Section 2: Implementing Brief Interventions

To successfully work with a client, it may be necessary for you to take a step back and perhaps remind yourself of how long it may have taken you to change a “habit” in your own life. There is a need to consider several factors that will influence how BI progresses and what is seen as a “successful” result. These include reminding yourself that “ambivalence” is a normal part of the change process and that change usually occurs over time. Also, the client may not have come into treatment or hospital willingly this time or in the past, and hence may be quite angry about mental health services — and yet may welcome having an opportunity to talk to someone. Therefore, keep an open, non‐judgmental, and reflective style; remain optimistic; and take a long‐term perspective.

During your initial session with the client, you can use the brief assessment to engage the client in talking openly about drug and alcohol use, mental health, and general well‐being. It is possible that they have not had a chance to sit back and talk about the role of their behaviour. Coming to see you may be an opportunity for clients to reflect and develop greater awareness.

In the previous section, we spoke about the different stages of brief intervention that consisted of five basic steps that incorporate FRAMES and remain consistent regardless of the number of sessions or the length of the intervention:

1. Introducing the issue in the context of the client’s health
2. Screening, evaluating, and assessing
3. Providing feedback
4. Talking about change and setting goals
5. Summarising and reaching closure.

The following sections will briefly explain the steps taken in BI and how to conduct BI appropriately with your client.

1. Introducing the issue

In this step, the counsellor seeks to build rapport with the client, define the purpose of the session, gain permission from the client to proceed, and help the client understand the reason for the intervention.

Counselling tips

Help the client understand the focus of the interview. State the target topic clearly and stress confidentiality; be nonjudgmental and avoid labels. Do not skip this opening; without it, the success of the next steps could be jeopardised.

2. Screening, evaluating and assessing

In general, this is a process of gaining information on the targeted problem; it varies in length from a single question to several hours of assessment on the targeted topic of change. It could involve a structured or nonstructured interview or a combination of both, coupled with questionnaires or standardised instruments, with the extent of the process determined largely by the setting, time, and available resources.

Counselling tips

Before you begin the brief intervention, decide how much information you have time to obtain and whether you want to have the client answer any questionnaires. Watch for defensiveness or other resistance, and avoid pushing too hard. For example, when screening for alcoholism (for more information, please refer to Reading D), the counsellor can incorporate CAGE questions:

• Have you ever tried to cut down on alcohol?
• Do you get annoyed when you do not have access to a bottle?
• Do you feel guilt about your drinking?
• Have you ever had an eye-opener?

The counsellor can start with a few screening questions, then CAGE questions, and then assess the severity of the issue (medical, laboratory, behavioural and dependence).

3. Providing feedback

This component highlights certain aspects of the client’s behaviour using information gathered during screening. It involves an interactive dialogue for discussing the assessment findings; it is not just counsellor driven. Feedback should be given in small amounts. First, the counsellor gives a specific piece of feedback and then asks for a response from the client. Sometimes the feedback is a brief, single sentence; at other times, it could last an hour or more.

Counselling tips

Use active listening. Be aware of cultural, language and literacy issues. Be nonjudgmental. The following image will give you a brief view of how the feedback process occurs or can take place.

Client Feedback and Plan of Action

Give specific feedback to the patient, then advise in a firm but empathic manner

If diagnosed as at risk:

• Advise patient of risk
• Advise abstinence or moderation
• Set drinking goals
• Schedule followup to discuss progress

If diagnosed as alcohol dependent:

• Advise patient of objective evidence
• Advise on plan of action
• Assess acute risk of intoxication or withdrawal
• Medical and psychiatric comorbidities
• Agree on plan of action

Plan of Action

• Involve family: refer for family treatment and self-help (e.g., Al-Anon,etc.) (must have patient permission and involvement)
• Stress abstinence
• Urge patient to attend self-help meetings (AA, NA, Self-Management and Recovery Training [SMART], etc.)
• Consider referral to addiction medicine specialist, and/or possible pharmacotherapy with disulfiram (Antabuse) or naltrexone (ReVia)

Source: ASAM, 1994

4. Talking about change and setting goals

Talking about change involves talking about the possibility of changing behaviour. It is used with clients in all stages of change, but it differs profoundly depending on the stage the client has reached. For example, in pre-contemplation, clients are helped to recognise and change their view of consequences; in contemplation, they are helped to resolve ambivalence about change. In action, the focus is on planning, removing barriers, and avoiding risky situations; in maintenance, the emphasis is on establishing new long-term behaviours. The counsellor must assess the client’s readiness to change if it is not already known. In talking about change, the counsellor often suggests a course of action and then negotiates with the client to determine exactly what he is willing to do. Sometimes, talking about change is premature (i.e., before the assessment and feedback have happened). In that case, it should be postponed in the intervention.

