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Counseling Performance Domain MCAP Back to Course Index



Counseling is a collaborative effort between a counselor and client. Mental health and substance abuse professionals help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem, and promote behavior change and optimal mental health.

There are many specialties in the field of counseling such as:

  • Addictions counseling
  • Child and Adolescent counseling
  • Gerontological counseling
  • LGBTQ counseling
  • Grief counseling
  • Sex therapy
  • Trauma counseling
  • Marriage and Family

There are also various types such as individual, couples, family and group counseling.



Individual counseling is a personal opportunity to receive support and experience growth during challenging times in life. Individual counseling can help an individual deal with many personal topics in life such as anger, depression, anxiety, substance abuse, marriage and relationship challenges, parenting problems, school difficulties, career changes or any issues that are hard to face alone.

It is a joint process designed to help people overcome obstacles to their well-being. It can increase positive feelings, such as compassion and self-esteem. People in therapy can learn skills for handling difficult situations, making healthy decisions, and reaching goals. Many find they enjoy the therapeutic journey of becoming more self-aware. Some people even go to ongoing therapy for self-growth.

The first session of therapy often focuses on gathering information. A counselor speaks with the person in treatment about their past physical, mental, and emotional health. They also discuss the concerns bringing the person to therapy. It can take a few sessions for a therapist to have a good understanding of the situation. Only then can they determine the best course of action.

Many therapists encourage people in treatment to do most of the talking. At first, it may be hard for a client to talk about past experiences or current concerns. Sessions may stir up intense emotions. It is possible that they will become upset, angry, or sad during individual counseling.  However, counselors can help people build confidence and become more comfortable as sessions progress. 

Individual counselors might assign “homework” to help the people in their care build on topics discussed in therapy. Individuals in treatment can also ask questions at any point in the process. As time passes, people in therapy may develop a more positive mood and healthier thinking patterns.

Individual therapy is also called therapy, psychotherapy, psychosocial therapy, talk therapy, and counseling.   



Every couple experiences ups and downs in their levels of closeness and harmony over time. This can range from basic concerns of stagnation to serious expressions of aggressive behavior.  

Couples counseling is a type of therapy in which a counselor helps two people involved in a relationship gain insight into their relationship, resolve conflict and improve relationship satisfaction utilizing a variety of therapeutic interventions. Although the practice of couples therapy may vary depending on the therapist’s theoretical orientation, all couples therapy tends to involve the following general elements:

  1. A focus on a specific problem (i.e. sexual difficulties, Internet addiction, jealousy)
  2. Active participation on the part of the therapist in treating the relationship itself, rather than each individual separately.
  3. Solution-focused, change-oriented interventions early on in treatment.
  4. A clear establishment of treatment objectives.

Couples therapy will usually begin with some standard interview questions regarding the history of the relationship as well as some exploration into each partner’s family-of-origin, values, and cultural background. The counselor might use the initial sessions for crisis intervention if necessary.

The counselor will then assist the couple in identifying the issue that will be the focus of treatment, establishing treatment goals and planning a structure for treatment.

During the treatment phase, the counselor will help the couple gain insight into the relational dynamics maintaining the problem, while helping both partners understand each of their roles in the dysfunctional interactions. This will help them change the way they perceive the relationship and each other.

Although gaining insight is important, another crucial aspect of couples therapy involves actually changing behaviors and ways of interacting with each other. Couples therapists will often assign partners homework to apply the skills they have learned in therapy to their day-to-day interactions.

Most couples can come away from couples therapy having gained insight into relational patterns, increased emotional expression and developed the skills necessary to communicate and problem-solve with their partners more effectively.

Overall, couples counseling can help couples slow down their spiral and reestablish realistic expectations and goals.



Family counseling is designed to address specific issues that affect the psychological health of the family, such as major life transitions or mental health conditions.  It is often sought due to a life change or stress negatively affecting one or all areas of family closeness, family structure (rules and roles) or communication style. This mode of counseling can take a variety of forms. Sometimes it is best to see an entire family together for several sessions.  Common issues addressed in family counseling are concerns around parenting, sibling conflict, loss of family members, new members entering the family, dealing with a major move or a general change affecting the family system.

Family counseling aims to promote understanding and collaboration among family members in order to solve the problems of one or more individuals. For example, if a child is having social and academic problems, therapy will focus on the family patterns that may contribute to the child’s acting out, rather than evaluating the child’s behavior alone. As the family uncovers the source of the problem, they can learn to support the child and other family members and work proactively on minimizing or altering the conditions that contribute to the child’s unwanted behavior.



Group counseling allows an individual to recognize that they are not alone in their type of life challenge. To be involved in a group of peers who are in a similar place not only increases one’s understanding of the struggles around the topic but also the variety in the possible solutions available. Typically, groups have up to eight participants, one or two group leaders, and revolve around a common topic like anger management, self-esteem, divorce, domestic violence, recovery from abuse and trauma, and substance abuse and recovery.

This form of counseling involves talking and listening to each other’s concerns and progress. Participants usually feel open to express their beliefs, thoughts, and emotions, without fear of judgment or retaliation.

Group counseling helps individuals develop a support system.  Not only do participants in group counseling learn social skills, but they also develop good, healthy friendships that tend to last and extend outside of therapy. 

Just knowing there are other people in the community that suffer from the same disorder they do, who are grieving like they are, who have been through trauma, etc. can be a very powerful tool in recovery and overcoming life’s obstacles. Knowing that they are not the only one, that they are part of a collective can be very therapeutic for many clients.



The primary assessment process takes place during the first meeting.  During this period a diagnostic interview is performed whereupon the interviewer will go over the results of the screening and ask more questions to get a better picture of the individual’s mental health and or drug or alcohol use and abuse. This may be done by one of two ways: either a structured interview or semi-structured interview.

Though the first, by way of set and structured questions, is easier for someone without an intense background in the field to administer, they do not result in as much detail, thus there is not as much information off of which to base a treatment plan. A semi-structured interview allows the professional, who is more skilled within this area, to supplement the structured questions by ones derived from their specific expertise within the field, allowing them to better cross-examine a person’s substance abuse.

information that is obtained by substance abuse and mental health professionals in an initial assessment is the cornerstone from which a comprehensive treatment plan can be developed. The effectiveness of the treatment plan relies heavily on the information gathered such as issues, disorders, obstacles, strengths, willingness, and abilities of the client.

There are several types of assessments including, assessments for status, treatment, as well as professional assessments on individuals who have very emotionally challenging careers such as police officers or professionals who have crossed the professional boundaries and have been sanctioned by professional licensing boards, law enforcement or their employer.  During this course, we will focus primarily on substance abuse and dual diagnosed mental health and addiction assessments.

Assessments are client-centered by their very nature and specifically relate to the distress and difficulties that each client must endure. 

