Session Two: Triggers, Consequences and Alternatives

Youth & Drugs and Mental Health: First Contact

Goals for Session 2

1. Continue to clarify mental health and drug-use goals.
2. Continue to promote the ideas of choice and control with regard to use.
3. Continue to provide a comfortable and supportive forum to talk about the difficulties and rewards of changing.
4. For groups, continue to highlight commonalities and build group cohesion.
5. Complete the weekly Check-in exercise with the following goals:
   • Monitor progress.
   • Highlight successes.
   • Aid in goal-setting (e.g., drug use, mental health and other life goals).
   • Increase awareness of urges, cravings and strategies.
   • Increase awareness of interactions of drug use, mental health symptoms and medication.
   • Search for exceptions to usual patterns.
   • Expand on clean time.
   • Share strategies.
   • Identify high-risk situations.
6. Complete the Triggers, Consequences and Alternatives exercise. Its goals are the following:
   • Generate clients’ options.
     Create awareness of triggers and consequences.
   • Explore barriers to change.
   • Increase self-efficacy by identifying what clients are already trying.
   • Identify relevant successes in past (e.g., “mining the past”).
   • Help clients understand their use patterns.
   • Emphasize the connection between consequences and triggers.
   • Address the differences between long and short-term consequences (positive vs. negative).

Check-in

The Check-in exercise is a way to reinforce and elaborate on themes introduced in Session 1. Part of the check-in is to ask clients to recall their use and/or their urges to use substances during the past week and keep track of their mental health symptoms and issues. Rather than focus on every day over the past week, you might ask that clients do the exercise for a good day and for a not-so-good day. For youth with concurrent disorders, the check-in is a time to explore mental health antecedents to drug use such as mood, behaviour, psychosis and medication effects.

In the first quadrant, clients identify the circumstances surrounding a craving or a use. This increases awareness of situations when they are likely to use. For clients with mental health problems, it is important to explore how their mental health symptoms trigger cravings or use and how use affects mental health symptoms. In quadrant 2, clients recall the various strategies that they used when they felt like using. This allows the counsellor to highlight what works for them, even if they are simply reducing the quantity or frequency of use.

The counsellor should explore incidents of success carefully to ensure that clients actually understand how they succeeded. In quadrant 3, clients recall the consequences of their actions, which can be negative or positive. For clients with concurrent disorders, it is useful to explore how cravings, drug use or abstinence affect their specific mental health issues. Discussion about what they can do to turn a negative outcome into a more positive one is useful. Finally, in quadrant 4, clients are asked to set goals for the coming week with respect to drug use as well as other life areas, including mental health issues.

There are a number of ways to do the check-in. Clients can complete the exercise on their own and then discuss their responses with the group. Or the discussion can take place in dyads. To avoid literacy issues the counsellor can go through the exercise verbally with the client, or use the art therapy module described on page 266.

Guidelines For The Counsellor

1. Explain the purpose of the Check-in exercise.

“This check-in sheet is a way for you to tell the group what went well during the week and what did not go well.”

Define a craving: A craving can be anything from a thought, such as, “I wouldn’t mind a joint right now,” to a more physical experience, such as palms sweating or difficulty sitting still.

Discuss progress over the last week:

• “Tell us about a situation you handled well.”
• “Tell us about your clean time last week…how can you get more of that?”
• “Was anything easier/better last week?”

Help clients support each other:

• “What are other people’s reactions to seeing friends?”
• “You were nodding when he/she was speaking, what were you thinking about?”

Help clients set goals for next week:

• “What are you going to do more of next week?”

2. Introduce the Triggers, Consequences and Alternatives exercise.

“This exercise follows from some of the things that we talked about during the check-in. It will help you to think about the patterns of your use, what the triggers, payoffs and consequences are. Understanding these connections is the first step to you taking control of your use.”

Explain triggers, behaviours and consequences - begin by discussing triggers:

• “When we talk about triggers, we are talking about the situations that lead to use. Triggers can be people, places, things, times and feelings. The behaviour is the drug use. The consequences are the things that happen after you use. They can be both positive and negative. Who can give me some examples of triggers?” (Suggestion: have one of the clients at a flipchart writing client responses down.)
• “What triggers happened last week (refer to check-in)?”
• “What other triggers can you think of?”

Discuss consequences:

• “What is some of the stuff that happens after use? Is there anything you notice about the timing of the consequences?”
• “Some clients have said that using was really fun in the beginning but that now it is not as much fun. Has anyone experienced that?”
• “Some consequences are hidden, some are lost opportunities. Has anyone experienced missing out on something because they were using?”

Discuss alternatives to use:

• “On non-using days, what has worked for you?”
• “What is going to help you not use?”
• “What might be frightening about doing something different when you want to use?”
• “What would be the easiest thing to do differently?”

3. Wrap up.

Look at ways that the Triggers, Consequences and Alternatives exercise could apply to daily life outside the session:

• “What is one alternative to substance use that you can try this week to help you not to use?”

Exploring Patterns of Use

The Triggers, Consequences and Alternatives exercise can help clients understand their use patterns by emphasizing the link between the triggers/antecedents of use and the resulting positive and negative consequences. This exercise can also help the client explore the relationship between drug use and mental health symptoms. Many of the goals of this exercise are drawn from issues raised during the check-in, such as how to identify triggers and generating alternatives to use. Sometimes clients maintain that there are no triggers to their use. What usually helps in this situation is to go over the potential list of people, places and things (e.g., emotions, time of day) that can serve as triggers. Also, clients may have mentioned something during the Check-in exercise that provides a clue as to what triggers are salient to them.

It is important to talk about the timing of the consequences of use if the subject does not naturally come up in discussion. On one hand, when people drink or use drugs, they are seeking the positive consequences (e.g., temporary relaxation) that can occur during or shortly after use. On the other hand, the negative or harmful consequences are often delayed and are difficult to link with the actual substance use. For instance, a gradual decline in the quality of one’s schoolwork could be a long-term result of substance use that would not be directly related to any single occasion of use.

Strategies For Change

After discussing the clients’ triggers and alternatives to substance use, the counsellor encourages them to select one alternative that they are willing to try during the coming week. Sometimes clients do not feel confident about engaging in new activities in high-risk situations and these concerns need to be explored. Two useful strategies to increase clients’ self-efficacy in trying alternatives are:

• identifying what clients are already doing to reduce their use. Clients sometimes fail to realize that they already engage in some activities that deal with urges or remove them from high-risk situations. Even simple things like keeping busy, listening to music, or spending time with family or friends who do not use drugs should be acknowledged and encouraged.
• drawing parallels with a previous accomplishment (e.g., “mining” the past). It is also helpful to find out if clients have tried to reduce or quit in the past and how they did so. Even if their strategies were only temporarily successful, discussing how those strategies can be modified or supplemented can be a fruitful way to build on the clients’ existing resources.

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