MODULE 11
RETURN TO
SUBSTANCE USE

	

Table Of Contents

TABLE OF CONTENTS…………………………………………………………...………………	II
MODULE 11:RETURN TO SUBSTANCE USE………………………...…………………………….	1

UNDERSTANDING A RETURN TO SUBSTANCE USE……..…………………………………………………….	1
Shift in motivation……………………….………… ………………………………………………………………...	1
Problems with coping ……………...………………………………………………………………………………..	1
Reaction to use …………………………………………………………………………………………………………	2
INTRODUCTION …………..………………………..…………………………………………………….……………	2
		Affirm client’s decision to return ………………….…………………………………………………………………	2
Discuss rationale …………..…………………………………………………………………………………………	2
SET THE AGENDA  ……..……………… ………………………..……………………………………………………	3
DISCUSS THE CLIENT’S IMPRESSION ………………….. …………………………………………………………3
EXAMINE REASONS FOR RETURN TO SUBSTANCE USE ………………….. …………………………………	3
Shift in motivation ………………………………….. ………………….………………………………………………	3
Language ……………………..……….………………………………………………………………………………	3
Planning ….……………………………………………………………………………………………………...…	4
Mood ….……………………………………………………………………………………………………………	4
PROBLEM IN COPING ………………………………………………………………………………………………..	4
Situation ………………………………….. …………………………………………………………………………...	4
Coping …………..……….………………………………………………………………………………………….	4
REACTION TO USE ……………………………………………………………………………………………………	4
Negative self attribution ………………………………….. …………………………………………………………...	4
All or nothing thinking …………..……….……………………………………………………………………….…	5
Emotional reaction ….…………………………………………………………………………………………..…	5
DETERMINE SESSION DIRECTION…………………………………………………………………………………	5
Shift in motivation ………………………………….. ………………………………………………………………...	5
Problems in coping …………..……….…………………………………………………………………………….	5
Reaction to use ….…………………………………………………………………………………………………	6
EXPLORE MOTIVATION …………………………………………………………………………………………….	6
Use of exercises and discussion to enhance motivation ………………………………….. ……………………………	6
Consolidate commitment to resume abstinence …………..……….…………………………………………………	8
Summarize ….………………………………………………………………………………………………………	8
EXPLORE SITUATIONAL RISKS AND COPING SKILLS …………………………………………………………	9
Conduct a functional analysis ………………………………….. …………………………………………………….	9
Antecedent to use ……………………… …………………… …………………………………………….…	9
Expectations …. ..……………………………………………………………………………………………….	9
Coping strategies ………………………………… …………………… ………………………………………	10
Lifestyle factors …………….. ..………………………………………………………………………………..	10
ADDRESS SPECIFIC PROBLEMS ………………….. ……………………………………………………………..…	10
DISCUSS COGNITIVE-AFFECTIVE REACTION TO USE ………………….. ……………………………………..	11
Examples of alternative ways of thinking ………………………………….. ………………….……………………….	11
Important points to cover in reframing an episode of use: ……………………..……….……………………………	11
	DEVELOP PLAN FOR RESUMING ABSTINENCE ………… ………………………………………………………	13
	TROUBLESHOOTING ………… ……………………………………………………………………………………....14
SUMMARIZE SESSION ……………….……………………………………………………………………………….	14
	PREVIEW NEXT SESSION ………… …………………………………………………………………………………	14
REVIEW HOME ASSIGNMENT ……………….……………………………………………………………………...	14
END SESSION ……………….………………………………………………………………………………………....	15

REFERENCES…………………………..………………………….. …………………………………..	16
	
	UNDERSTANDING MY USE ………… ……………………………………………………………………………….18
RECOVERING FROM AN EPISODE OF DRINKING OR DRUG USE ……………….…………………………….	19
MODULE 11 SESSION CHECKLIST……………….……………………………………………………………….....	20

Module 11: Return to substance use

The objective of this module are to: 1) explore motivation to resume abstinence, 2) determine whether learning new coping skills will help the client maintain abstinence, 3) determine whether cognitive-affective reactions to resumed use are contributing to continued use, and 4) develop a plan for resuming abstinence.

