MODULE 6:
SOCIAL SUPPORT

	

Table Of Contents

TABLE OF CONTENTS…………………………………………………………...………………	II
MODULE 6: SOCIAL SUPPORT………………………………………………………………………	1

	BACKGROUND ……………………. …………………………….................................................................................	1
	TYPES OF SOCIAL SUPPORT  ……..….…………………...........................................................................................	1
Self-help groups……… …………………………………………………………………………………………….2
Professional help…………………………………………………………………………………………………...	3
Spiritual or religious affiliations……………………………………………………………………………………3
Personal relationships………….……… ……………………………………………………………………………3
Co-workers………………………………………………………………………………………………………….	4
Community service agencies…………………………………………………………………………………….....	4
CHECK-IN…………………………………..……………………………………………………………….………….	4
SET THE AGENDA ……………………………………………………………………………………………………..	4
DISCUSS RATIONALE FOR SOCIAL SUPPORT………… …………………………………………………………	5
DISCUSS DIFFERENT TYPES OF SUPPORT................................................................................................................	5
DEVELOPING A PLAN FOR SEEKING SUPPORT …………………………………………………………………..6
Review how to ask for support……………………………………………………………………………………..	6
Review Obstacles to Using Support ……………………………………………………………………………….	7
IMPLEMENTING THE PLAN…………… …………………………………………………………………………….8
TROUBLESHOOTING………… ……………………………………………………………………………………….	8
SUMMARIZE SESSION.........................................................................................................................................…......	10
PREVIEW NEXT SESSION …………………………………………………………………………………………….	10
REVIEW HOME ASSIGNMENT ……………………………………………………………………………………....	10
END SESSION……………….…………………………………………………………………………………………..	10

REFERENCES………………………….. ………………………………………………………………10
APPENDIX A: SESSION MATERIALS………………………….. …………………………………..12

PLAN FOR SEEKING SUPPORT………………… ……………….…………………………......................................	13
MODULE 6 SESSION CHECKLIST……………….………………………………………………………………...…	14

Module 6: Social Support

The primary objectives of this module are to: 1) help the client identify the types of social support that might be helpful in maintaining abstinence, 2) examine barriers to using social support, and 3) help the client improve his or her ability to ask for support.

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

Target Discussion Points

	Check-in
	Set the agenda
	Discuss rationale for social support
	Examine different types of support
	Review how to ask for support
	Explore obstacles to seeking support
	Conduct agency-specific tasks
	Summarize session
	Preview next session
	Review home assignment
	End session

Background
Without a strong support network, it may be difficult for clients to make changes in their alcohol or drug use.  Some of the social problems that clients face includes: continuing to interact with family and friends that use alcohol or drugs, missing out on social interactions that involve alcohol or drug use, feeling anxious about socializing without alcohol or drug use, and facing a diminished social network  of people who do not engage in alcohol or drug use.  Having a network of people who understand and support the client’s efforts to change can be extremely helpful to the client.

Types of social support
Social support can come from many different places – friends, family, professional helpers, organizations in the community, service agencies, or coworkers.  Social support serves many different purposes – it can help a client learn how to manage his or her alcohol or drug use, solve other problems related to use (e.g., unemployment, loss of housing), and cope with painful emotions or crises (e.g., death of loved one, chronic illness).  Different types of support may be helpful to a client in recovery regardless of 

whether the support is specifically focused on alcohol or drug use or helping clients cope with other problems in their lives.

Self-help groups
This includes groups such as Alcoholics Anonymous (A.A.), Narcotics Anonymous (N.A.), and Cocaine Anonymous (C.A.).  The groups are composed of a fellowship of men and women who have similar problems with alcohol or drugs and who help one another stay abstinent through the 12 steps of recovery.  All these groups are peer lead and depend on the participants sharing their experiences and helping each other.  A.A. meeting include a clear focus on spirituality as an important aspect of recover as evidenced by references to God, open prayers and spiritual step.  Similar types of self-help groups that do not focus on spirituality are also available such as Women for Sobriety and SMART.  The latter groups emphasize personal responsibility and the need to learn coping skills as the path to recovery and are led by a trained moderator.  There to learn coping skills as the path to recovery and are led by a trained moderator.  There are significantly fewer groups available of the latter type in some areas, making it more difficult for a client who is interested in this approach to find one.  Nonetheless they offer an important alternative for clients who are not comfortable with some of the tenets of A.A. or other similar 12-step groups, if they can be found.