Counselling tips

Offer change options that match the client’s readiness for change. Be realistic: Recommend the ideal change but accept less if the client is resistant.

5. Summarising and reaching closure

This step involves a discussion summary and a review of the agreed-upon changes. If no agreement was reached, review the client's positive action during the session. At this point, scheduling a follow-up visit is important to discuss how the client is progressing. The follow-up could be another face-to-face meeting, a telephone call, or even a voicemail message. The goals of closing on good terms are to arrange another session, to leave the client feeling successful, and to instil confidence that will enable the client to follow through on what was agreed upon.

Counselling tips

Tailor your closure to the client and the particular circumstance of this brief intervention; interpret any client resistance positively, leading to progress. Thus, if a client has been unwilling to commit to changes, thank them for their willingness to consider the issues and express the hope that they will continue to consider committing to changes.

Clients in the pre-contemplation stage are often difficult to motivate towards change because they don’t see themselves as ‘having a problem’ and are not interested in changing. In many cases, they are only talking to a counsellor because they have been referred or because someone else in their life is making them. In such cases, the goal is to raise the client’s awareness of the problematic nature of their behaviour rather than launch into trying to discuss specific change strategies.

Counsellors working with clients in the pre-contemplation stage will typically seek to:

• Establish trust and rapport by acknowledging the client’s perspective
• Explore the events that have precipitated the client speaking to the counsellor (for example, what caused them to be referred or why does their loved one think they have a problem?)
• Commend clients for coming
• Raise awareness of the impact that their behaviour is having on themselves and those around them
• Explain and personalise the risk (for example, provide the client with information about the negative impacts of their behaviour but do so in a way that makes sense to them and is personal rather than simply providing dry statistical information)
• Encourage client self-exploration. For example, some commonly used tools are to encourage clients to engage in a ‘Body Scan’ or ‘Be a Witness’ to their own internal experience. Those tools are designed to facilitate the mind-body connection and improve the client’s connection to their own internal experience (which may include feelings of anxiety, shame, guilt, or anger resulting from their behaviour).

The counsellor mustn't try to ‘force’ the client into change. Instead, the counsellor should respect and validate the client’s perspective towards change but seek to raise the client’s awareness of the negative impacts of their behaviour to facilitate the client’s desire to change.

Let’s look at an example of how a counsellor can work effectively with a client in the pre-contemplation stage.

Case Study

Kate has been engaging in binge drinking regularly as an “escape”, which is starting to affect her performance at work. Kate used to binge drink on Friday and Saturday nights, but now Kate is finding that she requires more alcohol to get the “same buzz” and that she is craving alcohol every day now. Kate’s punctuality, attendance, and work performance have all suffered. Kate thinks it’s an “overreaction” and “not really a problem”. Kate doesn’t want to lose her job but feels like her boss is “making a mountain out of a molehill”. Kate’s boss has referred her to the EAP (Employee Assistance Program) counsellor. Kate wasn’t keen but felt like she was forced to choose between getting counselling and losing her job. So, reluctantly, Kate is seeing the counsellor.

Counsellor:	Kate, you are here because your boss suggested you should engage in counselling.
Kate:	Suggested? Ha! It was more like he forced me to come.
Counsellor:	Why do you think that happened?
Kate:	Because he’s got all riled up about the fact that I’ve been late a couple of times, and he thinks my performance has slipped.
Counsellor:	Are you concerned about the change in your work attendance and performance?
Kate:	Not really. It’s not like I’m taking every day off or anything.
Counsellor:	OK, so you’ve come here only because your boss is concerned. What do you think your boss hopes you’ll gain from coming here?
Kate:	I guess…he wants things to change back to how they used to be.
Counsellor:	Can you describe the way things used to be?
Kate:	Well, you know, me coming in early every day, being motivated to work, not calling in sick a lot.
Counsellor:	OK, so when did that start to change?
Kate:	Around the time I started drinking more, I guess.
Counsellor:	Are you concerned about the link between these two things?
Kate:	Well, I guess they are connected, and the more I drink, the more likely I am to miss work the next day, but I still think I have it under control… I mean, I think I do. I don’t think my drinking impacts me that much.
Counsellor:	Would you be interested in exploring this link?
Kate:	Yeah… I guess.
Counsellor:	Some people find it useful to keep a diary of sorts. You could take note of your drinking over the next week and monitor whether or not it feels under your control and whether or not it’s having an impact on some form of your life (most predominately work). Would you be open to that?
Kate:	What would I have to do?
Counsellor:	OK, over the next week, I’d like you to note when you feel like drinking, when you resist the urge to drink, and when you don’t resist and actually drink. I’d also like for you to note when the drinking results in you not being able to function the way you have been able to previously (e.g., getting to work on time, being able to concentrate at work, etc.). How does that sound?

