Phase 2: Building Rapport
Phase 2 of the C.A.R.E. model prioritizes Relationship building with new clients navigating ambivalence around cannabis. Our primary focus during this phase is building a strong and trusting therapeutic relationship. This solid foundation allows us to collaboratively explore the various aspects of their presenting issues and gently consider how cannabis use might be interwoven with those concerns. We are creating a space where, should it become relevant and feel right for them, we can openly discuss the possibility of moving into a deeper exploration of their cannabis use in later phases. For now, our attention is on understanding their current challenges and building a strong partnership to support their well-being.
Approximate Sessions: 1-4
Phase 2: Essentials
1
How to Prepare
I keep some decision-balancing sheets to see the pros and cons of change. I ensure I include a score for each item, as I will add the scores when evaluating the importance of each quadrant.
Diary cards are essential to introduce early. Tracking skill use, maladaptive behaviors, and substance use are some of the things helpful to include early on.
2
Goals of the Phase
Joining with the client in their goals builds rapport. You should see if the client can maintain use and achieve their goal by bolstering their coping skills.
It is important not to judge the use at this stage; as the clinician, you are collecting data and encouraging change talk.
3
Key Skills
At this time, having some fluency in motivational interviewing and DBT skills can be helpful.
You can teach emotional regulation skills to help with the presenting problem and use a diary card to check how often the client is not feeling well, using specific skills, how effective it is, and how frequently they use it.
Hear about Building Rapport
Key takeaways:
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Phase 2 of the framework focuses on building rapport with the client.
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At this stage, the client may be ambivalent about the impact of their cannabis use.
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Treatment involves addressing the client's presented issues while occasionally checking in about their cannabis use.
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Progressing to the next phase ("the experiment") depends on the client achieving their goals.
It's important to remember that not all cannabis use is problematic. Suppose you are working with a client, and they are seeing the changes they want to see without adjusting their cannabis use. In that case, they may be able to use it recreationally, like someone can drink in moderation without any issues.
In Phase 2, we are honoring the client's self-determination by allowing them to choose what they are working on while keeping an eye on their cannabis use. We would treat them as if they were any other client except that we are paying attention to their use and ensuring we look for any change talk and try to draw more of it out if that arises. One skill that is useful in looking for change talk is the OARS Skill.
OARS
A Motivational Interviewing (MI) Skill
This skill is called OARS and can be used in all phases of the model. OARS is one of the MI skills that can be particularly helpful in building rapport and can help improve motivation for change. The OARS includes four basic skills: O = Open Questions A = Affirmations R = Reflective Listening S = Summarizing. SAMHSA TIP 35 is a great resource if you want to learn more.
Open-Ended Questions
Invite the client to share their thoughts without leading them.
Example: Can you tell me about your cannabis use over the past week? Vs Did you use cannabis this past week?
Affirmations
Reinforce the client's motivation for change. It also helps establish rapport.
Reflective Listening
Involved actively listening to the client and using simple reflecting to interpret the meaning of what the client is saying.
Summaries
Can have multiple functions but often let the client hear the information back to reflect on it.
Helping build rapport
Building rapport with students exploring their relationship with cannabis use begins with a strong therapeutic alliance. Active listening becomes key to deeply understanding their individual experiences and motivations surrounding cannabis. Collaborative partnerships empower these young clients, fostering their autonomy and intrinsic drive for change within the therapeutic process. Unconditional positive regard establishes a crucial foundation of non-judgmental acceptance, encouraging open and honest self-reflection. Skillfully repairing ruptures in the therapeutic relationship further strengthens this connection, allowing for sustained progress in addressing their cannabis use.
01
Active Listening
Show genuine interest in the client and be able to paraphrase and summarize the client's words to show you understand them or allow them to clarify.
02
Collaborative Partnership
Have the client take an active role in treatment. "Empowering clients to make
informed decisions, set goals, and take responsibility for their actions." Like Virgil guiding Dante, your role is to guide their journey, not solve their problems.
03
Unconditional Positive Regard
Unconditional Positive Regard means accepting the client fully and non-judgmentally. This can create a safe place for them to explore and grow.
04
Repair Ruptures
Therapeutic ruptures happen; when they do, address them in the session if possible. Let them know you appreciate the feedback. This can strengthen the alliance.
Decisional
Balancing
Worksheet
If you suspect problematic cannabis use is impacting a student's presenting issues, using a decisional balancing worksheet can be a powerful way to initiate a non-judgmental exploration. This technique helps to build rapport by inviting the student into an open dialogue about their cannabis use, examining both the perceived advantages and disadvantages from their perspective. By working through this worksheet together, you create a space for honest self-reflection, fostering trust and allowing for a more comprehensive understanding of how cannabis may be impacting their overall well-being and student goals, without feeling accusatory or directive.
Case Vignette:
Tony
Tony and I began addressing his anxiety related to ED. Early on, I inquired about a potential link between his cannabis use and ED, but Tony remained insistent there was no connection. We explored his thoughts and feelings surrounding sexual performance, considering if he was "getting in his head" before sexual activity. Tony's primary motivation for seeking a solution was his partner's increasing frustration and the threat of a breakup. We remained in Phase 2 for several weeks. I then came across an article discussing a possible relationship between cannabis use and ED. I printed it, provided it to Tony in session, and asked if he'd be willing to read and discuss it in our next meeting. In our 6th session, Tony discussed the article and appeared more open to considering a connection. He also revealed his partner had given him an ultimatum. I proposed an experiment to test the hypothesis of cannabis and ED, explained the process, and Tony agreed to reduce his use. We collaboratively set an initial goal of reducing to once-daily use on smoking days, aiming to decrease to 5-6 days per week.