=====╣Module Outline╠===========================================

Target Discussion Points

	Introduction
	Set the agenda
	Discuss the client’s impression of use
	Examine reasons for use
	Determine session direction
	Explore motivation
	Explore situational risks and coping skills
	Discuss cognitive-affective reactions to use 
	Develop plan for resuming abstinence
	Conduct Agency-specific tasks
	Summarize Session
	Preview Next Session
	Review home assignment 
	Session Closure

Understanding a return to substance use
There are many reasons that a client may resume alcohol or drug use after a period of abstinence, even while in treatment.  From a cognitive-behavioral skills-building perspective, the reasons for returning to substance use can be catergoerized within three broad categories.

Shift in motivation
Some clients simply experience a change in motivation to remain abstinent and make a decision to resume their use.  Resuming abstinence in this case may require exploring motivation including the importance, confidence and readiness to change.

Problem with coping
Clients may return to using in a situation that they were not prepared to handle because it was either far too risky or because the client did not have the adequate skills for coping

with it.  In this case, the therapist may need to help the client strengthen specific coping skills that would enable him or her to manage these situations and/or strengthen plans for avoiding very high-risk situations.

Reaction to use
There are clients who may not be able to recover from a single episode of use after setting a goal of abstinence.  When clients make a commitment to abstinence and re having trouble living up to this commitment, they may suffer from the “Abstinence Violation Effect” described by Marlatt and Gordon (1985).  This reaction may include a strong emotional component (e.g., hopelessness, guilt, shame) that leads clients to continue using alcohol or drugs.  In this case, the client may benefit from reframing the experience as something to learn from, and encouragement to renew his or her commitment to abstinence.

Introduction
The introduction of this module into the treatment plan will likely occur at the beginning of a session when the client reports an episode of substance use after he or she has been abstinent.  Shifting the focus of the session to this module should occur within the session that substance use is reported. 

“We had planned to talk about social pressure today but given what you have told me, it might be a good idea to take some time and talk about what happened if that’s OK with you.”

Affirm client’s decision to return
Many clients will not return to treatment immediately following a period of resumed substance use.  Feelings of guilt, shame, and embarrassment are common.  Patterns of thought also sometimes interfere with clients making use of treatment:

“My therapist will be upset with me”
“I can’t go back until I get on my feet again.”

When clients do return to treatment and are willing to discuss their experience, it is important to affirm their decision to return.

“Let me first say that I’m really glad that you are here talking with me about this.  Sometimes people have mixed feelings about coming in to talk with me about using again.  If there is any time that treatment can be most helpful, my hope is that it is right now.”

Discuss rationale
Some clients may express reluctance to talk about their return to substance use.  It can be helpful if clients recognize what can be gained from talking about the episode of substance use.

“Talking about what led up to you drinking again may give both of us a better understanding of the important risk factors that contributed to your drinking.  If we can gain a better sense of what those risks were, then we may be able to help you prevent it from happening again.  Essentially, let’s see what we can learn from it and move on.”

Set the Agenda

“So if it’s OK with you, we can take whatever time we need from our session today to talk about what happened, think about what you can learn from it, and make some plans based on what we learn.  How does that sound?”

Discuss the client’s impression
There are a number of different reasons that clients may start using alcohol or drugs again after a period of abstinence.  As mentioned above, this may relate to a change in the client’s motivation, problem in coping, or changes in the client’s thoughts or feelings about abstinence in response to a single episode of use.  By asking the client to give their impression of what happened and how they have reacted to it, the therapist can begin to look for indicators of which direction to take the module.  Use of open-ended questions may help the therapist to gather an initial understanding of the episode of use.

“Tell me a little bit about what happened.”
“What is your impression about what happened?”
“What do you make of this?”
“How have you been feeling about this?”

The goal of this discussion is to gather information that will determine the direction of the session; engaging the client in problem solving around the episode of use too quickly may impede an accurate assessment of the factors that led up to resuming substance use.

Examine reasons for return to substance use
As the client discusses the episode of substance use, the therapist may begin to recognize the contributing factors.

