I contend that the outcome of a given treatment episode is often determined right at the outset, based on why the clients is in treatment in the first place.

In a way, the thinking process of someone just beginning treatment resembles a negotiation, except with oneself rather than another person.

It’s based on the answers to four questions.

First: what do I need to accomplish based on this decision?

Then, what else do I want to accomplish beyond the necessities (there’s usually  something.)

Third, do I have alternatives in case this doesn’t work out?

And finally, are there any deadlines or time constraints I have to consider?

In practice, the outcome of a given treatment episode is often determined at the outset, based on why the client decided to come to treatment in the first place.

Example: Owen, 33, has been sent by his attorney in hopes of avoiding further consequences for his second drunk driving offense in just over two years.

Need:  to avoid jail time. In this case, it means completing treatment satisfactorily.

Want: he’s also hoping to get permission to skip some sessions so he can work extra overtime hours and make extra cash to pay off some debts.

Options: he’s curious if there are other programs that might require less in terms of time commitment on his part.

Timing: turns out he’s already procrastinated, so his attorney wants him complete most of the required sessions prior to his next court appearance.

At this point, Owen’s motivation is entirely external. Hopefully that will change, but right now, we can’t rely on him to self-motivate. We want to build external monitoring into the treatment plan, possibly through a contingency contract that includes frequent checks.

Compare that to Sarah’s situation: a nurse who came to treatment as the result of a family intervention, she was deeply shocked that others knew of her prescription painkiller abuse. She thought she’d successfully concealed it. Her parents told her that if she refused help, they’d consider reporting her to the licensing board. She freaked when she heard that, and immediately agreed to treatment, on the condition that her secret remain safe.

For Sarah, preserving her nursing license is all-important, and to her, that means secrecy. She rejects the state nurses assistance program on the grounds that it can’t guarantee confidentiality. Her career, she fears, would be ruined.

As it stands, outside authorities are not yet involved, and she wants that to continue to all costs.

It’s fair to say that both Owen and Sarah are in treatment to avoid responsibility, not to accept it.  If their  motivation doesn’t change, relapse is likely. Might as well not have bothered with treatment.

By the way, treatment will get the blame for failure. But this is far more about the client’s intentions than the clinician’s skill.

One way to approach such situations is by initiating another negotiation, this time between clinician and client, with the goal of altering the outcome in favor of recovery.

We’ll take another look at that in a future post.


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