However, the initial assessment is not the only time to assess how the client is doing.  Evaluating progress throughout counseling helps to maintain client communication and accountability and to allow the counselor to make appropriate changes in the treatment plan and level of care to continue to provide appropriate therapy.  

Client progress assessment includes reviewing attendance, helping clients to continue to identify their strengths, weaknesses and needs, observing client behaviors during sessions, gaining input from the client, and continuing to establish community and family support systems for the client to step down with.

Ongoing assessment includes:

  1. evaluating clients’ symptoms
  2. measuring the occurrence of specific target behaviors
  3. assessing progress toward specific goals

Research shows that when both therapists and clients receive feedback on progress, clients tend to have better outcomes.

Clients may track and report the occurrence of panic attacks, angry outbursts, or incidents of self-harm behavior. They may also track the frequency and amount of alcohol, drugs, nicotine, or food they ingested in the previous week—or the number of minutes they engaged in compulsive rituals. The type of monitoring and assessment varies from client to client, based on the goals they’ve decided they want to work toward. When clients do not make expected progress, they conceptualize the difficulty.  It is important to modify treatment accordingly when appropriate. Sometimes clients notice improvements almost immediately, especially when they have three kinds of experiences:

  • They realize that the treatment plan their counselor describes makes sense to them. They understand how it is that they’ll overcome their difficulties. And they have confidence that their particular therapist will be competent and helpful.
  • They change their unhelpful thinking in session and feel better.
  • They enact an “action plan,” at home and notice an improvement in their mood. The action plan, collaboratively designed with their counselor usually includes (1) reading “therapy notes” of the most important things they learned in session and (2) engaging in specific activities that are linked to the accomplishment of their goals. For example, a depressed client might make plans with friends; an anxious client might expose himself to a feared situation to find out to what degree a negative outcome occurs.

These three kinds of experience increase hope and clients are able not only to arrest their downward negative spiral but also to reverse direction. They then find themselves on an upward positive spiral. 

Clients can help assess their progress by asking themselves:

  • How is my mood throughout the week (not just at the end of sessions)? Is it at least gradually improving (albeit with ups and downs)?
  • Are my specific symptoms or problematic behaviors improving?
  • Am I solving problems and working toward my goals?

For the counselor, outcome measurement tools allow counselors to measure the impact of treatment over the course of time.   The choice of standardized measurement varies significantly between counselors.  There are performance-based, self-reported, or a hybrid of outcome measurements. All are helpful, but consider that self-reported outcomes project a client’s belief of accomplishment (and can be skewed based on self-limiting or grandiose beliefs), whereas performance-based metrics showcase actual therapeutic findings.

Client progress is also detailed through treatment notes that help measure results.  It’s important to distinguish outcomes from satisfaction. Clients who feel comfortable with their counselor may have high satisfaction because they enjoy the time with their counselor but the outcome, stopping the use of alcohol is not attained.




Change happens easily when there are clear punishments for continued same behavior and clear rewards for changed behavior.  We stop touching hot stoves early on because we get hurt. If we find out that something makes us feel happy and there are no costs, we’re going to do it more often. But sometimes, change can be more complex. Making the decision to leave a romantic partner, or to switch careers, might take years of thought and heartache. There are countless pros and cons that cannot easily be boiled down to “better” or “worse”.

Psychotherapy is the art and science of helping others create change through psychological means, and the countless approaches give us several ways to achieve these goals. Some theories view change as a purely behavioral process. Others focus on genetics as the influence on behavior.  Still, others suggest that the answer is education. If a person learns about the possible consequences of a behavior, they will change.

Motivational interviewing, sometimes referred to as MI, is a client-centered, directive counseling method aimed at enhancing intrinsic motivation that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior. It is a practical, empathetic, and short-term process that takes into consideration how difficult it is to make life changes.

Motivational interviewing is often used to address addiction and the management of physical conditions such as diabetes, heart disease, and asthma. This intervention helps people become motivated to change the behaviors that are preventing them from making healthier choices. It can also serve as a pre-curser to other types of therapies that can address other issues. Research has shown that this intervention works well with individuals who start off unmotivated or unprepared for change. Motivational interviewing is also appropriate for people who are angry or hostile regarding the changes that are necessary. They may not be ready to commit to change, but motivational interviewing can help them move through the emotional stages of change necessary to find their drive and make peace with change.

Motivational interviewing evolved from Carl Roger’s person-centered, or client-centered, approach to counseling and therapy. It shares Carl Rogers’ optimistic and humanistic theory about people’s capabilities for exercising free choice and changing through a process of self-actualization. The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership.  Jumping off from this foundation, clinical psychologists William R. Miller and Stephen Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures. Core concepts evolved from experience in the treatment of problem drinkers, and Motivational Interviewing was first described by) in an article published in Behavioural Psychotherapy.   Compared with non-directive counseling, it is more focused and goal-directed and departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. 

Client-Centered therapy uses an empathetic style of interaction.  The therapist expresses acceptance toward the client, even if they feel their behaviors are harming them or their loved ones.  The therapist does not need to condone the behavior, but acceptance is key.  Acceptance is the willingness to listen, understand, and to respect the client as a human being. 

The Motivational Interviewing process is aimed at increasing an individual’s reason for the change and then for the individual to fully commit to the change that is necessary. As opposed to simply stating a need or desire to change, hearing themselves express a commitment out loud has been shown to help improve a client’s ability to make those changes. The role of the therapist is more about listening than intervening. Motivational interviewing is often combined or followed up with other interventions, such as cognitive therapy, support groups such as Alcoholics Anonymous and stress management and coping strategy training.

There are four overlapping processes that comprise Motivational Interviewing: engaging, focusing, evoking and planning. They are both sequential and recursive, and often depicted in diagrams as stair steps, with engaging at the bottom as the first step.

  1. Engaging: the process of establishing a working relationship based on trust and respect. The client should be doing most of the talking, as the counselor utilizes the skill of reflective listening throughout the process. Both the client and counselor make an agreement on treatment goals and collaborate on the tasks that will help the client reach those goals.
  2. Focusing: the ongoing process of seeking and maintaining direction.
  3. Evoking: eliciting the client’s own motivations for change, while evoking hope and confidence.
  4. Planning: involves the client making a commitment to change, and together with the counselor, developing a specific plan of action.

Motivational interviewing is a counseling style based on the following assumptions:

  • Ambivalence about change is normal and constitutes an important motivational obstacle in recovery.
  • Ambivalence can be resolved by working with a client’s intrinsic motivations and values.
  • The alliance between the counselor and the client is a collaborative partnership to which each brings important expertise.
  • An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.)

