Session One: The Decision To Change

Youth & Drugs and Mental Health: First contact

The Decision to Change exercise provides a way to discuss and address clients’ ambivalence to change by asking clients to identify the pros and cons of using alcohol and/or drugs and the pros and cons of changing their drug use. The primary goal is to increase clients’ awareness of changing their use as a decision wherein some trade-offs are made. Just being aware of the possible pros and cons and asking clients to prioritize them facilitates self re-evaluation, a process that is crucial to increasing one’s readiness to change. The Decision to Change exercise gives clients a way to talk about the difficulties of changing as well as the consequences of not changing.

While a counsellor may have the urge to talk about how to solve the problems or overcome the obstacles presented, first it is important to acknowledge the obstacles and what would be lost by changing. In a group, members will talk about their own experiences with obstacles to change. You will need to use some clinical judgment in situations where a client seems to be getting discouraged by the obstacles to change. To help a client gain perspective, provide (or have the group provide) some encouraging words and support self-efficacy. For example, it is sometimes useful to affirm a client’s decision to seek help, or to draw parallels between a previous accomplishment that took time and effort and his or her present situation. In this way, the counsellor highlights the client’s resources for change without taking on the teacher role.

Goals For Session 1

1. Provide a clear understanding of the purpose, format and goals of First Contact.
2. Facilitate group formation by:
   • introducing group leaders and clients
   • establishing group rules, norms and expectations
   • beginning to highlight commonalities among group members to foster support.
3. Create a comfortable, accepting atmosphere using an “ice breaker” and encourage discussion of what brought the clients to the program and what they hope to get out of treatment.
4. Complete the Decision to Change exercise with the following goals:
   • Help the client to become aware of the decision to change process.
   • Provide a forum to talk about the difficulties of changing.
   • Highlight the consequences of changing and not changing.
   • Acknowledge what would be lost by changing.
   • Introduce the idea of choice and control with regard to drug use.
5. Introduce Check-in (weekly use/goal monitoring).

Guidelines For The Counsellor

1.  Introduce the program.

“This group is for young people age 15 and younger (or 16 and older). You will meet for two hours, once a week for four weeks. After four weeks, this group will end and you can decide where you want to go from there.”

“The purpose of the group is to look at the impact that drugs and alcohol have on your lives and to explore how your drug use and mental health problems affect each other. This is your group and you are here to help each other out; therefore, what you have to say to each other is very important. We (the therapists) are here to help build some trust and encourage you to participate. We also have some problem-solving tools to share with you. In addition to this group, some of you will also be attending appointments to help you with your mental health concerns.”

“Some of you are in different places when it comes to your drug use:

• Some of you have no intention of changing your drug use.
• Some of you are here to deal with your mental health issues.
• Some of you have very mixed feelings about changing your drug use.
• Some of you are thinking about changes but don’t know where to start.
• Some of you have already made some changes.

2.  Discuss participation in the group and confidentiality.

“This group is a place where you can start solving some of the problems you’re facing. So, the more you share, the more you are going to get out of the group. We will have a chance in the group to talk about your life goals and your drug use goals, but what you actually decide to do is up to you. Because people are going to be sharing things, it is important that we all agree that what is said in the group stays in the group.”

“Something that is important for us to talk about is your confidentiality. What is said in here stays in this room. We need your permission to talk to or release information to others. However, there are some limits to confidentiality. If you are going to harm yourself or others, or if child abuse is an issue, then, legally, we need to break confidentiality. But aside from those exceptions, your confidentiality is maintained.”

3.  Introduce clients.

“In this group, we are going to be talking a lot and getting to know one another better. As a way to begin, we can do an ice breaker…”

Icebreaker - the 4 corners

Purpose

• To relieve some of the tension around being in a group for the first time or attending a group with people you do not know.
• To highlight for the clients some of the things they have in common with other group members and to help everyone acknowledge that there are differences between members. This can serve as a good starting point for talking about group norms and how to make everyone feel safe, given that there are many similarities and differences.

Method

Everyone stands in the middle of the room. Group leaders will give instructions to group members to go to different corners (or the middle) of the room according to their answers to specific questions. E.g., Anyone who woke up today before 6 a.m. go to that corner; everyone who woke up between 6 and 7 a.m. go to that corner; everyone who woke up between 7 and 8 a.m. go to that corner; and anyone who woke up later than 8 a.m. go to that corner. If the room is large, it may not be a good idea to use all the corners since people will be too far away from each other. You can use sitting, standing, being by the door, etc.

