Strategies for Addressing Common Clinical Problems
The counselor should respond to common clinical problems in a manner consistent with the treatment approach, that is, reflection and reframing that follow the principles of MET and, when indicated, a more active problemsolving approach.
Counselor’s Response to Missed Session
The counselor should attempt immediately to phone a client who does not show up for a scheduled therapy session to find out why the session was missed. Clients sometimes miss sessions because they slipped and are embarrassed to admit their failure to the counselor or they are ambivalent about making a permanent change. Careful inquiry by the counselor reveals which situation is the case.
The counselor should cover six basic points when speaking with the client again:
• Clarify the reasons for the missed appointment.
• Affirm the client and reinforce him or her for having entered the program.
• Express eagerness to see the client again.
• Briefly mention serious concerns that have emerged in treatment and express appreciation (when appropriate) that the client is exploring them.
• Express optimism about the prospects for change.
• Reschedule the appointment.
If no reasonable explanation (e.g., illness, lack of transportation) is offered for the missed
appointment, the counselor can explore with the client whether the missed appointment might
reflect any of the following:
• Uncertainty about whether the treatment is needed (e.g., “I don’t really have a problem”).
• Ambivalence about making a change.
• Frustration or anger about having to participate in treatment (particularly in clients who were mandated to enter the program).
• Embarrassment about a relapse. If client’s absence was because of a slip, the counselor should be nonjudgmental and should encourage the client to come to a session clear headed and process the experience, noting that both the client and the counselor will learn from the discussion.
When a client returns to treatment after a missed session, the counselor should show appreciation.
Counselor’s Response to Slips
If a client slips and continues to use episodically, making statements such as “I messed up,” “I’m a failure,” or “This isn’t working,” the counselor can commend the client on his or her honesty and convey the idea that occasional slips are common in the course of treatment; they do not mean that the treatment is not working or that the client is a failure:
C: You may find it hard to stay abstinent. Slips are actually common occurrences and nothing
to feel ashamed about. You were abstinent for about 3 weeks before the slip. That was
a significant amount of time! What are some things you can do to remain abstinent and
Goal of Abstinence From Marijuana
Marijuana Treatment Project participants were told that their counseling would focus on achieving abstinence. It was made clear, however, that individuals who wanted to reduce use would not be dropped automatically from the program. People working toward a moderation objective were encouraged to learn to be abstinent for several months. The rationale for this suggestion included two main points:
1. Learning refusal skills during a period of abstinence develops many important strengths needed to become permanently abstinent.
2. A period of abstinence likely gives the client more information about what it is like not being intoxicated on an ongoing basis.
When following the BMDC approach, the counselor explains that ambivalent feelings about accepting abstinence as a goal are common. He or she encourages the client to discuss these feelings and any slips that occur. In addition, clients whose initial goals were to reduce use may make abstinence their new goal later.