In this section, we will explore the five basic principles of Motivational Interviewing that can be used to address ambivalence and to facilitate the change process. We will also look at approaches to use with clients in the early stages of treatment.



Ambivalence is defined as the state of having mixed feelings or contradictory ideas about something whereas denial is defined as the action of declaring something untrue.  It is important to see the difference between these two.  They both might be part of an issue, but they are different.  An individual who is obese, addicted to substances or gambling or perhaps has anger issues is usually aware of the dangers of their behavior but continue anyway. They are somewhat unsure of their ability to control these behaviors.  There is certainly an element of denial in the seriousness of the issue, but everyone knows that smoking is bad for your lungs.  Everyone is aware that donuts are not a healthy snack.  An individual may want to stop smoking, but at the same time, they don’t want to quit either.  There is a positive intention and most of the time a reward for their behavior despite the knowledge they have regarding the drawbacks of continuing the behavior.  They enter treatment programs because a family member or court system makes them while they express the problem isn’t that big.  These disparate feelings can be characterized as ambivalence, and they are natural, regardless of the client’s state of readiness. It is important to understand and accept the client’s ambivalence because ambivalence is often the central problem.  If a counselor interprets ambivalence as only denial or resistance, friction between the counselor and the client tends to occur.  Ambivalence is, “I want to quit drinking because I’m an angry drunk and always fight with my wife when I drink but I enjoy the social aspects and its so hard.”  Denial is, “the only issue with my drinking is my wife is no fun and gets on my case”. 

The motivational interviewing style facilitates exploration of stage-specific motivational conflicts that can potentially hinder further progress. However, each dilemma also offers an opportunity to use the motivational style to help your client explore and resolve opposing attitudes.

To effectively implement Motivational Interviewing Dr. Miller and Dr. Rollnick developed three mnemonics to assist: RULEPACE, and OARS.

RULE can be used to remember the core principles of MI.  First, Resist the righting reflex, which means the counselor should resist giving suggestions to the client for his or her problem. While the counselor may mean well, offering suggestions might make the patient less likely to make a positive change. A counselor can attempt to Understand the client’s motivation by being a careful listener and attempting to elicit the client’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the client. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.



PACE is the “spirit” or mindset that clinicians should have when conducting MI.  Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the counselor is a clinical expert, the client is an expert in prior efforts at trying to change his or her circumstances for the better. The therapeutic environment should be as positive as possible so that the client will find it comfortable to discuss a change. The client should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.  While the counselor continues to educate the client about the harms of behaviors such as excessive drinking or substance use, they recognize that ultimately the decision is the clients. Every effort should be made to draw from the clients’ goals and values, so that the client, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that the counselor is on the client’s side and that his past choices in life do not negatively affect the counselor’s perception of him. The client should be accepted for who he is, and not met with disapproval over any personal decisions that he made. Exercise Compassion towards the client’s struggles and experiences, and never be punitive. Every attempt to have discussions that can be Evocative for the client should be made. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.



OARS is an acronym to represent core interviewing skills.  OARS stands for Open-ended questions, Affirmations, Reflection, and Summaries

Open-ended questions get the client to think before responding, providing frequent affirmations of the client’s positive traits, using reflective listening techniques while the client talks about his disorder, and providing succinct summaries of the experiences expressed by the client throughout the encounter to invite continued exploration of his behaviors are all skills for the counselor to develop.

Examples of open-ended questions include:

“What brought you here today?”
“Help me…” or “Tell me more about…”
“What will happen if you don’t….”
“Suppose you don’t make a change, what is the worst that might happen?”
“What would you like to see different about your current situation?”


Affirmations are used to recognize a client’s strengths, successes, and efforts to change.  Examples of affirmations include:

“Your commitment really shows by….”
“You showed a lot of strength by…..”
“It is clear this is important to you because you….”


Reflections keep the counselor connected to the client’s thoughts, suspending judgment, acknowledging what the client said and helps them to feel validated.  Examples of reflections include:

“What I hear you saying is….”
“It seems as if….”
“I get the sense that you want to change, and you have concerns about…”
“It sounds like…”


Summaries can be used throughout an interaction.  They are a form of reflective listening.  Examples of summarizing include:

“So what I understand you have said is….”
“If I hear you….”


Five Principals in Motivational Interviewing

Motivational interviewing has been practical in focus. The strategies of motivational interviewing are more persuasive than coercive, more supportive than argumentative. The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments (Miller and Rollnick, 1991, pp. 51-51).

The clinician practices motivational interviewing with five general principles in mind:

  1. Express empathy through reflective listening.
  2. Develop discrepancy between clients’ goals or values and their current behavior.
  3. Avoid argument and direct confrontation.
  4. Adjust to client resistance rather than opposing it directly.
  5. Support self-efficacy and optimism.



Empathy is the ability to understand and share the feelings of another.  It is the experience of understanding another person’s thoughts, feelings, and condition from his or her point of view, rather than from one’s own. Empathy facilitates pro-social or helping behaviors that come from within, rather than being forced, so that people behave in a more compassionate manner.  Reflective listening is sometimes used to build and show empathy through understanding.  It is a communication strategy involving seeking to understand a speaker’s idea, then offering the idea back to the speaker, to confirm the idea has been understood correctly. It attempts to reconstruct what the client is thinking and feeling and to relay this understanding back to the client.

Empathy should not be confused with identification with the client or the sharing of common past experiences. The key component of expressing empathy is reflective listening.

An empathetic style:

  • Communicates respect for and acceptance of clients and their feelings
  • Encourages a nonjudgmental, collaborative relationship
  • Allows you to be a supportive and knowledgeable consultant
  • Sincerely compliments rather than denigrates
  • Listens rather than tells
  • Gently persuades, with the understanding that the decision to change is the client’s
  • Provides support throughout the recovery process

Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client’s unique perspective, feelings, and values. The attitude of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected is again a very important piece of this approach. Motivational interviewing is most successful when a trusting relationship is established between you and your client.

Understanding and empathy can be conveyed through skillful reflective listening with the knowledge that acceptance facilitates change and ambivalence is a normal feeling. 


Discrepancy Between Client’s Goals or Values and Current Behavior

Although MI is client-centered, unlike classic Rogerian therapy, it is more goal-driven and directional. That is, there is a clear positive behavioral outcome, e.g., quitting smoking, losing weight, adhering to medication. As clients experience a discrepancy between their current behavior and their personal core values or life goals through their own words a clarification of values occurs that often leads to an affliction of the comfortable.  When clients perceive discrepancies between their current situation and their hopes for future change is likely to occur.

The counselor’s task is to help focus the client’s attention on how current behavior differs from ideal or desired behavior. The discrepancy is initially highlighted by raising your clients’ awareness of the negative personal, familial, or community consequences of problem behavior and helping them confront the behavior, i.e. substance use, that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.