In this example, the counsellor validated the client’s feelings and did not try to force change. Instead, the counsellor suggested an activity that would raise the client’s awareness of the impact of her drinking behaviour. In this case, the client had been referred to the counsellor for several sessions, so the counsellor would review the results of this activity with the client in the following session before engaging in additional awareness-raising activities.

Motivational Interviewing Role-Play - Precontemplative Client Who Reports Being in Action Stage

This video features a motivational interviewing (MI) counseling role-play session in which MI techniques are used to identify and explore ambivalence. In this role-play, the client (played by an actress) is in the precontemplation stage of change, but reports attitudes and plans consistent with the preparation and action stages.

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A common approach used in brief interventions is motivational interviewing (MI). Let’s have a look at motivational interviewing now.

Motivational Interviewing Role-Play - Precontemplation Stage - Weight Loss

This video features a counselling role-play in which motivational interviewing is used to treat a client who is in the precontemplation stage of change. The client is struggling with weight gain. Answer the questions that follow. 

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Motivational interviewing (MI) developed from Prochaska and DiClemente’s stage of change model. As the name suggests, it is focused on increasing the intrinsic motivation of clients to make changes in behaviour. Typically, the prospect of changing a behaviour/habit gives rise to feelings of ambivalence in people. MI is used to enhance motivation through the resolution of this ambivalence by exploring the various “pros and cons” and the client’s motivations.

What is Motivational Interviewing?

In this video, Dr, Grande describes how and why therapists use motivational interviewing. 

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While motivational interviewing shares many of the same principles as person-centred counselling, it differs from person-centred counselling in that it is slightly more directive in nature and in MI the counsellor does attempt to influence the client rather than just leave them to explore themselves.

Step 1: Engaging: Shall we walk together?

This starts with a successful person-centred therapeutic alliance and uses effective communication and listening techniques.

Step 2: Focusing: Where?

This involves the client’s agenda (for example, what they came to talk about). Focusing is where the counsellor collaborates with the client to help shape their progress towards the desired change. This is where goals are also starting to emerge, and this process helps to clarify where the client wants to go and how the counsellor can help them get there.

Step 3: Evoking: Why?

This involves stimulating the client’s motivations for their desired change. The counsellor starts to facilitate decision-making and planning regarding how the client will reach that goal/change. This evoking process makes the client an active participant and collaborator in their own change process. The most important thing here is that the clients are the ones that talk themselves into the change process not the counsellor talking the client into changing their behaviour.

Step 4: Planning: How?

This final process is kicked into gear when the client has reached the requisite level of readiness that helps them start to plan and engage in when and how discussions regarding change rather than whether and why. This planning stage also involves the counsellor helping the client envision their life once they’ve made this change and helping the client see how they can commit to change and develop a plan of action. This is another place where the promotion of the client’s change talk is very important.

If you look closely at the four steps, you will find that in a motivational interview, a counsellor engages with the client, focuses on what their goals are, stimulates the client’s motivations to change, and finally helps the client to develop a plan of action. The basic skills that MI is dependent on are often explained by the acronym ‘OARS’ – namely, asking Open-ended questions, making Affirmations, using Reflections, and Summarising. The following extract provides more information about these skills and what they look like in counselling.

^{(Adapted from Rosengren, 2017)}

MI has been found to be most useful for clients who have started thinking about changing their behaviour  (are in the contemplation stage). Some key things to keep in mind while conducting a motivational interview with a client who is contemplating change include:

• Engage with the client in a supportive, non-judgemental way while demonstrating active listening and empathy
• Establish what is important to the client (for example, friends, job, alcohol and drugs)
• Introduce insight by asking if there is anything important to the client that ‘takes over’ their life or ‘controls them.’
• Explore areas of conflicting importance (e.g., ‘How does being a dad fit in with using drugs?’)
• Explore attractions and impact of the problem behaviour (for example, ‘What’s good about gambling? What’s not so good about gambling?’)
• Establish resources
• Establish a previous blueprint for change (for example, “Have you had to make a change before? If so, what helped you at that time?”)
• Distinguish between current reality and desired reality (for example, ‘If you didn’t make a change to stop smoking, what would your life look like in five years? If you were to make a change to stop smoking, how do you think things would be in five years?”)

To help you better understand the motivational interviewing process, let’s return to the case study of Kate, who had been referred to the EAP counsellor. In the previous case study, Kate was in the pre-contemplation stage. However, the activity of monitoring her drinking and its impacts has made her start considering change (she is now in the contemplation stage).