Shift in motivation
Some indicators of a shift in motivation include:

Greater Commitment
	I am not going to let this happen again
	I am going to get through his and stop again	I would like to stop again
	I should probably get back on track right away
I’m not sure that stopping is what I want right now
	I don’t want to stop anymore
Lesser Commitment

Language
Clients may sound less committed to their goal after a period of use.  Listening for commitment language as they describe the episode of use may help the therapist to identify potential motivation problems. Regardless of whether this shift occurred 
before or after the episode of use, addressing client motivation in the session may help the client to recover from an episode of substance use.

Planning 
Planned episodes of use are more likely related to motivation shift than unexpected episodes in which coping resources were overwhelmed.

Mood 
Clients who have some commitment to a goal of abstinence will usually experience some negative mood related to returning to substance use (e.g., regret, embarrassment, disappointment).  If the client is not expressing these types of changes then it may be an issue of motivation.

Problem in coping
The therapist will need to determine whether the client returned to substance use as a result of not having coping skills available or not effectively using them at the time he or she faced a risky situation.

Situation
Clients may gain skill and confidence with situations that they can anticipate and plan coping for ahead of time.  Unexpected situations may be particularly challenging if the client has not had time to prepare for the situation.  Situations that are out of the ordinary may also challenge client’s coping skills.  Some situations may be overwhelming due to the high-risk nature of the situation and be very difficult for most clients to manage.

Coping
If clients are unable to cope well with a situation it may be because they lack coping skills for managing the situation or they have coping skills but the situation was unexpected and they were not prepared to use the skills.  It may also be important to recognize that clients may overestimate their ability to cope with certain types of situations that are extremely risky.

Reaction to use
Some clients may fail to stop using substances once they start again as a result of their reaction to the initial episode of substance use.  These thoughts may interfere with the client’s motivation and/or his or her perceived ability to cope with new situations.

Negative self attribution
Sometimes clients will attribute their return to using substances to some internal factors that emphasizes self-blame.

“I’m a screw up”
“I have no willpower”
“I’ll never change”

Because beliefs like this have no immediate remedy, they may leave clients feeling hopeless about maintaining abstinence and less determined to stop using substances once they have started.

All or nothing thinking
Sometimes clients will perceive the initial use of substances as a complete failure in their efforts to maintain sobriety.

Typical thoughts that represent this reaction include:

“Now that I have blown it, I may as well go all out.”
“Now that I have started, there is no way I can stop myself.”

Emotional reaction
Clients who have some commitment to a goal of abstinence will usually experience some negative mood related to returning to substance use (e.g., regret, embarrassment, disappointment).  This may also affect their desire to stop using substances again.

Determine session direction
Once the therapist has formed an initial impression of the contributing factors, a summary reflection can be used as a transition to work within one of the three areas of this module.

Shift in motivation
For clients who are again struggling with ambivalence about the importance of remaining abstinent, confidence in remaining abstinent, or readiness to change, the session will likely be focused on motivational enhancement strategies.

“As we have been talking, I have gotten the impression that going back to drinking was really what you wanted in the moment.  It sounds like you have been torn between wanting this life of not drinking for yourself, but also really missing some things about how your life used to be.  You may be wondering if quitting drinking is really what you want right now.  I think we should take some time today to talk about it.  How does this sound to you?”

Problems in coping
For clients who report being faced with a situation or set of circumstances that overwhelmed his or her coping abilities, the session will likely be focused on teaching or strengthening specific coping skills.

“As we have been talking, I have the impression that you were not expecting to encounter this situation and you were surprised by how overwhelming the desire to drink was.  You have been upset about how quickly this happened and you seem disappointed in yourself that you were not able to handle it better.  I have a good sense that abstinence is still your top priority.  Does that sound about right to you?”

“If your goal is to maintain sobriety and you have situations like this come up again, it would be great if you had a plan for how to handle it.  We can spend some time now talking about the situation in some more detail, understand what made this particular situation so risky for you, and make some plans for how you might handle something like this in the future.  How does this sound?”

Reaction to use 
For clients who report that they have had difficulty recovering from a single episode of use and that changes in their thinking about abstinence or emotional reactions to use are getting in the way of resuming abstinence, the session may be focused on reframing the client’s thinking.