A successful strategy is to separate the behavior from the person and help the client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current behavior. This requires the counselor to listen carefully to the client’s statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlighting this concern to heighten the client’s perception and acknowledgment of discrepancy can help produce the client’s own cognitive shift.

Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, the counselor can amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perceive discrepancy is sometimes called the “Columbo approach” (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client’s problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).

Motivational Interviewing information is frequently presented using an ELICIT-PROVIDE-ELICIT framework. The counselor first elicits the person’s understanding and need for information, then provides new information in a neutral manner, followed by eliciting what this information might mean for a client, using a question such as, “What does this mean to you” or “How do you make sense of all this?” MI practitioners avoid trying to persuade clients with “pre-digested” health messages and instead allow clients to process information and find what is personally relevant for them. Autonomy is supported by also asking how much information the client might desire.

Developing discrepancies include:

  • Developing awareness of consequences helps clients to examine their behavior
  • A discrepancy between present behavior and important goals motivates change.
  • The client presents the arguments for change.


Avoid Argument

A counselor may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If the counselor tries to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not the counselor, who voices arguments for change, progress can be made. The goal is to “walk” with clients (i.e., accompany clients through treatment), not “drag” them along (i.e., direct clients’ treatment).

Resistance can be seen as a signal to change strategies or listen more carefully to the client’s reasons for a particular behavior.  Resistance offers the counselor an opportunity to respond in a new, perhaps surprising way to gain an alliance toward overcoming a legitimate obstacle to new behavior.


Roll With Resistance

Confronting clients can evoke reactance and shut them down. Therefore, Motivational Interviewing counselors “roll with resistance” rather than attempt to argue with the client. Such reflections can be thought of as “comforting the afflicted.” The counselor can “pull up alongside clients,” essentially agreeing with the client, even if the statement is factually incorrect or unfairly places blame on others. Examples include: “You really enjoy smoking weed. You look forward to lighting up at night and giving it up seems very difficult” or “eating at McDonalds has filled a need for you. It’s cheap, convenient, and really works given your busy schedule”. Such reflections help capture the client’s reasons for not changing and allow them to express their resistance without feeling pressured to change or worrying about being judged.

Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, the viewpoint is that resistance is a signal that the client views the situation differently. This requires the counselor to understand the client’s perspective and proceed from there.

Adjusting to resistance is similar to avoiding an argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible and divert or deflect the energy the client is investing in resistance toward positive change.


Simple Reflection:

The simplest approach to responding to resistance is with nonresistance, by repeating the client’s statement in a neutral way. This acknowledges and validates what the client has said and can elicit an opposite response.

Client: I don’t plan to quit drinking anytime soon.

Clinician: You don’t think that abstinence would work for you right now.


Amplified Reflection:

Another strategy is to reflect the client’s statement in an exaggerated form–to state it in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.

Client: I don’t know why my wife is worried about this. I don’t drink any more than any of my friends.

Clinician: So, your wife is worrying needlessly.

Amplified negative reflections are a way of arguing against change by exaggerating the benefits of or minimizing the harm associated with risky behavior.  It may take the form of “, so you see no benefit in changing XX”.  The counselor, by arguing against change can exhaust the client’s negativity. In response, clients will often then reverse their course, and start to argue for change. This type of reflection poses some potential risks and can occasionally backfire. Important here is for the counselor to avoid any tone of sarcasm. This type of reflection is particularly useful when clients appear stuck in a “yes, but” mindset.


Double-Sided Reflection:

A third strategy entails acknowledging what the client has said but then also stating contrary things they have said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.

Client: I know you want me to give up drinking completely, but I’m not going to do that!

Clinician: You can see that there are some real problems here, but you’re not willing to think about quitting altogether.

Double-sided reflections capture client ambivalence and communicate to the client that the counselor heard their reasons both for and against change; that the counselor understands the decision is complex, and they are not going to prematurely push them to change. Double-sided reflections typically take the form of “on the one hand, you would like to change XX, but on the other hand, changing XX would mean giving up XX” or “you are torn about changing XX….”


Shifting Focus

A counselor can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm the client’s personal choice regarding the conduct of his own life.

Client: I can’t stop smoking pot when all my friends are doing it.

Clinician: You’re way ahead of me. We’re still exploring your concerns about whether you can get into college. We’re not ready yet to decide how marijuana fits into your goals.


Reframing a client’s reflections can help them feel understood so the need for resistance is lower. 

Client:  I don’t understand why my wife attacks me about my drinking.  I drink a lot less than most people.  Everyone I know drinks after work.

Clinician:  It sounds like your wife really cares about you, but you feel judged by how she brings it to your attention.

Rolling with resistance can shift perceptions and create new ways of thinking without imposing on them on a client.  The client is a valuable resource for finding solutions to his or her problem.


Reflection On Omission

Sometimes a counselor can reflect on what clients have not said. This can include reflecting on the client’s silence or reluctance to talk about a particular issue; “you don’t seem like talking today or you didn’t have much of a reaction to what I just said. ” In such cases, an omission reflection is an extension of rolling with resistance. However, an additional permutation includes reflecting the client beliefs, solutions to problems, sources of help, etc. that have not been raised. For example, if an otherwise happily married woman states that she has no one to exercise with, the counselor could reflect “so it sounds like your husband is not the answer.” Another variation might include, “so I assume you probably have thought about trying XX solution/option but that doesn’t seem to work for you.”


Support Self-Efficacy

The client’s feeling of selfefficacy through his or her having an active role in the decision-making process ultimately has a very positive effect on the outcome of therapy.  Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires the counselor to recognize the client’s strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial the clinician also believes in the clients’ capacity to reach their goals.

A strong sense of efficacy can be developed through mastery experiences, vicarious learning experiences, and physical and emotional states.

Mastery experiences are personal experiences that give people a sense of accomplishment and a feeling of mastery. By managing challenges through successive achievable steps, people develop a sense of mastery. Mastery experiences are the most effective way to develop a strong sense of efficacy because they offer the most authentic evidence that one can do what it takes to succeed. Success experiences help build self-efficacy, while failures undermine it. For example, using the weight loss example, a person who has lost weight in the past is more likely to have higher self-efficacy in this area than someone who has not been able to lose weight previously. 

Vicarious experiences through social modeling are another way to develop self-efficacy. If people see others similar to themselves succeed through persistent effort, they may come to believe they, too, can succeed in similar activities. The impact vicarious experiences have on self-efficacy depends on how similar to the model people perceive themselves to be. The greater the perceived similarity, the more impact the model’s successes and failures will have on a person’s self-efficacy beliefs.