Case Study

Case Study (Contd)

Counsellor: Kate, you’ve spent the last week monitoring your drinking and your thoughts around drinking. What have you learned?	Here we can see the counsellor trying to establish where the client is in the stage of change. The counsellor is not pushy but engages with the client in a focused manner by asking an open-ended question.
Kate: I learned that it’s become a bigger problem than I thought. I’m now much more conscious about my drinking, and I’m starting to think I might need to make a change.
Counsellor: That’s great to hear that your perspective has shifted just from that awareness-raising homework. When you were monitoring your drinking, what did you find were the attractions to drinking?	The counsellor here reflects back to the client and affirms the change in the thought process that has occurred. This is then followed by a question that will help the client explore the attractions to the problem behaviour.
Kate: It started out as just an escape from the stress of the day, a way to unwind, you know? But over the last week, I’ve seen that it’s actually a physical craving to drink, and it’s on my mind all the time.
Counsellor: OK, so initially it was quite attractive as a way to relax and escape, but that’s changed. So, what would you say is not so good about drinking?	The counsellor is being non-judgmental and supportive while listening actively
Kate: The way that it’s now controlling me and dictating how I’m feeling. It’s also damaging my relationships with other people, including those at work.
Counsellor: I can see why that would be concerning you. Do you feel like you want to change your drinking habits?	The counsellor is evoking the client by asking a question about her motivation to change
Kate: Yeah, I do, actually. Don’t know if I’m ready to necessarily start taking steps, but I’m finding myself thinking more and more about wanting to make a change.
Counsellor: What do you think is stopping you from feeling ready to start making a change?	The counsellor notices that the client is desirous of making a change but is experiencing a barrier in terms of taking the necessary steps and explores what the barrier may be for the client in a supportive manner.
Kate: Being scared of what my life will look like once I take off the beer goggles.
Counsellor: It’s normal to be scared when thinking about change. Could you expand on what you’re worried you’ll see?	When the client shares that she is not prepared for how the change will impact her life, the counsellor empathises with her by normalising it and then directs the client to further explore this barrier
Kate: I am worried I may not be able to cope with the regular situations of my life. Will I be able to respond with confidence? Will I be comfortable in social interactions without it?
Counsellor: Kate, you have recognised how the drinking has been controlling you, and you are keen to make a change. While you wonder how you will survive without it, your self-awareness demonstrates a strong ability to understand yourself and others – I’m sure this strength will be useful in managing these changes. Making a change in behaviour usually becomes easier when you have additional support and new skills, and we will discuss that shortly. But first, how do you think your life may change for the better if you made this change?	Here the counsellor has summarised what the client has been talking about, which helps Kate look at the bigger picture, commends her strengths, and then asks her a question that would help Kate distinguish between her current reality and the desired one.
Kate: Ohh, that’s easy. So much would change. For starters, my work performance would improve drastically. I wouldn't need to call in sick regularly. Some of my friends cut off from me because I annoyed them with my drinking. They would be really pleased with the change in me. I have also had trouble being in a long-term relationship as, eventually, the guys I dated would start picking on my habit. I think this would change.
Counsellor: It seems you are aware of several positives that can be gained if you quit drinking, like improving work performance, restoring friendships, and possibly dating again.	The counsellor affirms the client and summarises what she has said – helping her move into the preparation stage of change
Kate: What do you think I could do to get started?	Throughout the session, the counsellor has allowed the client to lead the decision.

3 Motivational interviewing Core Skills in Action

This role play displays three core skills for motivational interviewing. Answer the question that follows. 

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Once a client is ready to make a change, the counsellor’s focus needs to be on selecting appropriate strategies to support the client to explore their choices, set goals, and identify relapse prevention strategies.

Your task is to help clients set clear goals for change in preparation for developing a change plan. Changing any longstanding behaviour requires preparation and planning. Clients must see change as being in their best interest before moving into the action stage. Developing a change plan that is accessible, acceptable, and appropriate for each client is key. The negative consequences of ignoring the preparation stage can be a brief course of action followed by a rapid return to consequential behaviour. By the end of the preparation stage, clients should have a plan for change that guides them into the Action stage.

The following table presents the counselling strategies for preparation and action.

To help you understand this process, let’s look at an example. Imagine a client named Donnelly who has approached a counsellor with a desire to make changes in her lifestyle to manage her weight. Donnelly is already in the preparation stage and is now thinking about implementing changes. Since brief interventions are client-led processes, the counsellor’s role is to be there to support her and to select the most appropriate strategies for her circumstances.

Some questions that the counsellor asks to help Donnelly explore the choices she has are outlined in the following table, along with Donnelly’s responses.

As you can see, the counsellor asked specific questions to explore Donnelly’s available resources and support options. This style of questioning helps the client to explore their options fully.

It is important for the counsellor to consider all support options and to remember that some clients may require more support service involvement. For example, a client may be engaging in a brief intervention to address their drinking and concurrently attending AA. Therefore, when a counsellor engages in an assessment of the client’s needs and resources, they should take note of where the support gaps may emerge and offer additional supports (for example, support groups, helplines, electronic and print resources) as well as help the client identify resources in their life that may have been overlooked.