“As you have been telling me about your recent drinking, I have gotten a clear impression that you are pretty upset with yourself for what happened.  So much so, that part of why you kept drinking once you had started was to get some relief  from feelings like guilt and shame.  You seem to be determined to get back on track with maintaining abstinence, but this episode feels like a major set back to you.  I think it might be helpful to spend some time talking about ways to think about this and hopefully help you put this behind you so that you can move on with your goal of not drinking.  How does this sound to you?”

Explore motivation
If it appears that the client is struggling with ambivalence about a goal of abstinence the therapist may choose to utilize any of the motivation enhancing exercises within Modules one through three (Enhancing Motivation For Change, Decision Making, And Functional Analysis And Treatment Planning) to explore and possibly bolster the client’s motivation for resuming abstinence.

Use exercises and discussion to enhance motivation

The following techniques may be used as needed to enhance client motivation.  Select the one(s) that seems most appropriate for client.

•	Help the client weigh the positive and negative aspects of continuing use against the positive and negative aspects of stopping use.  Use open-ended questions and focus on eliciting self-motivational statements from the client on advantages of resumed abstinence and costs of continuing use.

“I’m wondering what your thoughts are about drinking again? Do you have any concerns about it? Perhaps we could take a look at what you’re enjoying about drinking again and what may not be so good about it.  Where does this fit in with your goals?”

•	Review client’s original reasons for stopping his of her use and making a commitment to abstinence.  In particular, ask the client about reasons that have made alcohol or drug use more important.
“Some of the things that made quitting important to you when we started were the problems at home and work.  It may be that these things are not so important any more.  I’m wondering if we could talk a bit about what has changed since we began working together.  I would also like to understand if there are reasons that drinking seems important again? Are there things you’ve missed about drinking?”

•	Review possible consequences of continuing alcohol or drug use.  Ask the client to consider problems that have occurred in the past as a result of drinking which may have brought him or her into treatment.  Were there medical, social, relationship, or legal concerns that made stopping drinking important?  What possible consequences might there be in the future if the client continues to drink?

“In our first session you expressed a number of concerns about your drinking, mostly related to negative effects of drinking on your health and marriage.  I’m wondering what thoughts you have about how continuing to drink will affect these things in the future?”

•	Review the Benefits of Change worksheet.  Were there benefits to the client during his or her period of abstinence that he or she is not recognizing (e.g., improved relationships, better finances)?  Was the client disappointed that he or she did not experience some anticipated benefits early in abstinence?

“Sometimes people get discouraged with abstinence because they don’t feel that they are achieving any benefits, especially in the short-term.  I’m wondering what types of positive changes you noticed during the time you stopped drinking? Is this what you expected? Were there other benefits that you hoped to achieve in the short-run? How will drinking again affect the benefits you hope to achieve in the long-run?”

•	Use the personal rulers worksheet to review Importance, Confidence and Readiness for change.

“Sometimes a person’s view of how much of a problem drinking presents to them changes while they’re in treatment.  In the beginning of treatment you rated importance of change fairly high because you were concerned about the negative impact your drinking was having on your family and your work performance.  I’m wondering if we can revisit this and take a look at how important you feel it is right now.  Then maybe we can look at confidence and readiness and see if either of these have changed.”

•	Use the Decisional Balance Exercise to review the perceived advantages and disadvantages of making a change.  This may be particularly useful if the client’s perceived importance of change seems diminished.

“It sounds as if you’re not sure right now whether you want to continue drinking or want to stop drinking again.  There are some things that you really enjoy about drinking so it’s a hard choice.  Earlier on in treatment it seemed as if abstinence was the right choice for you but now you’re not so sure.  How would if be if we reviewed the pros and cons of drinking again?  Maybe that would help you make the decision again.”

•	Use the Revising Past Successes procedure to bolster self-efficacy.  This exercise may be especially helpful if the client’s low confidence seems to be a factor in resuming substance use.

“It’s easy for people to get discouraged if they’ve said they wanted to remain abstinent and then they hit a bump in the road and use again.  It seems like there has been a shift in your confidence.  I’m wondering if we could take a look at some things you feel you’ve done really well in the past that were difficult and see if there are some skills you can apply to your drinking.”