Clients frequently use their physical and emotional states to judge their capabilities. An elevated mood can enhance self-efficacy, while a negative mood may diminish it. Clients tend to associate stress, tension, and other unpleasant physiological signs with poor performance and perceived incompetence. In activities requiring strength and stamina, feelings of fatigue and pain cause self-efficacy beliefs to decrease. Clients with a strong sense of efficacy are more likely to view their state of emotional arousal as energizing, while people with a weak sense of efficacy will view their state of emotional arousal as debilitating.

Discussing treatment or change options that might still be attractive to clients is helpful when helping to develop self-efficacy, even though they may have had limited success in the past. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, “one day at a time,” may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients’ sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how to make changes. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

A belief in the possibility of change is an important motivator.  The client is responsible for choosing and carrying out personal change. 


Overview Of Motivational Interviewing As A Therapy

(Parts of this section are from Stephen Rollnick, Ph.D., & William R. Miller, Ph.D. What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.  Dr. Rollnick and Dr. Miller are credited in part with the developed Motivational Interviewing.)

When implementing motivational interviewing it is important to distinguish between the spirit of motivational interviewing and the specific techniques of the therapy. Clinicians who become too focused on techniques can lose sight of the concepts that are central to the approach. A counselor should focus on the idea that motivation to change is elicited from the client, and not be imposed. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client’s intrinsic values and goals to stimulate behavior change. 

It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict. For example, “If I stop smoking, I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive.” The counselor’s task is to facilitate the expression of both sides of the ambivalence impasse and guide the client toward an acceptable resolution that triggers change.  

Direct persuasion is not an effective method for resolving ambivalence.  These tactics generally increase client resistance and diminish the probability of change.  

The counseling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counselor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to “confront client denial,” easily slip into pushing clients to make changes for which they are not ready.  

The counselor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioral coping skills, although the two approaches are not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.

Resistance and “denial” are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client’s autonomy and freedom of choice (and consequences) regarding his or her own behavior. Viewed in this way, it is inappropriate to think of motivational interviewing as a technique or set of techniques that are applied to or (worse) “used on” people. Rather, it is an interpersonal style, not at all restricted to formal counseling settings. It is a subtle balance of directive and client-centered components shaped by a guiding philosophy and understanding of what triggers change.

The motivational interviewing style includes:

  • Seeking to understand the person’s frame of reference, particularly via reflective listening
    Expressing acceptance and affirmation
  • Eliciting and selectively reinforcing the client’s own self-motivational statements and expressions of problem recognition, concern, desire and intention to change, and ability to change
  • Monitoring the client’s degree of readiness to change and ensuring that resistance is not generated by jumping ahead of the client.
  • Affirming the client’s freedom of choice and self-direction. The point is that it is the spirit of motivational interviewing that gives rise to these and other specific strategies and informs their use.


In early treatment sessions, a counselor should determine the client’s readiness to change by asking open-ended questions.  Open-ended questions help a counselor understand the clients’ point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, they help the counselor to avoid making premature judgments, and they keep communication moving forward.

Reflective listening, summarizing, affirming, eliciting self-motivational statements can all help the client move to new behaviors that better serve their values and goals.


Components of successful Motivational Interviewing:

  • Empathy– the ability to understand and identify another person’s experience and communicate that perception back to the person is one of the main components of establishing rapport. Empathy and Hope are the most important components of good counseling.
  • Active Listening– involves attending skills and reflective listening. This helps counselors connect with the client by reflecting what the client’s underlying thoughts and feelings are back to the client.  The counselor can also provide useful feedback to the client that may include observations that the client had not considered.
  • Concreteness– the counselor will translate the vague aspects of the client’s statements and experiences into specific concrete terms in order to help the client develop more effective coping skills.
  • Paraphrasing– includes the therapeutic qualities of empathy and warmth. Comprises the counselor’s verbal responses that rephrase the content of the client’s statements into a meaningful conclusion. It allows the client to hear what he or she has just said and applies added clarity of meaning for the client.  This helps increase trust and reduces the client’s resistance.
  • Reflecting– This occurs when the counselor rephrases content that generated emotion in the client. It reflects feeling.  Reflection captures the essence of what a client is feeling and states it back to the client. This helps the client be aware of his or her own expressed emotions and how the counselor understood the client’s emotional message.  Counselors are warned not to interpret their clients’ feelings.  Do not offer opinions, judgments or advice at this point.
  • Simplifying– includes reflection and restatement of what the client is trying to convey in a concise and clear way. It removes confusion and avoids intellectualization. Simplifying helps clients stay focused on specific problems in the here and now.”
  • Summarizing– involves tying together the main points, themes and issues.
  • Attending– refers to how the counselor pays attention to the client using cues.
  • Probing– consists of asking open-ended questions in order to clarify information and help the client gains an insightful understanding.
  • Reframing– involves offering a different perspective on a problem or circumstance the client is facing.
  • Exploring Alternatives– helping the client develop and consider various options.
  • Self-disclosure– this is when the counselor shares something personal about himself or herself that is beneficial to the client.
  • Confrontation– this is when a counselor raises a point to challenge a discrepancy that the client presented.
  • Immediacy– this involves interpersonal counseling, where the clinician discusses issues between himself or herself and the client in the present.

Motivational interviewing has been shown to be a useful clinical intervention and is an effective, efficient, and adaptive therapeutic style.

Motivational interviewing has the following benefits:

  • Low cost. Motivational interviewing was designed from the outset to be a brief intervention and is normally delivered in two to four outpatient sessions.
  • Efficacy. There is strong evidence that motivational interviewing triggers change in high-risk lifestyle behaviors.
  • Effectiveness. Large effects from brief motivational counseling have held up across a wide variety of real-life clinical settings.
  • Mobilizing client resources. Motivational interviewing focuses on mobilizing the client’s own resources for change.
  • Compatibility with health care delivery. Motivational interviewing does not assume a long-term client-therapist relationship. Even a single session has been found to invoke behavior change, and motivational interviewing can be delivered within the context of larger health care delivery systems.
  • Emphasizing client motivation. Client motivation is a strong predictor of change, and this approach puts primary emphasis on first building client motivation for change. Thus, even if clients do not stay for a long course of treatment (as is often the case with substance abuse), they have been given something that is likely to help them within the first few sessions.
  • Enhancing adherence. Motivational interviewing is also a sensible prelude to other health care interventions because it has been shown to increase adherence, which in turn improves treatment outcomes.

Motivational interviewing is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Therapists help clients envision a better future and become increasingly motivated to achieve it.  The strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.  



Whether the issues bringing a client to treatment involve mental health, addiction or both there are many different treatment options available.  

