations that complicate treatment.

Developing and Using Reinforcers

After clients have planned for stabilization by identifying risky situations, practicing new coping strategies, and finding sources of support, they still have to build a new lifestyle that will provide sufficient satisfaction and compete successfully against the lure of drug use. Ultimately, a broad spectrum of life changes must be made if the client is to maintain lasting abstinence.

These changes must be adequately extensive and pervasive so that they supplant the client's former substance-using lifestyle. This represents a formidable task for the client whose life has become narrowly focused on acquiring and using substances. You can support this change process by using competing reinforcers and external contingent reinforcers in the early phases of treatment to encourage positive behavioral change.

Natural Competing Reinforcers

Competing reinforcers are effective in reducing substance use. A competing reinforcer is any source of satisfaction for the client that can become an alternative to drugs or alcohol. Research has demonstrated, for example, that laboratory animals are less likely to begin and continue taking cocaine when an alternative reinforcer (in this case, a sweet drinking solution) is available in their cages (Carroll, 1993).

This principle applies to humans as well; other studies in laboratory settings have shown that if given a choice between substances and money, people will choose to forgo substances when the alternative is sufficiently attractive (Hatsukami et al., 1994; Higgins et al., 1994a, 1994b; Zacny et al., 1992).

Clearly, people do make choices about their substance use, and it helps when the alternative choices are explicit, immediately available, and sufficiently attractive to compete with substance use. This is the ideal you are trying to work toward, and external reward systems can be especially helpful. (See the section on the voucher incentive system later in this chapter.)

The essential principle in establishing new sources of positive reinforcement is to get clients to generate their own ideas. You can guide them toward social reinforcers, recreational activities, 12-Step programs, and other positive behavioral reinforcements by developing a list of common pleasurable activities (Meyers and Smith, 1995).

Couples therapy is useful to help clients reconnect to things they used to do before they became heavily involved in substance use, or to activities that never occurred during a couple's relationship because they came together as a substance-using couple.

It is important to examine all areas of a client's life for new reinforcers, which should come from multiple sources and be of various types. Thus, a setback in one area can be counterbalanced by a positive reinforcer from another area.

Additionally, because clients have competing motivations, help them select reinforcers that will prevail over substances over time. Especially when substances permeate their lives, stopping can be a fundamental life change. As the motivation for positive change becomes harder to sustain, clients need strong reasons for overcoming the challenges they will face.

Small steps are helpful, but they cannot fill a whole life. Abstaining from substances is an abrupt change and often leaves a large blank space to fill. You can help your client fill this void by suggesting potential activities, such as the following:

Do volunteer work. This alternative is a link to the community. The client can fill time, reconnect with prosocial people, and improve self-efficacy. Volunteering is a direct contribution that can help resolve guilt the client may feel about previous criminal or antisocial behavior.

For example, a California program for Hispanics and African-Americans in recovery involved clients in a door-to-door survey, collecting data for the community and identifying people in crisis following the Los Angeles earthquake. Although the clients themselves did not get a monetary reward, the community benefited, and the daily debriefing solidified clients' commitment to their recovery by affirming their ability to help someone else.

Become involved in 12-Step activities. Similar to volunteering, this fills a need to be involved with a group and contribute to a worthwhile organization.
Set goals to improve work, education, health, and nutrition.

Spend more time with family, significant others, and friends.

Participate in spiritual or cultural activities.

Learn new skills or improve in such areas as sports, art, music, and hobbies. In the Native American community, for example, counselors take clients to the country and teach them about the gifts of nature (e.g., herbs, trees, animals) and how these gifts contribute to healing and continued recovery.

Clients do not have to make a big commitment or investment; they can just sample available opportunities (Meyers and Smith, 1997). Peer acceptance and meeting peer expectations within the context of a residential treatment or high-functioning therapeutic group serve as reinforcement. People in 12-Step programs, for example, try to excel in a newfound social network with the goal of reaching an altruistic state in the 12th step.

External Contingent Reinforcers

The principles of contingent reinforcement can be applied to sustain abstinence while clients work on building a substance-free lifestyle. The specific awards chosen can be tailored to the values of the clients and resources of the program. Besides natural reinforcers, some programs have used temporary contingencies to change substance use.