The counsellor may also consider the benefit of suggesting more long-term counselling options to address any potential underlying issues that may have contributed to the onset or maintenance of the problem behaviour in the first place (for example, unresolved childhood issues and relationship issues).

Another important step in supporting clients who are ready to make a change is helping them set measurable and achievable goals. A plan for change, including setting goals, should consist of relatively easy steps. The counsellor can help the client explore their end goal and then decide upon the specific steps they will need to take to achieve it. Breaking this process down not only helps facilitate client success but also builds client motivation as they are faced with a series of small steps instead of a seemingly insurmountable challenge.

It is important to plan how the behaviours may need to be altered from environment to environment. It is also important to record these goals and plans. By engaging in the planning process, the client can identify specific steps they should take, what barriers they might face, and what support they require.

For example, if the client from the previous case study, Donnelly, were to complete a goal-setting worksheet, it might look like this:

By documenting these goals and steps, Donnelly will be much clearer on what steps she will take and more likely to succeed. Once goals have been set, the counsellor may also encourage the client to share the goals with trusted support people in the client’s life to promote social accountability.

Explore client change goals

As mentioned in the first part of this section, once the client has decided to make a positive change and the commitment is clear, goals should be set. Setting goals is part of the exploring and envisioning activities in the early and middle parts of the preparation stage. Having summarised and reviewed the client’s decisional considerations, you should now be prepared to ask how the client might want to address some of the reasons to change listed on the positive side of the decisional balance sheet. The process of talking about and setting goals helps to strengthen clients’ commitment to change.

Clarify the client’s goals

Help the client set goals that are as realistic and specific as possible, addressing 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 Summarisation) to help clients clarify their goals, decide which goal to focus on first, and identify steps to achieving them. 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 clients perform to meet the goal.
• Setting goals is a joint process. The counsellor 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-centred counselling 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 their nutritional problem, such as binge eating, where they are at risk of obesity.
• Matching a client to the preferred nutritional treatment, such as brief intervention in counselling, will help them replace their thoughts of overeating as the basis of self-worth with more meaningful expressions of personal value. We can support the client in accepting more realistic weight goals for long-term health maintenance; this means they do not have to avoid the food they enjoy but rather have to reduce their consumption. We can also support our client in developing a tolerance towards strong moods and difficult events, such as stress; for example, when they are stressed, your client overeats, but now they are trying to redirect their stress thoughts to taking a walk or running. This will lead them to a pathway towards recovery because those strong thoughts are being re-directed to other events rather than food or eating.

Your task is to help clients identify their preferred change goals and to enhance their decision-making by teaching them about their treatment options.

Remember that the client’s preferred treatment goals may not match your preference. A client might choose a course of action you disagree with which is not in line with the treatment agency’s policies. For example, a decision to reduce but not completely stop substance use may go against the agency’s zero-tolerance policy for illicit substance use.

Exploring Goals and Values

In this video about Motivational Interviewing, the presenter focuses on the importance of exploring client motivation as it relates to goals and values, as well as strategies for doing this.

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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. The following approaches to goal sampling may be helpful for clients who are not committed to abstinence as a change goal in different scenarios such as nutrition, environmental problems and AOD.

Lifting the Burden in Motivational Interviewing

Motivational Interviewing founder William Miller talks about the change of role in Motivational Interviewing and how counselling is not about 'fixing' people. 

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Your final step in readying the client to act is to work with them and create a plan for change. Think of a change plan as a roadmap for the client to reach his or her goals. A solid plan for change enhances the client’s self-efficacy and provides an opportunity to consider potential barriers and the likely outcomes of each change strategy.

Use these strategies to work with clients to create a sound change plan:

• Elicit change strategies from the client
• Offer a menu of change options
• Negotiate a behavioural contract
• Explore and lower barriers to action
• Enlist social support

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 particularly helpful if clients have made past attempts to address substance use behaviours or have been in treatment before. For example, you might begin with a reflection on 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?”

Action Planning with Motivational Interviewing

This video provides a good explanation on how to identify a client's commitment to change.

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

• The plan can be very general or specific and 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 and identifying specific coping strategies.
• Some plans are very simple, such as stating only that the client will enter outpatient treatment and attend an Alcoholics Anonymous (AA) meeting every day.
• Other plans include details (for example, transportation to treatment, new ways to spend weekends).
• Many plans include specific steps to overcome anticipated barriers to success. 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 childcare.

Change plan worksheet

Creating a change plan using a joint process in which you and the client work together. One of your most important tasks is ensuring 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:

The intensity and amount of help needed

Encourage participation in community-based support groups (e.g., Alcohol Anonymous [AA], Narcotics Anonymous [NA], SMART Recovery, Rehoming Rehabilitation, Job Seeker or Mental Health Foundation Australia: Support), 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.

