Relapse Prevention in Addiction
Ideally, a treatment plan emerges from negotiations between the client and therapist to decide what problems are to be addressed in therapy, what goals are reasonable and worthwhile, what pathways and techniques are available, and what steps the client is willing and able to take toward those goals. Periodic review is built into the plan since treatment plans often change as new details come to light or as the client’s situation and the therapeutic relationship evolve. A plan for therapy gives both the therapist and client a sense of direction for their work together.
A well articulated plan also potentially enhances treatment efficacy by providing a clear means for tracking progress toward established goals. The therapist has several purposes in developing a treatment plan for a client with a substance use disorder. First and foremost, the therapist wants to motivate and empower clients to make beneficial changes in their substance use behaviors. To that end, the therapist structures the task at hand by helping the client identify a range of available options, and by encouraging the client to make informed choices from among those alternatives.
In addition to increasing the client’s knowledge, the therapist also plans treatment to boost the client’s sense of self-efficacy, so that clients will have some confidence in their abilities to make good choices and to implement plans of action. Treatment plans that are negotiated directly with clients invite the client to share both initiative and responsibility for determining the course of therapy, including both end goals and the steps to take in striving to reach those goals.
In sum, a workable treatment plan is responsive to the client’s stated interests, provides flexible structure, reinforces client choice, supports decision-making, and promotes responsibility for outcomes of client behaviors. Components of a Treatment Plan Once the therapist has a firm conception of the client’s definition of a problem and a sense of the client’s motivation to work on it, the therapist aims at articulating relevant goals and corresponding objectives, which can be explained as steps toward a goal.
Beginning with the client’s conception of the problem and the work to be done means that the therapist attempts to pace the course of therapy to move only as far and as fast as the client is willing to go, testing that boundary by pushing gently against it and adjusting the approach according to the client’s reaction. At the outset of planning treatment, the client may report many troubles, a small number, or none at all. The therapist refines the focus by helping the client select a workable number of issues to target. For clients with clear ideas about personal goals and priorities, this part is not difficult.
However, clients with diffuse or multitudinous problem statements can be reminded that setting and clarifying priorities makes more efficient use of the time available in sessions. The therapist can acknowledge the legitimacy of all the client’s expressed concerns and still encourage sharpening the focus of the treatment plan. When clients deny any problem or cannot think of a specific one, the therapist can create momentum by reflecting one complaint the client has mentioned already even if the client did not label it as a focus for therapy.
A viable treatment plan requires only one goal that both (or all) parties agree to work on, although it certainly may consist of more goals depending on the client’s current understanding. The therapist who responds, “You’re telling me the main thing you want out of coming here is to get out of trouble by satisfying the judge’s order that you get therapy. I’d say that’s something we can work on together,” will often obtain the client’s willingness to continue the conversation. That one goal can become the basis for an initial treatment plan to satisfy all aspects of the court order by considering what steps the client would need o take in order to do so. Revising a treatment plan In addition to the client’s starting point, the therapist simultaneously entertains ideas about problem definitions and resolution strategies based on what the client has said and done in sessions. The therapist is devising plans as the therapist gets to know the client. In negotiating a plan with the client, the therapist continually estimates how far the client’s ideas are from the therapist’s own, and how ready and willing the client seems to be to hear alternative perspectives the therapist has to offer.
The therapist continually decides how and when to introduce the therapist’s private thoughts into the joint planning process. The therapist’s decisions will rest on an assessment of how far the client has come, how far the client is willing to go, and what resources the client has available to support taking the next step between those two points. The therapist can enhance opportunities for collaboration by telling the client up front that together they can review the treatment plan periodically to decide whether to stick to the game plan or go back to the drawing board.
To facilitate collaboration in planning with clients, the therapist needs skills for balancing structure with flexibility. Planning treatment for substance abuse can involve negotiation with clients who are unfocused, skeptical, or resentful about treatment, or who may be trying to test or deceive the therapist. The therapist tries to give the client a framework to clarify expectations and guide progress, but also to remain open to modifying that framework as suggested by the client’s interests, needs, and attitudes. Conclusion
I have described treatment planning as a continuous process of offering recommendations, negotiating strategies, and encouraging client choice. Through careful and collaborative planning, the therapist develops a meaningful structure for the course of treatment and promotes increased motivation and self-efficacy on the part of the client. This is accomplished by providing a rationale for goals and strategies tailored to the client’s degree of self-efficacy and readiness for change. Since clients with substance use disorders often embody insufficient senses of structure, motivation, or efficacy to promote change (if not all three), effective lanning establishes therapeutic conditions under which substance abuse can be potentially reduced and positive changes in behavior can be undertaken.