Voucher incentive programs have several benefits that recommend their use. First, they introduce a clear and systematic point system that provides structure and clarifies expectations for both clients and staff. Second, they allow clients to select for themselves the rewards that they find desirable, which should maximize the effectiveness of the procedure.

Finally, voucher systems have been tested in research and shown to be effective (Budney and Higgins, 1998). Because it may take some time to establish the other new behaviors, these programs probably should be in place a minimum of 3 to 6 months.

Voucher incentives

Voucher programs are a type of contingency reinforcement system, and research has shown that they can be effective for sustaining abstinence in substance users. The rationale is that an appealing external motivator can be an immediate and powerful reinforcer to compete with drug reinforcers. Because a common correlate of substance addiction is the need for immediate gratification, vouchers and other incentives can be used to satisfy this need appropriately.

The reinforcers used in voucher incentive programs should be attractive and engaging to the individual client. Research has demonstrated that money or an equivalent alternative is nearly always appealing. Vouchers are slips of paper showing points the client has earned for abstinence. Each point has a cash value (e.g., $1).

Additional points are accumulated each time the client submits drug-free urine, for example. The voucher acts as an IOU from the program. In a typical voucher system, clients trade in their points for goods and services. Clients often want to pay bills with their voucher or spend their money on retail purchases (e.g., groceries, clothing, shoes).

Staff members arrange to pay the bills and purchase these items. An alternative to this system is to give the clients cash and let them make the purchases themselves. This is a risky option, however, because clients could use the money to buy substances. Therefore, the extra work for staff can be worth the effort.

Research has shown that voucher reinforcers work well to promote treatment retention and sustained abstinence among cocaine abusers enrolled in outpatient treatment.

For example, Higgins and colleagues, who developed and tested voucher incentives, showed that this procedure combined with an intensive behavioral counseling program could retain between 60 and 75 percent of cocaine abusers in an outpatient treatment program for 6 months (Higgins et al., 1993, 1994b).

In contrast, control patients in the investigators' clinic who received intensive counseling therapy but no vouchers had a 40 percent retention rate, and control patients who received 12-Step counseling had an 11 percent retention rate.

In voucher programs, patients not only stay in treatment but also remain substance free. In two published studies, 68 percent and 55 percent of patients in the voucher program were cocaine free for 8 consecutive weeks, whereas only 11 and 25 percent of the control patients who did not receive vouchers stayed cocaine free.

In these studies, voucher incentives were given only for the first 3 months of treatment, with lottery tickets offered during the second 3 months as an incentive for drug-free urine (Higgins et al., 1993, 1994b, 1995).

Voucher incentives can be effective for controlling cocaine use among methadone maintenance patients who chronically abuse cocaine (Silverman et al., 1996). In this study, patients receiving vouchers for cocaine-free urine samples achieved significantly more weeks of cocaine abstinence and significantly longer durations of sustained abstinence than controls.

Forty-seven percent of patients who were offered vouchers sustained 7 or more weeks of continuous cocaine abstinence whereas only one control patient achieved more than 2 weeks of sustained abstinence. These results are impressive because it is typically difficult to get methadone maintenance patients to stop using supplemental drugs during treatment.

Voucher-like interventions have been used effectively to motivate reductions in substance use and other behavior change among schizophrenics, people with tuberculosis, homeless, and other special populations of illicit substance abusers (Higgins and Silverman, 1999).

Other innovative programs have been tried. For example, one program used vouchers to encourage pregnant women to quit smoking. Staff solicited retail items from the community that could be earned by clients following each appointment if they passed a carbon monoxide breath test indicating they had not smoked.

Although a range of products and services were available for purchase by the vouchers, mothers most often chose baby items, affirming their motivation to quit smoking for their children's health.

A reinforcement system that is monetary but relies on the individual rather than a voucher is to help clients identify specific items they would like to have or enjoy--for example, a new bedroom set or computer. Clients then set aside money on a daily or weekly basis that would have been spent on substances and eventually purchase the item.

Obviously, there would be concern that any accumulated money could be used as part of a recurrence. As a solution to this problem, the saved money could be kept with a nonusing family member or friend.