These techniques can be used to help the client resolve ambivalence.  As with the early stages of change, eliciting and reflecting client change talk will help to bolster the client’s motivation to return to abstinence.

Consolidate commitment to resume abstinence
The time needed to explore motivation is up to the therapist’s clinical judgment.  At the point that the therapist believes the client is favoring a return to abstinence, a transition to asking the client what he or she wants to do can be made.  IF the client is willing to resume abstinence the therapist would help the client restate his or her goals and commitment to resume abstinence and develop a specific plan for how this will occur.

Summarize
It is very important to affirm the client’s willingness to come to treatment and share his or her resumed use with the therapist.  At the end of examining motivation the therapist should provide a summary statement that reflects what the client has indicated and then discuss what the client wants to do about it.

“I just want to tell you I’m really glad you came in today after drinking this week.  It really gave use a chance to talk through it and see where you are with your drinking.  Not everybody comes back when they start drinking again so thanks for trusting me and sharing this.  Now to pull things together, you’ve said that since you started drinking again you haven’t experienced any big problems.  In fact, you still find that it helps you to forget things for a while.  On the other hand, your family is not happy about it and they are worried it will get worse, which is also something you have concerns that you had initially when you decided to quit.  It seems like you have felt a lot better since you stopped drinking and things at work and home have been better which is helping your self-esteem.  So what are you thinking you want to do about the drinking at this point?”

Explore Situational Risks and Coping Skills
A client may resume alcohol or drug use as result of having difficulty coping with specific triggers or situations that overwhelm the client’s coping skills.  In this case the client may express a desire to remain abstinent but not be able to do so.

Conduct a functional analysis
To determine whether the client is having difficulty coping with specific triggers, lacks coping skills, or is trying to manage other lifestyle factors, the therapist should conduct an analysis of the client’s initial episode of drinking or drug use as well as factors involved in his or her continued use beyond this initial episode (if appropriate).  It is important to remember that the factors identified in the Functional Analysis (Module 3) as contributing to his or her use in the past may not be the same factors that contributed to his or her resumed use.  Further, the client may be continuing to use alcohol or drugs or different reasons than he or she initiated their use again.

The functional analysis conducted in Module 3 provided a broad view of the triggers and desired effects that maintain substance use.  In this module, a modified functional analysis can be used to gather more detailed information about a single trigger for substance us.  Important areas to focus on in conducting the functional analysis are: 1) antecedents of use, 2) client expectations, 3) coping strategies, and 4) lifestyle issues

The Understanding My Use Handout (Appendix A) can be used in session to help guide this process.  This should be handed to the client to look at during the discussion.

Antecedents to use
Help the client understand which elements in the situation may have contributed to his or her use.

Where was the client?
What was the client doing at the time?
How did the client feel before using?
What thoughts did the client have before using?
Who was the client with at the time?
What was happening in the situation that may have increased client’s desire to drink or get high?

Expectations
Often clients resume their use of alcohol or drugs because they assume that they will achieve a certain effect by using the substance (feel more relaxed in social situation, feel less depressed).  It can be important to determine if the client’s experience of using alcohol or drugs again in a specific situation matches his or her expectations.

What did I expect to happen from drinking or drug use?
How did I think I might benefit from using in this situation?

What actually happened during and after I drank or got high? Did this match what I expected?

Coping strategies
It may be important for the therapist to determine if the client had the coping abilities to manage a specific situation without alcohol or drug use.  Has the client used any specific strategies to avoid using in this situation in the past?  Would it be useful to learn new ways to cope with this situation?

What made the situation risky?
What did I do to try to avoid using in the situation?
What else could I have done? How else might I have coped with situation?

Lifestyle factors
Clients often think about returning to drinking or drug use or start taking risks that lead them back to using again before the day they pick up a drink or drug.  If the client is unable to identify specific situation(s) that triggered their initial use, there may be more global lifestyle factors making it difficult for the client to remain abstinent.  The therapist may need to inquire about these as well.

Some questions to consider:

What was happening in the client’s life at the time that the drinking or drug use    occurred that increased the risk of using again?
Was there a reason that using looked more attractive again?
Was the client allowing problems to build up or unable to deal with specific problems?
Was the client placing himself or herself in risky situations without acknowledging a desire to drink or get  high?