What does this offer?  Many clients who have problems with alcohol or drugs find that seeking the help of others with similar problems can help them to maintain abstinence.  Involvement in self-help groups may be particularly important for clients whose current social network supports drinking [or drug use] rather than abstinence, or clients whose lives are devoid of support (Project MATCH Research Group, 1998a).

Self-help groups may be effective because they provide a new support system for a client.  Establishing a new support network by oneself can be a daunting task that many clients avoid or do not know how to accomplish on their own.  In these groups, clients can compare their reactions to people who have and similar experiences and count on people for support at times it is needed the most.  The meetings offer suggestions on how to change as well as a message of hope.

Clients with a supportive network may also benefit from self-help groups.  Belonging to a group may reinforce the decisions that the client is making to change and members of the group who have long-term sobriety may help to serve as role models for someone who is new to stopping their use.

If a client is interested in groups such as A.A., it may be helpful for the therapist to emphasize that actively participating in certain activities is important for change to occur.  For example, researchers have found that reaching out to other.  A.A. members for assistance, having a sponsor, and working the steps are important in predicting whether an A.A. member will relapse (Montgomery et al., 1995; Sheeren, 1988).

How does one decide what to recommend?  This may depend on availability (i.e., in some communities A.A. is the only type of group available), program philosophy (i.e., there are significant differences in philosophies across self-help groups and even within A.A. there are likely to be differences across groups), spirituality (i.e., while A.A. focuses on spirituality, SMART does not), and similarity (i.e., clients may feel most comfortable in a meeting where they have something in common with the group in terms of gender, age or ethnicity).

Professional help
This may include outpatient counseling either in an individual or group format, focused on alcohol or drug use as well as other problems such as anxiety or depression.  If a client is using alcohol or drugs to manage feelings or other psychiatric symptoms, addressing these other problems is often essential for them to remain abstinent.

What does this offer?  Attending regular group therapy meetings can provide the client with structure in his or her life.  In addition, the client may benefit from feedback from group members in a setting where confidentiality is expected and enforced.  If the client is in individual therapy this may provide an opportunity for the individual to raise additional matters that he or she may not feel comfortable discussing in a group setting.  In professional settings it is also likely that co-occurring problems will be addressed as part of the client’s treatment.

Spiritual or religious affiliations
This includes places of worship associated with a particular religion, religion-based groups or clubs, and non-denominational spiritual centers.

What does this offer?  Involvement in faith based practices, religious groups, and spiritual organizations can provide a sense of community or belonging, an appreciation of provide guidelines on how one should live his or her life without alcohol or drugs.  Many religious groups also expect their congregants to participate in activities to help other people and this may help the client with abstinence as well as lifestyle change.  Many religious groups also offer special services to help clients who are part of their congregation to help them refrain from sing alcohol or drugs.

Personal relationships
This may include family and friends (abstinent and non-abstinent)

What does this offer?  Sober friends are often important for someone who is in the early stages of stopping alcohol or drugs because they have a unique understanding of the client’s situation.  A client may be able to relate to a sober friend in a different way than non-sober friends because they have shared a certain type of struggle in their lives.  Sober friends may e able to provide moral support and encouragement as well as information on how to change and appreciate the client’s need to sometimes share difficult moments that could trigger substance use.  Sober friends may also be willing to engage in leisure activities or find new activities to engage in that do not involve alcohol or drugs.  When a client meets a new sober friend, it is important for him or her to make certain that the person is able to manage his or her own situation with alcohol or drugs before the client attempts to get too close to the person.
There may also be people in a client’s life from his or her family or the client may have longstanding friends that are not abstinent but do not have a problem with alcohol or drugs.  The client may continue to benefit from these relationships in terms of obtaining emotional support, sharing leisure activities, or getting help with problem-solving as long as the person is able to respect the client’s desire to change and does not attempt to sabotage this (e.g., by using in front of the client).

Co-workers
What does this offer? Working can offer clients a sense of purpose in life. Having cordial and productive relationships with co-workers may also provide clients with a sense of stability and support if their relationships with co-workers are positive.

Community service agencies
At times the clients may need help with emergency housing, financial matters, employment, or transportation.  There may be local agencies in the client’s community that he or she will need to contact to get assistance with these matters.  The therapist should try to have a list of local community resources available to help clients with these types of problems.