In the Community Reinforcement Approach (CRA), monetary incentives (external motivators) are meant to be spent on activities or retail items that will directly increase the client's chance of achieving stated goals (intrinsic motivators). Under this model, external and intrinsic factors must be congruent or the voucher system will have little influence (see the section later in this chapter).

When families are included in treatment, a voucher incentive can be developed with the client and key family members. For example, when the client is abstinent for 90 days, he can visit his parents for Sunday dinner, or when another client has made 90 meetings she can have her children over for a visit. Parents might want to work out vouchers with recovering children; for example, after six therapy sessions the child can go out on the weekend or use the car, and after 90 days of sobriety the allowance or other "goodies" can be reinstated.

What types and amounts of incentives should be used? The voucher programs tested so far have offered more than $1,000 that could be earned during a 3-month period. Research with cocaine abusers has demonstrated that the greater the value of the monetary incentive, the more powerful a reinforcer it is--that is, more people become abstinent (Silverman et al., 1997).

Aside from theoretical issues about the optimal size of rewards, there are practical considerations having to do with financial, staffing, and administrative resources of the clinic. Voucher systems offering smaller incentive values have not been systematically tested yet, but they are likely to work for some clients. Treatment programs can consider soliciting prizes from local businesses as a source of program incentives.

Clinicians and programs may also find creative ways to make naturally occurring sources of financial support contingent on abstinence. Family members have often spent large amounts of money treating, supporting, and handling the adverse consequences experienced by a substance-dependent loved one.

It is possible to negotiate with the family to stop all such noncontingent support, and instead, offer financial support in a manner that helps the person establish sobriety. By special arrangement (e.g., with the client's consent), noncontingent support checks could be channeled through a contingency plan.

Not all contingent incentives must have a monetary value. In many cultures, money is not the most powerful reinforcer. For example, offering money would be disrespectful among cultures that value benefits to the community over individual gain. In more communal cultures (e.g., Native American, African-American), spirituality may be interwoven in the ethnic value system.

Contingency incentives can reflect those ceremonies and activities that support the sacred. In the Native American community, these can include gifting, earning a feather, honoring spiritual kinship, using a talking feather, and smoking a prayer pipe. The case study in Figure 7-6 highlights the importance of cultural values as motivators for change. Contingency incentives should be culturally appropriate and linked to the clients' values.

Community Reinforcement Approach

CRA emphasizes the development of new natural reinforcers that are available in the everyday life of the substance user and that can compete with powerful psychoactive substances. (See Chapter 4 for a discussion of CRA in the contemplation stage.) Essentially, this holistic approach uses behavioral strategies in an attempt to make a person's abstinent lifestyle more rewarding than the destructive patterns associated with drinking or drug use.

This entails bolstering alternative sources of positive reinforcement derived from legitimate employment, family support, and social activities. Furthermore, the clinician tries, insofar as possible, to make these alternative sources of reinforcement immediately contingent on sobriety in order to boost motivation for remaining substance free. CRA also builds new competencies through skills training, with information about the need for particular coping skills derived from a functional analysis that identifies high-risk situations. Some of the strategies used in CRA include

Using motivational counseling to move participants toward their goals
Building competency
Applying competing reinforcers
Tying reinforcers to abstinence
Emphasizing the multifaceted nature of recovery

Tying natural reinforcers to abstinence is a central feature of CRA. Unlike vouchers, natural reinforcers such as praise for a job well done, occur in a client's normal, daily environment. A natural, uncontrived reinforcer can also be internal, such as perceiving oneself as a good worker.

While straightforward in concept, the attempt to link reinforcers to abstinence can be difficult to implement in practice. For example, an ideal situation would be one in which an employer would agree to allow people to work and earn money only on days when they test drug and alcohol free. In this way, the benefits of work, including the money that can be earned, are tied to abstinence and denied temporarily in the event of substance use.

The treatment program would either have to make special arrangements with employers or operate its own worksite, and easy access to a drug-testing laboratory would be needed to provide immediate feedback. The workplace described in Figure 7-7 is an example of this type of program.

Another source of immediate reinforcement is the romantic or marital partner or other substance-free supporter. Much research indicates the efficacy of behavioral marital therapy (O'Farrell, 1993). In CRA, a contract can be negotiated between clients and their partners that outlines abstinence contingent interactions.