Address specific questions
If the client describes using in response to a specific trigger and lacks coping skills to manage this type of situation (e.g., social pressure, negative moods), the therapist may need to help the client determine if there were other ways to manage this trigger (e.g., develop better refusal skills, improve mood management skills).  In some cases the client may benefit from a review of coping strategies for specific triggers, especially if he or she has been able to manage this situation without using in the recent past.  Some clients may need to learn new strategies to cope with situations that they have not faced in the recent past without alcohol or drug use.  The therapist should refer to the Module that is relevant to the specific type of trigger or coping strategies that the client needs to review/learn (e.g., coping with urges, coping with social pressure, or mood management).

If the client begins using alcohol or drugs again to cope with ongoing stressors or risks and appears motivated to remain abstinent then it would also be appropriate to focus on helping the client build better skills to cope with the ongoing stressors in his or her life.

If the client reports using in order to achieve a certain effect (e.g., to feel less depressed or experience more pleasure) but did not achieve the desired effect this discrepancy may be pointed out to encourage the client to look for other strategies.  The therapist may need to work with the client to determine if there are other ways to achieve this desired effect (e.g., mood management or social and recreational counseling).

Discuss cognitive-affective reactions to use
For clients who have made a commitment to abstinence, a single episode of use may lead to a change in thinking or an emotional reaction that contributes to continued use rather than an attempt to resume abstinence.  Thoughts that may contribute to continued use are likely to include: “I can’t change,” “I can’t cope,” or “I’ll never change.”  Emotional reactions that contribute to continued use may include guilt, frustration, shame, anger, disappointment, or anxiety.  The client may re-examine his or her commitment to change, identity as someone who is changing, or ability to change.

It is important for the therapist to assess how the client reacted to the initial episode of alcohol or drug use and if the client is struggling with these types of cognitive or affective changes, the therapist may need to help the client reframe what happened.

Examples of alternative ways of thinking:
Initial Thought	Alternative thought	
“What’s the use, I’ll never be able to stop using drugs.”	“I just didn’t handle this situation well-next time I may need to ask a friend who doesn’t use drugs to come with me when I have to go into my old neighborhood.”	
“I guess I don’t really want to change or I wouldn’t have had something to drink or gotten high.”	“Maybe I need to think about how to handle this situation better without using.”	
“What’s the point of trying? It’s clear I’ll never be able to control myself.”	“A lot of people try several times before they succeed, it doesn’t mean it’s not worth it or I can’t do it.  In fact there have been many situations since I started treatment that I got through without drinking or using again.”	

Important points to cover in reframing an episode of use:
1.	Stopping alcohol or drug use is a process and people have unplanned episodes of use.
2.	If you drink or use drugs, the situation can be used as an opportunity for learning rather than a chance to give up or blame yourself.
3.	The goal is to figure out what happened and how to be better prepared in the future by avoiding situations or learning new coping skills.

THERAPIST: “ I think it might be helpful to talk a bit about the situation in which you first smoked crack again.  Would that be okay?”
 