What does this offer?  Clients may not be able to focus on recovery efforts and may be extremely distressed if they are not able to meet the basic needs of food and shelter.  Addressing these needs is essential to helping the client to focus on achieving and maintaining abstinence.

Check-in
The therapist should conduct a brief check-in to assess how the client has been doing.  Time for discussion of client’s thoughts, questions, or concerns about the session material from the previous week can be taken as needed

“Welcome back.  It’s good to see you again.  How have you been doing since our last session?”

“Do you have any questions or thoughts about what we worked on last time we met?”

Set Agenda
Set the agenda for the session goals including: 1) provide rationale for social support, 2) discuss different types of support, 3) develop a plan for building support, 4) examine barriers to using support, and 5) practice requesting support.

“I’d like to spend our time today talking about social support.  Particularly, I’d like to take some time to talk about the different types of support that are available and your experiences with using support.  Perhaps we can look at some ways in which you may be able to enhance your current support network.”

“How does that sound?”
Discuss rationale for social support
The rationale for building social support will be dependent upon the client’s current social functioning.  For example, if the client’s social network supports continued alcohol or drug use, the client may benefit from lessening these non-supportive relationships and developing (or strengthening) relationships that do support abstinence.   For clients who have appropriate support, expanding the support network and strengthening the use of support may bolster the client’s current efforts.

Asking the client for his or her view about he importance of support may elicit thoughts about the value of different types of support and the client’s willingness to use support.  Asking about the client’s experience with non-supportive friends or family may help the client to recognize the goals of increasing positive support and lessening non-supportive relationships.

“You mentioned in our previous meetings that you have found the support of certain people helpful in your efforts to stop drinking and to get through some tough times.  I would like to hear more about how others were helpful or supportive for you.”

“You also mentioned that some people seem to be less interested in seeing you quit drinking; I’m curious what you meant by that.”

Discuss different types of support
The therapist may begin talking about the different types of support by asking the client about their experience with using social support.  Understanding what types of support have been used and how these supports have been beneficial, will help in guiding a discussion of expanding the client’s use of support.

“I would like to learn more about the types of support that you have used in the past, or are using right now.”

“Can you tell me what made this type of support helpful?”

For any category of support that is not covered in the preceding discussion, targeted questions can be used to assess the client’s use of all the types of support presented in the background section of this module.

√	Self-help groups
√	Professional help
√	Spiritual or religious affiliations
√	Personal relationships
√	Co-workers
√	Community service agencies

The therapist should also inquire about what the client did not find helpful wit the types of support he or she used in the past.
“Now that we’ve spent some time talking about the types of support you’ve found helpful, I also think it would help to know what types of support you’ve not found so helpful and why.”

The therapist might consider inquiring about the client’s willingness to consider types of support that he or she has not previously used.

“Perhaps we could talk about some types of support you haven’t used in the past that you might be willing to consider using in the future?

In addition, if the client has not had experience with a specific type of support, the therapist might try to elicit the client’s thoughts about how it might be helpful in the future.

“Although you’ve never attended A.A. you seem to know a little bit about what happens at an A.A. meeting, I was wondering, in what ways do you think A.A.  could be helpful to you?”

Developing a plan for seeking support
Using the Plan for Seeking Support Worksheet (Appendix A), the therapist and client can work together to develop a plan for obtaining support.  The therapist can encourage the client to try out new types of support, especially for circumstances in which a deficit of support may be one factor in ongoing substance use.  The therapist should not insist, however, that the client utilize any one type of support.

“You’ve been to A.A. a few times and it didn’t seem to help you out.  Given how A.A. meeting can differ from one another, I wonder if you think it would be worth trying out some other meetings?”

“Another possibility is to try a different type of self-help group.  Would you be willing to try SMART?”

In some cases a client may identify family members or friends as a source of support.  Family members or friends who want to be supportive may need to be educated about what type of support the client needs to remain abstinent.  For examples, the client may need to speak to his or her spouse about the importance of being away from home several evenings in a week in order to attend A.A. meeting s or counseling.  Asking supports for help with specific tasks (e.g., childcare, household chores) may help the client to reduce daily stress.

Review how to ask for support
The client may or may not have the interpersonal communication skills to effectively ask for support or may be concerned about asking for support from a mistrustful spouse or family member who is already angry about the client’s alcohol or drug use.  In some cases, a client may not be getting adequate support because the support person in unaware of what client needs, or is providing support that the client does not find to be helpful (e.g., reminders to go to A.A. are perceived by the client as nagging).