For example, partners may agree to prepare special meals or take part in activities that clients enjoy so long as they remain abstinent. Alternatively, if there is evidence of a recurrence of substance use, the partner agrees to forego favored activities and withhold social reinforcers, possibly even leaving the home temporarily until there is evidence of return to abstinence. To make this work, the treatment program should provide regular information to partners about drug-test results (after obtaining consent from clients) so they can take appropriate action in accordance with the contract.

Partners also most likely need support, encouragement, and problem-solving help from the clinician.

New social and recreational activities can be important sources of alternative reinforcement. This is often a difficult area in which to make changes, however, and clients may need support to get started on new activities. CRA involves the clinician as an active change agent, helping the client directly achieve the goal and modeling new behaviors. This can be especially valuable in encouraging new social or recreational activities.

In addition to arranging for appropriate delivery of reinforcers in the natural environment, setting goals, and modeling new behaviors, the CRA clinician teaches skills that the client may need for acquiring and sustaining alternative reinforcers. This may include social skills, problemsolving skills, and various self-management skills such as assertiveness. Particularly for clients from disadvantaged groups, it may be especially important to teach the skills needed to get a job.

A special component of CRA called the Job Club offers clients skills training, critique of job applications, tips on making telephone calls to potential employers and dressing for interviews, and practice in being assertive and positive with potential employers (Azrin and Besalel, 1980; Meyers and Smith, 1995). The four key areas of emphasis are

Telephone contact skills
Telephone contact goals
Job application skills
Job interview skills

Job Club is a highly structured program that guides participants toward higher levels of concrete action--for example, by making 10 phone calls per day to relatives or friends who have jobs and making "cold calls." Research supports its efficacy in helping clients find employment (see, for example, Azrin and Besalel, 1982).

The program also coaches individuals with substance abuse disorders on the sensitive issues they face. A man, for example, who spent several years in jail can benefit by learning how to handle gaps in his employment history that may be questioned during a job interview. The program also emphasizes identifying competencies from the client's history and putting them in the resume. For example, a woman with young children may not have held a paying job for years, but she may have performed volunteer work. This experience should be included in her resume.

Job Club counselors make clear that finding a job is sometimes difficult. Because disappointments inherent in any job search can present the first setback for clients after they enter treatment, Job Club coaches them on how to handle rejection and gives them a safe setting in which to work through any sense of failure. It also gives participants a forum where they can talk and reduce their feelings of isolation and loneliness.

When clients get jobs, their participation in Job Club ends. At that point, it is usually up to the counselor or clinician to continue any work needed for sustaining employment (i.e., check client expectations versus perceived realities, identify and solve job-related problems).

Job Club is particularly valuable because employment and financial support are crucial elements of identity and lifestyle. Both stopping substance use and getting a job reflect large, abrupt changes in lifestyle; however, the skills needed to achieve one goal can complement attainment of the other. Job Club fills a need because it helps clients take action. In terms of the model of change, research shows that clients need to feel successful in changing behavior to stay in the action and maintenance phases. Although Job Club may seem directive, it assists with behavioral change that can promote treatment success.

Motivational techniques can be used when talking to clients about their vocational goals and even when implementing skills training aimed at finding a job. The clients' commitment to becoming employed may have to be revisited using decisional balance techniques. Expectancies can be discussed about both the skills-training and job-finding processes. The value of program-based skills training, however, is that fears can be allayed by repeated role-playing performed in a protected environment with a clinician who will provide objective, nonjudgmental feedback.

Finally, job-skills training may have to be broadened to include a component on job maintenance--or how to keep a job. Keeping a job requires skills that are often eroded by substance abuse disorders, including being punctual and organized, being able to solve problems that arise on the job, and being able to trust others and work effectively in a team.

Employment serves as an immediate reinforcer by meeting the practical need for money, but other aspects of employment take time to become reinforcing. For example, employment builds self-efficacy. It also gives clients an opportunity to learn new work skills and meet new drug-free people. Other areas of a client's life--socializing, romance, family, recreation, education, and spirituality--also may take time to realize full potential as alternative reinforcers.