Time should be given for everyone to find the appropriate corner and allow for conversation to be initiated between members within each corner. Group leaders can then foster more cohesion by saying, “Now, suppose it was a Saturday, where would everyone be standing?” These exercises can be tailored to the needs of the group using them, such as who lives near water or a park, who goes hunting, fishing, snowmobiling, skiing, etc.

Group leaders go through a series of questions so members are constantly shifting themselves throughout the room and joining up with new people. People can be asked to notice whether they are often in the same corner with another person or who they have the most in common with, and, conversely, who they have the least in common with.

Topics can get increasingly focused on clients’ attendance at group, using questions such as whether they would like to make changes to their drug use, alcohol use, or both. Another suggestion is to instruct clients, “If you are here because you want to be, go to this corner; if you did not want to come today, go to that corner; if you are not sure why you are here, etc.

This can lead into a discussion about respect for different interests, goals and reasons for attending group.

4.  Introduce the Decision to Change exercise.

“We’d like to talk about some of the issues you may be struggling with in deciding to stop or reduce your use. What will you gain - and lose - by changing? What about not changing?”

Ways to encourage discussion in this exercise:

• “Which cost (or benefit) is most important?”
• “Why are you concerned about that cost?”
• “How mixed are your feelings about changing your use?”
• “What are some of the fears or hopes you have right now?”

Participants can fill out their own exercise sheet and then discuss their responses with the group, or it can be done with the group as a whole, noting the responses on a flip chart. In residential settings, with clients who are not using, it may be appropriate to only do the second part of this exercise, though most clients find it helpful to reflect back on what it was like for them when they were using.

5.  Introduce Check-in exercise.

Finally, although the Check-in exercise will be completed in Session 2 and at the start of each subsequent session, it is worthwhile to introduce this exercise at the end of the first session. Previewing the Check-in exercise gets clients thinking about monitoring use, urges and coping during the coming week so that this information will be easier to recall in Session 2. “This sheet is what we will be using each week as a way of you telling the group what went well during the week and what did not go well. Over the next week, think about what your drug-use goal will be. Also, try to remember when you used, when you craved, and how you dealt with it. In addition, try to recall how your mental health was during the week. Those are the things that we will talk about next week.”

6.  Wrap up.

• “What’s one thing you will do this week to meet your substance-use goal?”
• “Was the group what you expected? Do you have any questions?”
• “What will you be saying to each other on the way back to the elevator? It is important to say it here in the group.”
• “What stood out for you in this session? What would you say to someone else about today’s group?”

Goal Setting

Early in the treatment process, clients should clarify their intentions about stopping or reducing substance use. Many clients may not choose a goal of abstinence. First Contact takes a pragmatic approach by assisting clients to establish and work towards their substance use goals. In the short term, this strategy seeks to decrease the adverse impact of substance use in a style that supports clients’ autonomy. In the long term, setting and reviewing goals for reducing or stopping use can be a process whereby clients build the motivation and skills needed for minimal or no use.

Research supports the notion of providing goal choice in that:

• There appears to be no basis for expecting that the therapist assigning treatment goals to clients will affect outcome (Sanchez-Craig, Annis, Bornet & MacDonald, 1984).
• Clients will be more likely to comply with treatment when they themselves have made the decision to pursue that strategy (Sobell & Sobell, 1993).

In discussing substance-use goals, it is important to make clear to the client that allowing goal choice does not mean that the counsellor is condoning or encouraging substance use; in particular, the use of alcohol by anyone who is under legal drinking age and the use of illicit substances by youth of any age. In the spirit of informed choices, this point can be made by stating that the most effective way to eliminate the chance of negative substance-related consequences is to not use at all. For those clients who do not choose a goal of abstinence, however, it is important to provide the message that reduction can decrease substance use-related harms. The First Contact program is as relevant for people with non-abstinence goals as it is for those who are prepared to quit altogether.

When clients consider reducing their use, the counsellor should emphasize the feasibility and reasonableness of the chosen goal. For example, when there are reasons why substance use would be too great a risk (e.g., if it would lead to serious legal problems or loss of family relationships), it is an opportunity for the counsellor to determine how the client perceives the potential risks involved, even with reduced use, and the benefits of an abstinence goal.

Because most clients will not know what goal is most realistic for them at first, weekly review of clients’ goals is recommended. A reduced substance use goal should be clearly defined so that:

• The client has specific, well-thought-out rules about drinking or drug-use limits when he or she encounters a possible high-risk situation.
• The substance use goal does not change over time in a way that leads to the pre-treatment substance-use pattern.

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