  • Psychotherapy– Psychotherapy is the therapeutic treatment of mental illness provided by a trained mental health professional.  Psychotherapy explores thoughts, feelings, and behaviors, and seeks to improve an individual’s well-being.  Psychotherapy paired with medication is the most effective way to promote recovery.  Examples include Cognitive Behavioral Therapy, Exposure Therapy, Dialectical Behavior Therapy, etc.
  • Medication – Medication does not outright cure mental illness.  However, it may help with the management of symptoms.  Medication paired with psychotherapy is the most effective way to promote recovery.
  • Support Group – A support group is a group meeting where members guide each other towards the shared goal of recovery.  Support groups are often comprised of nonprofessionals, but peers that have suffered from similar experiences. 
  • Complementary & Alternative Medicine – Complementary and alternative treatment and practices refer to options that are not typically associated with standard care.   These may be used in place of or in addition to standard health practices.
  •  Peer Support – Peer Support refers to receiving help from individuals who have suffered from similar experiences. 

Other and complementary treatments include:

  • Electroconvulsive Therapy
  • Art Therapy
  • Animal-Assisted Programming
  • Relapse Prevention Skills Group
  • Communications Training
  • Recovery Management Skills Building
  • Stress Reduction Skills Training
  • Yoga
  • Spiritual Care
  • Emotional Regulation
  • Distress Tolerance Skills Training
  • Experiential Therapy
  • Process Focused Group Therapy


Treating Addiction

Let’s explore the options for addiction treatment in more detail.  Addiction is a chronic disease, much like diabetes or hypertension.  Individuals with drug or alcohol addiction need to actively manage the condition over their lifetime.   A quality treatment program helps clients learn to manage their symptoms, first within the structure and support of a treatment setting whether outpatient, intensive outpatient, inpatient or residential and eventually in their home environment on their own where they are in charge of their sobriety. For example, an individual might start out in an inpatient facility and, as progress is made, participate in a less intense outpatient program. As the individual gains and strengthens recovery skills and the risk of relapse lessens, the level and frequency of clinical services can be decreased until maybe all that’s needed is participation in a Twelve Step group. 

There are numerous treatment approaches that are built on evidence-based addiction therapies. 

Frequently used therapies, techniques, and practices include:

Dialectical Behavioral Therapy

Dialectical Behavior Therapy (DBT) is a treatment approach that emphasizes balancing behavioral change, problem-solving and emotional regulation with validation, mindfulness, and acceptance.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is a form of treatment that focuses on exploring patterns of thinking that lead to self-destructive actions and identifying the beliefs that direct these thoughts. Through CBT, people can learn to modify their patterns of thinking to improve their coping skills.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) uses mindfulness and behavioral activation to increase psychological flexibility and the ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions or sensations.

Motivational Enhancement and Interviewing

Motivational Enhancement and Interviewing is collaborative and helps patients identify “what’s in it for me,” with regard to staying sober, working through difficult issues, and developing the skills necessary to accomplish goals.

Medication-Assisted Therapies

Medications are primarily used to treat substance use disorders related to opioids and alcohol, helping to ease withdrawal symptoms and reduce cravings. The use of medication-assisted treatment for opioid dependence with naltrexone and buprenorphine/naloxone is supported by scientific research and recommended by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA), National Institute on Drug Abuse (NIDA), Washington Circle (a policy group devoted to improving care for substance use disorders) and the Veterans Administration. Medication-assisted therapy should always be used in conjunction with the Twelve Steps and other behavioral therapies, with abstinence as the end goal.

Contingency Management/Motivational Incentives

Contingency management (CM) involves incentive-based interventions. Studies show that tangible rewards reinforce positive behaviors and are highly effective in increasing treatment retention and promoting abstinence from drug use.

Interpersonal Therapy

Interpersonal therapy, or IPT, is a short-term, limited-focus treatment for depression.

Solution Focused Brief Therapy/Solution Focused Therapy

Solution Focused Therapy focuses on a person’s present and future, rather than past. This is considered goal-oriented therapy. The symptoms or issues that brought a person to their current situation are usually not the target in this therapy setting.

Mindfulness-Based Cognitive Therapy

Mindfulness-Based Cognitive Therapy (MBCT) is used to help prevent depression relapse. This approach works especially well for those with major depressive disorder.

Educational Groups and Lectures

This specific type of group therapy focuses on educating people about disorders and developing coping strategies.

Twelve-Step Facilitation

Twelve Step Facilitation was originally designed as an approach to actively engage patients in abstinence-based Twelve Step groups such as Alcoholics Anonymous. Today, the interventions are more widely utilized to help patients achieve and sustain recovery from both substance use disorders and mental health issues that affect the mind, body, and spirit.

Treating Co-Occurring Disorders

More often than not, addiction comes with complicating factors such as depression, anxiety or trauma, also known as co-occurring disorders. With such complex conditions, the most effective approach to care integrates treatment for addiction and mental health so that both issues are addressed at the same time. Services should be provided by psychiatrists, psychologists, marriage and family therapists, and other mental health professionals. Services may include individual or group therapy, family therapy, diagnostic assessments or medication management.

To provide appropriate treatment for co-occurring disorders, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services recommends an integrated treatment approach. Integrated treatment is a means of coordinating substance abuse and mental health interventions, rather than treating each disorder separately and without consideration for the other.

Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. Integrated treatment may include the following:

  • Help patients think about the role that alcohol and other drugs play in their life. People feel freer to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
  • Offer patients a chance to learn more about alcohol and drugs—how they interact with mental illnesses and with other medications—and to discuss their own use of alcohol and drugs.
  • Help patients become involved with supported employment and other services that may help the process of recovery.
  • Help patients identify and develop recovery goals. If a person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated treatment can help that person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
  • Provide counseling specifically designed for people with co-occurring disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

All substance-abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with CODs. It is the responsibility of each provider to identify clients with both mental and substance use disorders and to assure them that they have access to the care needed for each disorder.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with COD’s. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location where clients are based for the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), client fears of being seen as mentally ill (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not a diagnosis. The four quadrants are

I.  low addiction/low mental illness severity
II.  low addiction/high mental illness
III. high addiction/low mental illness
IV.  high addiction/high mental illness

The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers in order to deliver appropriate care to every client with co-occurring disorders.


Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance-abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse-prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use drugs or drink.


Group Therapy

Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.


Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings. Some offer several hours of weekly treatment, which can include mental health and other support services as well as individual and group counseling for substance abuse. Others provide minimal services, such as one or two brief sessions to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Individuals with COD often need a range of services besides substance-abuse treatment and mental health services. Generally, important needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse-prevention interventions after outpatient treatment need to be modified so that clients can recognize symptoms of psychiatric or substance abuse relapse on their own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly, since the return of psychiatric symptoms can often trigger a bstance-abuse relapse.


The Medical System

Although not substance-abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health interventions do occur in medical units. Acute care refers to short-term care provided by intensive-care units, brief hospital stays, and emergency rooms (ERs). Providers in acute-care settings are not usually concerned with treating substance-use disorders beyond detoxification, stabilization, and/or referral.