Asking for support may take some negotiation.  The therapist should help the client determine who he or she might need to ask for support and discuss specifically how the support can be of help (e.g., emotional support, help with a specific task such as cleaning up at home, sharing a leisure activity once a week that does not involve alcohol or drugs, going to meeting together).  It is also important to consider whether the individual is likely to be good support (e.g., someone who is stable and doe not have problems with alcohol or drugs).  Finally, the therapist should talk with the client about how to ask for support.  If the client is uncertain what to say to the individual to ask for support of concerned that it will be an adversarial situation the therapist should encourage the client to practice in session what he or she might say using a behavioral role play.

Some of the tips that could be offered to the client who wants to ask for support are:

•	Be specific about what type of support you need
•	Show appreciation for the person’s support if it was helpful
•	Give feedback to the person if he or she is giving support that was not helpful 
•	Find a way to support the other person

Review Obstacles to Using Support
If the client has had experience with a specific type of support the therapist should ask about potential barriers to using this type of support.  If the client is not able to report many obstacles the therapist may review some common obstacles (see below) and assess the client’s experience with the obstacles.

Some of the common obstacles to using social support:

•	Client reports it is too difficult to find or develop new sober friendships
•	Client reports that it is too risky to talk about having urges to family or friends because it will disrupt the trust in his or her relationship
•	Client wants to appear to be doing well and is not comfortable letting people know he or she is struggling with urges

Many clients also struggle with thoughts that prevent them from using support as follows:

•	“I can’t go to AA by myself and I have no one to go with”
•	“I don’t wan to be a burden to other people or be seen as a whiner”
•	“I don’t want to tell someone my personal business”
•	“I should be able to handle my own problems.  I’m an adult”
•	“Seeking support is a sign of weakness and I don’t want to be seen as weak”
•	“No one can understand me unless they’ve walked in my shoes”
•	“I’m not sure I want to be talked out of drinking or using drugs”

When the client identifies obstacles to support, it is important for the therapist to engage the client in problem-solving and help to resolve these obstacles.  If the client is engaging in thoughts that prevent using social support, discussing alternative ways to think may help to resolve this obstacle.

Implementing the plan
The final step in developing a plan for seeking support will be to help the client develop a plan for getting support.  Planning in detail will help the client to anticipate obstacles and follow through with the plan.

“Which self-help group will you try out next week?”
“What night of the week are you able to schedule therapy?”
“Do you know which church you would like to join?”
“What would you do with your friend on a Saturday afternoon?”

The client may need referrals from the therapist to assist in this developing a detailed plan (e.g., AA meeting schedule, contact numbers for therapists, information on community programs).

Troubleshooting
Clients may be more likely to try support activities (e.g., attending A.A.) if attendance is encouraged and not required.  Reluctance to using support should be explored in a nonjudgmental manner.  Understanding the client’s thoughts about the value of using support and his or her thoughts about how other people will perceive him or her for asking for support may reveal some distorted thinking.

Therapist:  “You recognize that support from your family would make a big difference right now, but it sounds like you don’t want to involve them right now.”
	Client: “I’ve been enough of a burden on them already.”
Therapist:  “You are worried that helping you stop drinking would be an imposition for them.”
Client:  “I’m sure they would help me, they tell me to call… but I’ve been down this road before and I always feel bad when I let them down.”
Therapist: “So you are afraid that you will begin drinking again and they will be disappointed.”
Client:  “Yes. Wasted effort, once again.”
Therapist: “So if you spare them the effort and you do drink again, they won’t be disappointed.”
Client:  “Actually, they will be upset with me for isolating and not talking to them.”

The therapist may try to correct errors in thinking that hinder use of social support, but should not insist that the client engage in support building exercises.  Asking permission 

to return to the topic of enhancing social support is helpful for retaining the possibility of working on this module at another time.

“It sounds like you are pretty sure that AA is not something you want to try out right now.  Would it be OK if we looked at this again sometime later in treatment?”