Available social support

Discuss who will be involved in treatment (for example, family, Women for Sobriety members, community members), where it will take place (for example, at home, in the community), and when it will occur (for example, 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.
• 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 is to complete 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 views and opinions, although it is helpful to “soften” your statements and permit clients to disagree.

For example, you might soften your suggestion by saying, “This may or may not work for you, but many people find it helpful to go to NA meetings to meet others trying to stay away from cocaine.” Other techniques of MI, such as developing discrepancy, empathising, and avoiding arguments, also are useful during this process.

Offer a menu of change options

1. Enhance clients’ motivation to take action by offering them a variety of treatment choices. Choices can be about treatment options or other types of services. For example, clients worried about their weight might not want to practice mindfulness training but might be willing to attend the gym with their partner, attend an obesity or weight management community group or remove high-calorie food from their pantry. Encourage clients to learn about their options and make informed choices to enhance their commitment to the change plan.
2. 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 and safe shelters for clients experiencing intimate partner violence.
3. 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 decide on 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 ‘state of change’; note that it is common for people to go through the stages several times as they move closer to maintaining substance use behaviour change and stable recovery.
   • Remind clients that not completing a treatment program and returning to substance use are not failures but opportunities to re-evaluate 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.

The following change plan worksheet will help the clients focus on the plan's details, increase commitment to change, enlist social support, and troubleshoot potential roadblocks to change. This worksheet includes space for listing supportive individuals and describing how they can help.

^{(Miller & Rollnick, 2013)}

Explore and lower barriers to action

One category in the change plan worksheet 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 childcare
• 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 how 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 ‘intensive outpatient program’ treatment program 50 miles away three 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, 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.

Supporting the client’s action steps

DiClemente (2018) describes four main tasks for a client in the Action stage:

1. Breaking free of the bad habit using the strategies in the change plan
2. Continuing commitment to change and establishing a new pattern of behaviour
3. Managing internal/external barriers to change (for example, physical cravings, lack of positive social support)
4. Revising and refining the change plan.

Your role is to continue using motivational counselling approaches to support the client in completing these tasks and moving into the Maintenance stage and stable recovery.

To support clients in breaking free of substance use behaviours:

• Encourage clients to set a specific start date for each behaviour change (for example, a smoking quit date, exercise start date). Setting a start date increases commitment.
• Help clients create rituals that symbolise them leaving old behaviours behind. For example, some clients may make a ritual of burning or disposing of substance paraphernalia, cigarettes, beer mugs, or liquor. Support clients in creating personally meaningful rituals. As mentioned previously, picking up a chip at an AA meeting is a ritual supporting clients' steps toward abstinence and a new lifestyle.

To reinforce clients’ commitment to change:

• Continue to evoke and reflect change talk in your ongoing conversations with clients.
• Use reflective listening, summaries, and affirmations.
• Manage barriers to change by identifying those barriers (as described in the section “Explore and Lower Barriers to Action”), working with clients to brainstorm personally relevant strategies for lowering or reducing the impact of those barriers, and offering a menu of treatment options. For example, if a client experiences intense alcohol or drug cravings, you might explore referring the client to a medical provider for a medication evaluation, encouraging participation in a mindfulness meditation group, or both.
• Evaluate, revise, and refine the change plan as the final step in the Action stage.

From Evoking to Planning & Developing a Change Plan

In this video , the presenter discusses signs that a client is ready to begin planning for change, the process of moving from evoking to planning and developing a change plan with a client.

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Your goal for this stage of the change cycle is to help the client sustain successful actions for a long enough time that he or she gains stability and moves into maintenance. It is not likely that you and the client will be able to predict all the issues that will arise as the client initiates the change plan.

The client’s circumstances likely will change (for example, a spouse might file for divorce), unanticipated issues arise (for example, the client’s drug-using social network might put pressure on the client to return to drug use), and change strategies may not turn out to work well for the client (for example, the client loses his or her driver’s license and has to find alternative transportation to NA meetings). These unanticipated issues can become a barrier to sustaining change plan actions and may require revisions to the change plan (Swanson & Maltinsky, 2019).

Your task is to work with the client at each encounter to evaluate the change plan and revise it as necessary. Ask the client, “What’s working?” and “What’s not working?”. Miller and Rollnick (2013) suggest that counsellors consider this process “flexible revisiting.” The same strategies used in the planning process of MI apply to revising the change plan, including confirming the change.

When the client has taken steps towards a change, the counsellor needs to offer support/encouragement and celebration of the client’s success to reinforce their progress. Clients can be supported and encouraged by listening to them and asking them to reflect on their successes and lessons learned.