CLIENT: “OK.”
THERAPIST: “Tell me what happened the first time you used.”
CLIENT: “The first time I used again I went to see my brother-in-law and he was having a party.  I just went over there to drop something off for my wife but there were some people at his house drinking and smoking crack.”
THERAPIST: “Did you know he was having a party?”
CLIENT: “No, not really, but he does have people over a lot and I used to get high with him so I guess I should have known this might happen.”
THERAPIST: “So, in the past you would have gone over there to get high?”
CLIENT: “Yes.”
THERAPIST: “Were you alone when you went over there?”
CLIENT: “Yes, I’m afraid so.”
THERAPIST: “So, what were your thoughts when you walked in and saw the party?”
CLIENT: “At first I thought I should just get out of there, but then I started to talk to some people I knew so I decided to hang around.  I remember thinking, “Well I haven’t smoked crack for 3 weeks so maybe I’m cured and I can get through this without using.”
THERAPIST: “Did those thoughts change after you were there for a while?”
CLIENT: “It didn’t take very long.  Within 15 minutes or so I started thinking it would be fun to get high again and it would put me in a better mood.”
THERAPIST: “What was your mood like when you went over there?”
CLIENT: “Well, to tell you the truth I was feeling kind of angry.  My wife didn’t want me to go over there because she thought this might happen and I told her that I was perfectly able to control myself.”
THERAPIST: “So you feel like she’s watching you?”
CLIENT: “Yup and it’s annoying.  I want to be trusted.  I can’t just sit home all the time.  But, I guess she’s right.  I can’t be trusted.  Maybe it’s hopeless.”
THERAPIST: “Did your mood change in the way you expected?”
CLIENT: “Sure did, although it didn’t last.  After a while I started to feel guilty that I screwed up.  I knew I had to go home and face my wife and that she would be really angry.”
THERAPIST: “So what happened when you got home?”
CLIENT: “We had a big fight about it and I said some things I shouldn’t have said and now we aren’t getting along too well again.”
THERAPIST: “Any thoughts or feelings about what happened?”
CLIENT: “I’m disappointed in myself and I don’t know what to do to stop again.  It seemed like things were going so well.  Maybe I just can’t do this.”
THERAPIST: “Well, for about 3 weeks you were feeling pretty good and working hard on making some changes until you ran into this situation.”
CLIENT: “Well, I guess so.  But shouldn’t I be able to handle this kind of thing?”
THERAPIST: “Perhaps that is something we need to take a look at.  Maybe there are better ways to handle your interactions with your brother-in-law or other people you know who get high.”
CLIENT: “Maybe I just need to avoid him.  That seemed to be working well until I went over there that day.”
THERAPIST: “So you had figured out that avoidance may be the best strategy right now with him.  It also seems like getting high might have been a way to manage some frustration with your wife’s attitude.”
CLIENT: “Yea, doing crack is a great way to take me out of those feelings and maybe there was a little bit of “I’ll show her I can handle this.”
THERAPIST: “So, perhaps we can talk about how else to handle your feelings of frustration or anger when they occur.  Sound OK?
CLIENT: “Yea, I’m not too good at that yet…”
THERAPIST: “Are you having thoughts that you won’t be able to stop again now that you’ve started?”
CLIENT: “Well, that’s been my experience in past.  What can I do?”
THERAPIST: Let’s take a look at what you’ve been doing in past 3 weeks to help yourself and then think about how you can get back on track.  Maybe we can learn something from this situation and put it behind you.  It sounds like you would like to do this and just don’t know how.”

Develop plan for resuming abstinence
The overall message for the client is that it is possible to recover from an episode of use or continued use and resume abstinence if it occurs again.  There are some simple tips that the client can use if this occurs again.  These are covered in Recovering from an Episode of Drinking or Drug Use Handout (Appendix A).

Reviewing them within the session may be helpful if the client continued to use after an initial episode of drinking or drug use.  These tips are as follows:

Stop using right away – The sooner you stop using the better.  Continuing to use may make things worse and potentially make it harder to stop again.

Get out of the situation – Once you have started using, spending more time in the place where you use will only make it harder to stop.  Find a place you can go where you feel confident you won’t keep using.

Get rid of alcohol or drugs – Leaving un-used alcohol or drugs around will only be a temptation in the future.  Get rid of them as quickly as possible.

Get help – Use the support you have in your life.  Talk to somebody about what happened and ask for help when you need it.

Do something incompatible with drinking or drug use – Find something you can do that keeps you from using more substances.  Doing something that you enjoy which is safe from substance use may help you to get back on track.

Take it seriously but don’t beat up on yourself – Having some regret about using substances may be a motivation for you to work towards getting back on track.  Beating up on yourself for using substances may lead you back to using more.

Learn from the experience – if you can figure out what went wrong, you might be able to prepare for it the next time.  Learn something from your experience and move forward.

Troubleshooting
It is important to keep in mind when having a discussion about motivation for change that the therapist does not argue for resumed abstinence.  This may only increase a client’ efforts to argue against it.  The therapist should emphasize that it is the client’s choice about whether to make this change but look for all opportunities to reflect on self-motivational statements that support change.