Developing a Plan Sample Dialogue:

Therapist: “We’ve spent some time discussing the various types of available support and the kinds of help they provide.  You’ve identified several types of support and the kinds of help they provide.   You’ve identified several types of support that you may find helpful.  I’d now like to spend some time helping you to develop a plan for how to go about seeking this support.  How does that sound?
Client: “OK.”
Therapist: “What’s one type of support that you may find helpful.”
Client:  “My kids.  They are my biggest support.”
Therapist:  “How so?”
Client: “They give me a reason to go on.  My daughter told me how proud she was of me the other day.”
Therapist: “So it sounds like you kids help with motivation and provide you with encouragement.”
Client: “Exactly.”
Therapist: “So what if you were having strong urges to use.  Would that be something that you would seek the support of your children for?”
Client: “No way.  I couldn’t talk to my kids about something like that.  They wouldn’t understand.  It wouldn’t be right.”
Therapist:  “So your kids can be an important source of support but may not be the appropriate support in helping you with your urges.  What do you think would be helpful?”
Client: “Actually I’ve been thinking about giving A.A. a try.”
Therapist:  “Great.  How do you think A.A. would be helpful?”
Client:  “Well, I have an uncle who goes to A.A. and he’s been sober for years.  I guess it’s being with people who have the same problem.  They can understand what you’re going through.”
Therapist: “Would this be something you’d be willing to try before our next session?”
Client: “Yeah.  I’ll give it a try.”
Therapist: “Why don’t we come up with a plan for attending a specific A.A. meeting this week?  I happen to have a meeting list book of all the meetings in this area.  We could take a look together if you like.”
Client: “Here a meeting close to where I live on Thursday night.”

Therapist: “Let’s come up with a plan for attending this meeting.  I’m wondering, do you foresee any reason for not attending this meeting?”
Client: “Well I could get cold feet.  It sounds great talking about it here but I just can’t imagine walking into a room full of strangers all by myself.  I’m really self-conscious.”
Therapist: “Let’s see if we can find a way to work around this.  You mentioned earlier that you have an uncle who attends meetings.”
Client: “Yeah.  Hey, I could give my uncle a call and see if I could go to a meeting with him.”
Therapist:  “That sounds like an even better plan.  When do you think you might call him and set things up.”
Client: “I’ll give him a call when I get home tonight.”
Therapist: Great. Why don’t we check in next week and see how things went.”

Summarize Session
The therapist should end the session by summarizing the types of support that the client plans to use and how he or she will obtain it and how the client will avoid potential barriers to support.  Willingness to try new avenues of support to see if they are helpful should be reinforced by the therapist.

“We’ve covered quite a bit of material today.   I appreciate the time and effort that you put into our session.  We spent a great deal of time looking at the various supports that are available and the types of support that you have found helpful in the past while exploring additional support that you may be willing to try now.  You developed a plan for seeking support that includes attending an A.A. meeting with your uncle next week and we will check in during our next session to see how that went.  Again, I commend you for your willingness to try something new.”

Preview Next Session
The therapist should ask the client if he or she wants to continue to work on social support or move on to another topic.  In either case the client’s progress on the home assignment, Plan for Seeking Social Support will be reviewed in the next session.

Review Home assignment
The client should begin to implement the plan to build his or her support system as outlined on Plan for Seeking Social Support that was completed in the 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

Montgomery, H.A., Miller, W.R.,& Tonigan, J.S. (1995).  Does Alcoholics Anonymous involvement predict treatment outcome?  Journal of Substance Abuse Treatment, 12, 241-246

Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes.  Alcoholism: Clinical and Experimental Research, 22, 1300-1311.

Sheeren, M. (1988).  The relationship between relapse and involvement in Alcoholics Anonymous.  Journal of Studies on Alcohol, 49, 104-106.

APPENDIX A
SOCIAL SUPPORT
SESSION MATERIALS

Support

Support

Plan for getting this support

How this support will help

Support

Plan for getting this support

How this support will help

Plan for getting this support

Plan for Seeking Support

How this support will help

PREPARATIONS	•		
  Session checklist		
  Agency-specific paperwork		
  Plan for Seeking Support worksheet		
GETTING STARTED		
  Check-in		
  Review of previous session		
  Set the agenda		
IDENTIFYING SOURCES OF SUPPORT		
  Discuss rationale for social support		
  Explore client’s experience with social support		
  Examine different types of support		
DEVELOPING A PLAN FOR SEEKING SUPPORT		
  Review how to ask for support		
  Review obstacles to seeking support	 	
  Complete Plan for Seeking Support worksheet		
COMPLETION OF AGENCY-SPECIFIC TASKS		

WRAP UP		
  Summarize session		
  Preview coming session		
  Assign home exercise		

Module 6 Session Checklist
Social Support