Counsellors can praise and encourage clients for the changes they have been making and also provide information about additional opportunities to gain support. Additionally, the counsellor should work with the client to ensure that they are celebrating their own success – this helps the client learn how to consolidate their own gains.

Consolidation of gains is a buffer against relapse and can help clients maintain and sustain the achieved change goal, eliciting the client’s ideas about how to change, offering a menu of options, summarising the change plan, and exploring obstacles. Some strategies for change may need to be removed, whereas others can be adjusted.

For example, one client’s goal is to quit drinking, and her action steps include attending three AA meetings a week, including one women’s meeting. The client stops going to the women’s meetings because one of the regular attendees is a co-worker who likes to gossip, and the client is afraid that the co-worker will break her anonymity at work. Your first step is to identify the issue, and then elicit the client’s ideas about what else might work for her.

Open questions to start this process if a change strategy is not working include:

• "What now?"
• "What else might work?"
• "What’s your next step?".

Avoid jumping in too quickly with your own ideas. Adjusting a change plan, like creating the initial change plan, is a joint process between you and the client; the client’s own ideas and resources are key. Finally, summarise the new change strategy and explore how the client might respond to any new obstacles that might come up while initiating the revised change plan (Hardcastle et al., 2017).

In some cases, a client eventually reaches a point of stagnation and starts finding it difficult to maintain their initial enthusiasm for change. Congratulating the client and discussing how they can maintain changes through difficult times will help them stay focused. Reinforcing the benefits and importance of change and encouraging them to talk about how much better they feel can help keep them stay on track too.

Let’s return to the case study of Donnelly to see how the counsellor supports her progress.

Motivational Interviewing: Evoking Commitment to Change

In this video, the Physician works together with the patient to develop a specific focus and is a good example on how to encourage and support change. Answer the questions that follow. 

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Documenting these goals and steps is also a relapse prevention strategy. When the client identifies what they want to do along with the reasons for it, they are actually telling themselves why they must stay motivated to their new lifestyle. Additionally, when they reflect on what barriers they may face and how they can overcome them, they improve their preparedness to handle situations that may compel them to relapse.

Working with the client to identify potential barriers/challenges they might face is important.

Some common barriers/challenges include:

• Environmental challenges (for example, the social group of the individual reinforces binge drinking or the individual’s workplace is stressful, which reinforces their desire to smoke)
• Lack of resources/social support to sustain change
• The presence of underlying issues that caused the emergence of the problem behaviour to begin with.

Once the client has identified potential barriers/challenges, the counsellor can then work with them to develop strategies to address these.

When doing this, counsellors should:

• Maintain a collaborative approach with the client, gather information carefully, and plan in detail regarding circumventing the barriers.
• Once the information regarding resources, support, environmental challenges, etc. have been gathered, the counsellor should work with the client to determine how the client has weathered challenges and barriers to change in the past (even if it is unrelated to the problem behaviour).
• Use the client’s intrinsic strengths and problem-solving abilities help reframe these barriers/challenges into solvable issues.
• Reinforce existing progress and the client’s commitment to change.

Early warning signs and important coping skills

This video discusses the stages of relapse, how to recognise the early warning signs of relapse, as well as coping skills to prevent relapse in the future.

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When supporting clients who are in the progress of making changes, it is always important to identify and explore relapse prevention strategies. The following extract outlines some ways in which relapse can be prevented.

Another strategy in relapse prevention is continually rewarding success. Any progress (big or small) deserves to be recognised and sensitively brought to the client’s attention to reinforce how far they have already come.

The Four Essentials Of Relapse Prevention

This video describes the four essentials of a replace prevention plan to ensure the client's recovery is sustainable, helping them achieve a clean life filled with health, friends, independence, happiness, and self awareness.

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Lapsing occurs when the individual returns to the behaviour in a reduced capacity (for example, they were a binge-drinker who decided to quit drinking and then they lapsed and had one drink), whereas relapsing occurs when the individual returns to pre-intervention levels of use.

While the counsellor assesses the client’s needs and their available sources of assistance and support at the beginning of the brief intervention, that cannot always account for unforeseen changes in the lives and environments of clients as well as unforeseen triggers and challenges that the client might face as they attempt to maintain their change – therefore lapses and relapses do happen. Lapsing and relapsing is a part of behaviour change and clients who experience these must be supported.

Counsellors should provide the following support following a relapse/lapse:

• Normalise the relapse process (for example, tell the client that it is a recognised ‘normal’ part of the process given that behaviour change is difficult and sometimes quite hard to maintain).
• Review what led to the relapse (for example; Was it a predetermined trigger? Were there new triggers, or was it related to the presence of an adverse life event?).
• Review the action plan (for example; Were the processes not explained clearly enough? Were there insufficient or irrelevant coping strategies included?).
• Consider how past successes can be incorporated into helping the individual ‘get back on track’.
• Give the client the opportunity to forgive themselves for what happened (for example, it is important to intervene in the potential ‘negative loop’ of the client feeling like a failure and work to replace the negative thoughts with positive ones about how far the client came, how hard they worked and what knowledge they gained).
• Discuss support options for the client to address areas of concern/vulnerability and ensure their next attempt is sufficiently supported.