In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance-abuse treatment but may be able to provide brief interventions and treatment referrals.

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with co-occurring disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. Because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with co-occurring disorders.



Every client has different needs when it comes to substance abuse treatment. When patients first enter therapy, it is important they are assigned to the proper level of care.

This approach to treatment ensures that patients receive adequate care upon admission and are smoothly transitioned to a higher or lower level of care as needed. According to the American Society of Addiction Medicine, there are five main levels of treatment in the continuum of care for substance abuse treatment:

Level 0.5: Early Intervention Services
Level I:  Outpatient Services
Level II:  Intensive Outpatient/Partial Hospitalization Services
Level III:  Residential/Inpatient Services
Level IV:  Medically Managed Intensive Inpatient Services

The continuum of care was developed to ensure uniformity through the treatment process. This makes what happens in treatment more efficient for patients who transition from one level of care to the next.

As you will explore below levels 2 and 3 are further detailed into sublevels.


Level 0.5:  Early Intervention Services

Early intervention services are a precursor to treatment. They are designed for adults or adolescents who are at risk of developing a substance use disorder but do not display any diagnostic criteria to be admitted to treatment.

During early intervention, treatment focuses on the risk factors that predispose the person to drug addiction and educates the individual about the negative repercussions of drug misuse.

The duration of early intervention services greatly depends on the patient’s understanding of the perils of substance use and whether he or she makes behavioral changes to avoid the path to drug addiction. Patients are closely monitored for symptoms that indicate they need a higher level of treatment.

Examples of early intervention services:

  • Community policies that promote access to early childhood education
  • Education for physicians on prescription drug misuse
  • Community group offered to high-risk families to educates parents on how to strengthen bonding in their families and reduce risk factors
  • Peer support groups for adults with a history of substance abuse
  • Increasing the minimum legal drinking age to 21

Level I: Outpatient Services

Outpatient treatment requires patients to attend regularly scheduled meetings. This level of treatment allows patients to carry on with their routine while receiving face-to-face services with addiction or mental health professionals. It is ideal for people who have jobs or a strong support system at home, and it typically costs less than other levels of treatment.

Level I care includes evaluation, treatment and recovery follow-up services. It addresses the severity of the individual’s addiction, helps implement behavioral changes and ameliorates mental functioning. Patients may transition to the first level of treatment from a more robust program. Level I is also a stepping stone for people who are not ready or willing to commit to a complete recovery program.


Level II: Intensive Outpatient/Partial Hospitalization Services

Partial Hospitalization (PHP) and Intensive Outpatient Programs (IOP) provide clinical diagnostic
and treatment services on a level of intensity similar to an inpatient or residential program, but on a less than 24 hour basis. These services include a therapeutic setting, nursing, psychiatric evaluation, medication management, and group, individual, and/or family counseling. The treatment setting may be at a hospital, clinic or office and provides a highly structured environment to ensure continuity of treatment and safety. PHP and IOP may be appropriate when a patient does not require a restrictive, intensive 24 hour inpatient setting, but does need a higher intensity of services than outpatient treatment can provide. PHP and IOP provide a time-limited service to stabilize acute symptoms and can be used as either a step-down from inpatient care or as a stand-alone level of care to stabilize a deteriorating condition and prevent hospitalization.

Intensive Outpatient (level 2.1) means mental health services more intensive than routine outpatient and less intensive than a Partial Hospital Program.  Outpatient is three or more hours per week of direct treatment.  This program comprises counseling and education about mental health and substance use issues. Patients are referred to psychiatric and medical services if addiction specialists deem it necessary. However, intensive outpatient programs cannot treat unstable medical and psychological conditions.

Partial Hospital Programs (level 2.5) provide 4 hours of direct, structured treatment services per day.  Unlike intensive outpatient programs, where the patient has to be referred to outside psychiatric and medical professionals, partial hospitalization provides direct access to those services along with laboratory services.


Level III: Residential/Inpatient Services

Level III of the continuum of care provides residential substance abuse treatment. This level of treatment is typically appropriate for patients who have functional deficits or require a stable living space to help with their recovery.

Treatment and assistance are provided around the clock, and the facility is staffed 24 hours a day, seven days a week. The patients may live on-site or in a living facility in close proximity to the drug and alcohol treatment center so nearby services are readily available.

Clinically Managed Low-Intensity Residential Services (level 3.1) focus on teaching recovery skills, preventing relapse and improving emotional functions. Professionals also help people relearn essential life skills that will benefit them personally and professionally after treatment.

  • Outpatient substance abuse services
  • A structured recovery environment
  • 24-hour staffing
  • House meetings
  • A community that promotes living skills.

Clinically Managed Medium-Intensity Residential Services (level 3.3) is called extended or long-term care, this treatment program provides a structured environment and medium-intensity clinical services. It is designed for patients who have been deeply affected by substance abuse, including those showing temporary or permanent cognitive deficits.

Robust treatment is offered at a slower and more repetitive pace to help the patient overcome mental impairments such as Wernicke-Korsakoff syndrome, traumatic brain injury or intellectual disability associated with drug use. This level of treatment provides ongoing case management with services including housing, vocational needs, transportation, and continued self-help meetings. It aims to assist patients with societal reintegration.

Clinically Managed High-Intensity Residential Services (level 3.5) is designed for individuals who have multiple issues and have had a series of unsuccessful interventions. The issues may include substance use disorders, criminal activity, mental disorders, impaired functioning and difficulty adapting to societal norms. Level III.5 caters to people with chaotic, nonsupportive and abusive relationships.

Medically Monitored Intensive Inpatient Services (level 3.7)  is directed toward individuals with functional deficits such as withdrawal risks, medical issues or emotional issues that prevent the person from progressing in the recovery process.

Facilities offering level III.7 treatment provide 24-hour professional evaluations, observation, medical monitoring, and addiction treatment.


Level IV: Medically Managed Intensive Inpatient Services

Out of the four levels of treatment, level IV is the most comprehensive and intensive. It offers 24-hour medically directed evaluation, care and treatment, including daily meetings with a physician. The facilities are usually equipped with the resources of general acute care or psychiatric hospitals and offer substance abuse treatment that also addresses co-occurring disorders.

The last level of treatment focuses on stabilizing patients and preparing them for transfer to a less robust level of care for continued monitoring as they progress toward recovery.


Routinely Reassess Level of Care

Just as discussed in the client progress assessment section it is important to also reassess level of care.  Routine reassessment of patients throughout their care to support decisions relative to treatment efficacy, progress toward recovery goals, and appropriate changes in the level of care and corresponding services will rely on effective and consistent application of the ASAM criteria. Routinely reviewing each dimension will help to determine when and why a change in service and/or setting is warranted.