For this reason, voucher incentive programs can be useful at the start of therapy to bridge the gap. The delay in gratification inherent in starting new activities also suggests that the CRA counselor should encourage and assist clients in developing new behaviors and contacts in as many areas as possible because clients may not follow through in all areas and some areas may become reinforcing sooner than others.

As your clients focus on changing each area of their lives, there will be new opportunities both to teach skills and to enhance the network of nondrug social reinforcers. For example, studies have shown that women who attend parenting classes to learn about normal stages of child development generally develop social ties with other mothers and reap social benefits in addition to improving parenting skills.

Peterson's research in this area suggests that it would be beneficial to build parenting classes into treatment programs because of these multiple benefits (Peterson et al., 1996; Van Bremen and Chasnoff, 1994). Another novel concept is a parenting class for parents of teenagers, which would serve a similar need while enhancing social ties. Although such programming is not provided in most community treatment programs, it could be valuable.

CRA is a comprehensive approach to delivering therapy to clients. CRA counseling on its own has proven effective when tested with alcoholics, and CRA plus vouchers has proven highly effective as a treatment with cocaine abusers. CRA recognizes the importance of motivation and incorporates motivational techniques including abstinence contingencies to build alternative substance-free lifestyles.

Establishing a satisfying substance-free life takes time and perseverance, with many hurdles along the way. Commitment and motivation are recurrent issues. CRA and other motivational techniques can be valuable tools for the clinician as clients seek to change their lifestyles.

Motivational Counseling During Maintenance

To this point, this chapter has focused on helping clients prepare for and stabilize their recovery. As a final note, a motivational approach can also be quite useful in counseling clients during the maintenance stage. The most likely reason for your seeing a client after action-oriented treatment has concluded, of course, is a recurrence of substance use and related problems.

As described in the opening chapters, this TIP has been developed with a keen awareness of the language that is used in treatment and the underlying assumptions implied by common terms. The term "relapse" has been intentionally omitted because of the baggage it carries. The Consensus Panel sought not to find a euphemism for relapse but to write in a manner that fundamentally reconceptualizes the recurrence of substance use after treatment.

This reconceptualization recognizes several well-documented observations:

Recurrence of use is the norm rather than the exception after treatment. It is so common as to be thought of now as a normal part of the change and recovery process.

The term "relapse" itself implies only two possible outcomes--success or failure--that do not describe well what actually occurs. Client outcomes are much more complex than this. Often in the course of recovery, clients manage to have longer and longer periods between episodes of use, and the episodes themselves grow shorter and less severe.

The binary assumptions inherent in the "relapse" concept can also be a self-fulfilling prophecy, implying that once use has resumed there is nothing to lose, or little that can be done. Instead, the point is to get back on track as soon as possible.

The relapse concept, when applied to substance abuse, also lends itself to moralistic blaming or self-blaming. In fact, recurrence of symptoms is common to addictive behaviors, and indeed to chronic health problems in general.

Part of a motivational approach in maintenance, then, has to do with a mental set about the meaning of recurrent use and how to respond. When one thinks in terms of "relapse," there is a temptation to lapse into lecturing, educating, even blaming and moralizing ("I told you so"). The very same principles described for helping precontemplators and contemplators can be used here.

In fact, recurrence of use in a way constitutes a return to one of these stages. The reason for not considering change may be different, of course, the second or fifth time around. It may have more to do with discouragement, low confidence in the ability to change, or a defensive rationalization of resumed use. Your job is to help your client not get stuck at this point but move back into preparation and action.

There are no special tricks here. The approach is the same. Ask for your client's own perceptions and reactions to resumed use. Elicit from your client the self-motivational reasons for change, the reasons to get back on track. Explore what can be learned from the experience; a functional analysis of the process of resumed use may be helpful.

Normalize the experience as a common and temporary part of the spiral of recovery. Have your client talk about the advantages of abstinence. Use plenty of reflective listening, not just a string of questions. Explore the client's values, hopes, purpose and goals in life. Ask a key question--what does the person want to do now--and move on toward a plan for renewed change.

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From SAMHSA/CSAT  Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Chapter 7 From Action to Maintenance: Stabilizing Change