Summarize session

“I want to thank you again for coming in today so we could talk about what’s happening with your drug use.  We talked a lot about some of the reasons that you may have gotten started using again and what’s been keeping you using since that first day.  It sounds like you are still motivated to stop using drugs but you got caught off guard in a situation involving social pressure.  Maybe your decision to go over there that day was also in part a chance to test your control and let your wife know that you could be trusted.  You seem to have a good sense that dealing with social pressure and risky situations differently in the future might be helpful; you plan to take a friend along who doesn’t get high in any situations like this or just to avoid them for now.  You want to work on developing some better ways of managing your feelings so you aren’t as reactive and maybe even try to develop a larger support system so it’s not only your wife you are talking about this.  You think maybe if you had more people to talk to about this it would have helped you stop sooner rather than going through the week feeling angry and disappointed about it.  You’ve got a plan in place to go to a meeting every night this week just to get yourself back on track and to keep coming here.  Does this sound about right to you?

Preview next session
Provide a brief preview of what will be covered in the next session.

Review home assignment
The therapist may assign home exercises as needed to continue to work on the skills and concepts within the current module, or to prepare the client for material that will be covered in the next session.

End session

“I think we have made some good progress in today’s session.  Do you have any other questions, concerns or thoughts before we end today?”

References

Marlatt, G.A. & Gordon, J.R. (Ed.). (1985).  Relapse Prevention: Maintenance strategies in the treatment of addictive behaviors.  New York: Guilford Press.

APPENDIX A
RETURN TO SUBSTANCE USE
SESSION MATERIALS

Where was I before I used?

What was I doing before I used?

How did I feel before I used?

What thoughts did I have before I used?

Who was I with at the time?

What has happening at the time that increased my desire to use?

What did I expect from using?

What actually happened?  Did it match my expectations?

What made the situation risky?

What did I do to try to avoid using in the situation?

What else could I have done to cope with the situation?

Was there anything else happening in my life at the time that may have contributed to using?

What were my thoughts and feelings after I used?

Did my thoughts or feelings prevent me from stopping?

Understanding My Use

Stop using right away – The sooner you stop using the better.  Continuing to use may make things worse and potentially make it harder to stop again.

Get out of the situation – Once you have started using, spending more time in the place where you use will only make it harder to stop.  Find a place you can go where you feel confident you wont keep using

Get rid of alcohol or drugs – Leaving un-used alcohol or drugs around will only be a temptation in the future.  Get rid of them as quickly as possible.

Get help – Use the support you have in your life.  Talk to somebody about what happened and ask for help when you need it.

Do something incompatible with drinking or drug use – Find something you can do that keeps you from using more substances.  Doing something that you enjoy which is safe from substance use may help you to get back on track.

Take it seriously but don’t beat up on yourself – Having some regret about using substance may be motivation for you to work towards getting back on track.  Beating up on yourself for using substances may lead you back to using more.

Learn from the experience – If you can figure out what went wrong, you might be able to prepare for it the next time.  Learn something from your experience and move forward. 

Recovering from an Episode of Drinking or Drug Use

PREPARATIONS	•		
  Session checklist		
  Agency-specific paperwork		
  Understanding My Use handout		
  Recovering from an Episode of Drinking of Drug Use handout		
GETTING STARTED		
  Affirm client’s decision to return		
  Discuss rationale		
  Set the agenda		
DISCUSSING CLIENT’S IMPRESSION OF RETURN USE		
  Assess client’s understanding of reasons		
  Assess client’s reaction to use		
EXAMINING REASONS FOR USE		
  Shift in Motivation Reaction to Use		
  Problems with Coping		
  Reaction to Use		
DETERMINE SESSION DIRECTION		
  Shift in Motivation		
    Focus on motivational strategies outlined in Module 1-3		
  Problems in Coping		
    Focus on teaching or strengthening specific coping skills		
  Reactions to Use		
    Focus on reframing thinking		
DEVELOP A PLAN FOR RESUMING ABSTINENCE		
  Review Recovering from an Episode of Drinking or Drug Use handout		
COMPLETING AGENCY SPECIFIC TASKS		

WRAP UP		
Summarize session		
Preview next session		
Assign home exercise		

Module 11 Session Checklist
Return to Substance Use