Sometimes, a reassessment will be a byproduct of on-going counseling sessions when new information is shared that may indicate a change in the supportiveness of a patient’s recovery environment, the likelihood of withdrawal, and/or biomedical/mental health conditions. In the absence of unsolicited information; however, reassessments should take place at regular intervals to ensure there is adequate opportunity for changes in conditions to be revealed.



The importance of translating scientific advances in disease-specific interventions into clinical practice has been emphasized throughout the health care system, largely stemming from the consistent observation of a wide gap between research and practice.  This is where evidence based practice comes into play.

Evidence based practice (EBP) is the integration of research evidence with clinical expertise and patient values. 

In the original model, there are three fundamental components of evidence based practice.

  • best evidence which is usually found in clinically relevant research that has been conducted using sound methodology
  • clinical expertise refers to the clinician’s cumulated education, experience, and clinical skills
  • patient values which are the unique preferences, concerns, and expectations each patient brings to a clinical encounter.

This integration can be effectively achieved by carrying out the five following steps of evidence based practice.

The 5 Steps

1. Formulate an answerable question

One of the fundamental skills required for EBP is the asking of well-built clinical questions. By formulating an answerable question you to focus your efforts specifically on what matters. These questions are usually triggered by client encounters which generate questions about the diagnosis, therapy, prognosis or etiology.

2. Find the best available evidence

The second step is to find relevant evidence. This step involves identifying search terms which will be found in your carefully constructed question from step one; selecting resources in which to perform your search and formulating an effective search strategy.

3. Appraise the evidence

It is important to be skilled in critical appraisal so that you can further filter out studies that may seem interesting but are weak. Use a simple critical appraisal method that will answer these questions: What question did the study address? Were the methods valid? What are the results? 

4. Implement the evidence

Individual clinical decisions can then be made by combining the best available evidence with your clinical expertise and your patient’s values. These clinical decisions should then be implemented into your practice which can then be justified as evidence based.

5. Evaluate the outcome

The final step in the process is to evaluate the effectiveness and efficacy of your decision in direct relation to your client. Was the application of the new information effective? Should this new information continue to be applied to practice? How could any of the 5 processes involved in the clinical decision-making process be improved the next time a question is asked?

These steps may be more memorable if remembered as:

  1. Ask
  2. Acquire
  3. Appraise
  4. Apply
  5. Audit



A positive, collaborative therapeutic relationship is an essential component of successful substance abuse treatment.  To engage substance abuse patients in treatment, substance abuse and mental health professionals will need not only to connect with the clients but also gain their trust. 

The therapeutic alliance is seen by most forms of counseling as one of the main tools for achieving positive change in the lives of clients. The ability to develop a good therapeutic relationship with clients is focused on in training as an essential professional skill.  This alliance is developed through rapport.  Namely by the counselor displaying empathy, congruence and unconditional positive regard for the client. 

Where therapeutic alliance goes beyond rapport, which is the shared ability of the patient and the therapist to understand and to relate to each other on a deep level, the therapeutic alliance refers to the unconscious engagement in the task.  It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client.


Common Obstacles To Forming A Therapeutic Alliance

Substance-abusing patients are an especially difficult population with whom to establish a commitment to change.  At the height of his or her use of drugs, a patient often obtains far more gratification from the drugs than from the love and companionship of significant others, friends, and relatives. Therefore, the positive social reinforcement from a supportive counselor may pale in comparison to the high that the client gets from a line of cocaine. The counselor’s capacity to act as an agent of change is more limited and fragile than with many other patient populations.  
Substance abusers often enter treatment with ambivalence about relinquishing their habits.   From the very start, professionals will need to ascertain their clients’ respective levels of commitment to change in order to have the best chance of communicating an empathic understanding and to minimize the risk of pushing an unwanted agenda onto patients whose resistance than will likely increase.
Establishing Rapport
Rapport is the relational interaction between a client and a counselor, opening doors to emotional processing, healing, feedback, and interpersonal growth. Rapport is an unseen, unwritten connection made between a client and the helping professional.  It is a catalyst that enables a counselor to push a client beyond their comfort zone, striving for lasting changes and insightful breakthroughs.

An alliance is developed through rapport.  This development creates understanding, compassion, acceptance, and trust. Oftentimes, working with individuals with substance use disorders, shame and guilt are two of the more significant emotions the individual experiences. Walking into treatment can be one of the most anxiety-provoking experiences someone goes through. One question I’m often asked by new clients is, “Are you an addict?” or “Are you in recovery?” I generally avoid directly answering these, usually turning the questions back to the individual. A deeper meaning behind these questions is “Can you understand how I feel and what I’m going through?” 

Demonstrating compassion for the challenges that a client is confronted by is a second aspect in developing rapport. 

A third critical aspect of rapport development is acceptance—the ability to meet the client right where they are, without judgment. Acceptance leads to rapport by allowing a client to use self-determination in how therapy sessions proceed. 

Finally, trust within the therapeutic relationship provides safety and security, further developing the alliance. Trust is the confidential factor encompassing understanding, compassion, and acceptance, providing the individual with a safe environment to process painful (uncomfortable) emotions and memories. The trust and safety in a therapy session allow healing to take place. Often, clients with a substance use disorder are survivors of past traumas. Vulnerability and trust develop slowly over the course of the therapeutic relationship. The rapport developed between the client and counselor is based on trust and the ability for the client to become vulnerable in a safe place with someone who is dependable and respectful.

  • Speak directly, simply, and honestly.
  • Ask about the client’s thoughts and feelings about being in therapy.
  • Focus on the client’s distress.
  • Acknowledge the client’s ambivalence.
  • Explore the purpose and goals of treatment.
  • Discuss the issue of confidentiality.
  • Avoid judgmental comments.
  • Appeal to the client’s areas of positive self-esteem.
  • Acknowledge that therapy is difficult.
  • Ask open-ended questions, then be a good listener.

The therapeutic alliance includes three dimensions: goal consensus between counselor and client, collaboration on counseling-related tasks and emotional bonding.  To strengthen the alliance the counselor should contribute to those three dimensions. 

Goal consensus or agreement involves listening closely to the client’s distress and hopes and then being able to articulate that distress and hope back to the client.  

Collaboration on counseling-related tasks can involve nearly any task that is clearly described and that clients understand as related to their problems or goals.  This could involve everything from taking a social history to implementing a progressive muscle relaxation procedure.

Emotional bonding between counselor and client is different for every unique counselor and client. It might involve compassionate or empathetic listening or humor, or just sitting together while the client experiences strong emotions, or giving positive and supportive feedback to clients.  At the end of the day, a counselor’s authentic desire and determination to connect may be at the heart of the therapeutic alliance.

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