Relapse Is Part of Recovery

The presenter in the following TEDX Talks, discusses the stigma of mental illness and how to help people with mental health diagnoses find treatment, recovery, and peace.

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As unfortunate as relapse is, it is best not to spend too much time focusing on the negative. After briefly examining what occurred, the counsellor should focus on the positives and look to the future. Both lapsed and relapsed clients may require additional support services, changes to their environment, and, in some cases, referral to other services to deal with comorbid psychological issues and cognitive impairments.

Sources of assistance in this situation could include:

• Another counselling or therapy service (one geared towards more long-term engagement)
• Support/recovery groups
• Advocacy to help the client engage with other community services and supports
• Financial assistance/financial counselling services
• Health centres (especially for IV drug users)
• Rehabilitation centres.

For you to better understand this process, let’s return to the case study client, Donnelly, and see how the counsellor responds to a relapse in her behaviour.

Relapse Management Strategies

If clients return to their previous behaviour, help them avoid full relapse by teaching them the following (Grant et al., 2017).

Stop, look, and listen

Clients can learn how to become aware of events as they unfold and stop the process of recurrence before it goes further. Taking a step back from events as an observer can help clients gain perspective and allow them the emotional and cognitive space to assess the situation before reacting.

Keep calm

Staying calm is the emotional equivalent of stopping, looking, and listening. Thoughts, feelings, and behaviours are often tightly intertwined. Sometimes, clients don’t remember that, just because they feel anxious or have an impulse to use substances or reengage in risk behaviours, they don’t have to act on those feelings or impulses. Practicing calmness and not overreacting emotionally to a recurrence can help clients break this pattern of impulsivity.

Renew their commitment to recovery

A recurrence often discourages people, which can lower motivation and confidence about continuing on the recovery journey. Remind clients of previous successes with behaviour change (no matter how “small”) to allay hopelessness. Keep them looking forward by exploring their reasons for recovery and hopes, dreams, and goals for the future.

Review what led up to the recurrence

Review the events leading up to the recurrence and do a mini-relapse assessment considering lifestyle imbalance, thoughts of immediate gratification, urges and cravings, justifications, apparently irrelevant decisions, and the nature of the high-risk situation that triggered the lapse. Review early warning signs clients may have noticed but disregarded and explore the cognitive traps that led to disregarding the warning signs.

Make an immediate recovery plan

Work with clients to develop an immediate action plan for recommitting to recovery. The plan should include specific action steps clients can take to avoid a full relapse that is acceptable, accessible, and appropriate from their point of view. Write the plan on paper or a file card.

Include client-generated strategies for handling a recurrence, such as:

• Call a sponsor or recovery support person. Include specific names and phone numbers.
• Go to a recovery support meeting. Include specific meeting times and locations.
• Engage in cognitive, emotional, physical, and behavioural strategies for managing cravings.
• Engage in specific self-care or stress-reduction activities.
• Return to medication (if applicable). Include adherence strategies and names of prescribers.
• Call you or the treatment program to schedule a counselling session.

Group Therapy: A Live Demonstration Video

In this demonstration, Irvin Yalom's novel, "The Schopenhauer Cure" comes alive simultaneously in an unscripted group psychotherapy session.

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In this module section, you learned how to effectively implement brief interventions with clients at different stages of change. In the next section, you will learn more about how counsellors monitor brief interventions.

Boston Center for Treatment Development and Training. (2016). Module 10: Sobriety sampling. Retrieved from www.mass.gov/fles/documents/2016/07/ty/bt-manual module10.pdf

Grant, S., Colaiaco, B., Motala, A., Shanman, R., Booth, M., Sorbero, M., & Hempel, S. (2017). Mindfulness-based relapse prevention for substance use disorders: A systematic review and meta-analysis. Journal of addiction medicine, 11(5), 386.

Hardcastle, S. J., Fortier, M., Blake, N., & Hagger, M. S. (2017). Identifying content-based and relational techniques to change behaviour in motivational interviewing. Health psychology review, 11(1), 1-16.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.

Rosengren, D. B. (2017). Building motivational interviewing skills: A practitioner workbook. Guilford publications.

Swanson, V., & Maltinsky, W. (2019). Motivational and behaviour change approaches for improving diabetes management. Practical Diabetes, 36(4), 121-125.

Wadden, T. A., Tronieri, J. S., & Butryn, M. L. (2020). Lifestyle modification approaches for the treatment of obesity in adults. American Psychologist, 75(2), 235–251.