Guided self-change

1. Introduction

Version followed: the four-session Guided Self-Change (GSC) protocol in Sobell & Sobell (2011), Group Therapy for Substance Use Disorders: A Motivational Cognitive-Behavioral Approach, as set out in the matching therapist handouts (Assessment Session; Individual Sessions 1–4; Group Sessions 1–4) and client handouts posted by the Nova Southeastern University (NSU) Guided Self-Change clinic. The original problem-drinker version (Sobell & Sobell, 1993, Problem Drinkers: Guided Self-Change Treatment) is not drawn on; differences between the 1993 and 2011 versions are not documented here [uncertain].

What it is. GSC is a brief, time-limited outpatient treatment that combines motivational interviewing (MI), cognitive-behavioural problem solving and relapse-prevention ideas. Mark and Linda Sobell first built it for problem drinkers who are not severely dependent. It has since been tested with people who use drugs, adolescents and Spanish-speaking clients, delivered in groups, and extended to community-level interventions [source: Sobell & Sobell 2005 abstract; 1993 book description]. The standard format is one assessment session plus four semistructured sessions, individual or group. A follow-up call comes about one month after the last session, and further sessions are available on request [source: Therapist Handout 3.1].

How change happens. The client is treated as the agent of change. The therapist guides and speeds up a self-change process; the therapist does not impose it. Assessment data come back to the client as personalised feedback to build motivation. The client chooses the goal (abstinence or, where appropriate, low-risk drinking), weighs the pros and cons of change, and identifies personal high-risk situations. The client then uses a general problem-solving method to build options and action plans and tests them between sessions. Out-of-session readings, homework and self-monitoring are brought back into sessions; the assessment handout says this "helps accelerate their change" [source: Therapist Handout 3.1; Therapist Handouts 4.1–4.4]. The model's roots in research on natural (untreated) recovery are reported in summaries [uncertain].

2. Framework

Format [source: Therapist Handouts 3.1, 5.1; Sobell, Sobell & Leo 2000 abstract; Carballo et al. 2022 abstract]

Individual: one assessment plus four sessions, usually weekly. The handouts do not give the length of individual sessions [uncertain]; 50–60 minutes is a reasonable default [synthesis].
Group: two co-leaders, about 6–10 members, four sessions of 120 minutes each. Every group member first has an individual assessment. Leaders plan for 15–20 minutes before each group and debrief for 5–10 minutes after it. Client handouts and homework are the same in the group and individual formats.
Spouse involvement (research variant): in one trial the spouse also attended two individual sessions. In the "directed social support" arm, spouses were asked to support change actively and to respond to relapses in line with a relapse-prevention model. This arm did not do better than natural support [source: Sobell, Sobell & Leo 2000 abstract].
Best fit: drinkers or drug users with problems who are not severely dependent [source: 1993 book description]. Clients with severe dependence or withdrawal need a medical assessment and usually a more intensive level of care first [synthesis].

Phases and goals

Phase	Main goals	Core content	Homework set
Assessment	Gather history and data for feedback; explain GSC; get consent	Motivational opening; AUDIT and/or DAST-10; Drug Use History Questionnaire; 90-day Timeline Followback; readiness ruler; BSCQ; Where Are You Now Scale; group orientation if in group	Decisional balance; goal statement and goal evaluation; self-monitoring logs
Session 1: feedback and motivation	Review progress and goal; give personalised feedback; explore motivation	Log review; normative feedback and severity score; goal evaluation (contraindication guidance); decisional balance; five-million-dollar question	Identifying Triggers reading and exercise (two highest-risk situations from the past year)
Session 2: high-risk situations	Identify personal high-risk situations	Log review; triggers homework; reading on the long-term view of change (Mt. Change); BSCQ profile feedback; Where Are You Now Scale repeated	Developing New Options and Action Plans exercise
Session 3: options and plans	Turn options into action plans and plan to test them	Log review; options and action plans; anticipate situations to test plans; BSCQ repeated in session	New goal statement and goal evaluation; Request for Additional Sessions form
Session 4: review and next steps	Review progress, motivation and goal; decide what comes next	Before-and-during comparison of use; goal and decisional balance revisited; BSCQ comparison; Mt. Change revisited; Where Are You Now Scale repeated; review of the additional-sessions request	Continue self-monitoring and testing plans (if continuing)
Aftercare	Maintain change; offer more help	Therapist calls about one month after the last session; individual sessions on request	—

[source: Therapist Handouts 3.1, 4.1, 4.3, 4.4, 5.1–5.4; Table 5.1]

Criteria for moving between phases. GSC moves forward by session number, not by mastery: each session builds on the one before, and missed sessions are not made up in groups [source: Table 5.3]. The formal decision point is Session 4. There the client reviews the Request for Additional Sessions form and either ends with an aftercare call or books more (individual) sessions, with the number requested and the reasons documented [source: Therapist Handouts 4.4, 5.3]. Practical signs that more care is needed: no change in use across logs and feedback; confidence or Where Are You Now ratings that stay flat; emerging withdrawal; or a slip pattern that is getting worse. In those cases, offer more sessions or step up to more intensive or medical care [synthesis].

Preparation between sessions [source: Therapist Handouts 3.1, 4.1, 4.3]

After the assessment: prepare the personalised alcohol and/or drug feedback summary and the BSCQ profile graph. NSU provides spreadsheet programs that build the feedback and BSCQ graphs.
After Session 1: prepare the BSCQ graph for Session 2.
After Session 3: prepare the comparative BSCQ profile (assessment vs Session 3) and the comparative use feedback (90 days before treatment vs during treatment).

3. Guiding principles

[source: Therapist Handouts 3.1, 4.1–4.4, 5.1–5.4; Motivational Techniques and Skills handout; Tables 5.2, 5.3; Sobell & Sobell 2011 table of contents]

The client owns the change plan. The client learns a problem-solving approach and takes responsibility for the plan. In practice: ask the client for solutions before offering any.
The client chooses the goal, with information. Abstinence or low-risk drinking is the client's decision. Contraindications and low-risk limits are explained neutrally. In practice: never assign a goal; make sure the choice is an informed one.
Change is a choice. Frame reasons for change as choices (e.g., avoiding future problems), not as fixed traits such as "having a disease" or "lacking willpower", because a sense of inability can become self-fulfilling. In practice: reflect statements of inability back as decisions not yet made.
MI style throughout. Use open questions, reflections, summaries and affirmations; ask permission; avoid lectures and scare tactics. In practice: the client should do most of the talking.
Assessment is a "running start" (book chapter title). Every measure is collected so it can be fed back. In practice: choose and score measures with the Session 1 feedback in mind.
Feedback is personal, normative and neutral. Compare the client's use with population norms and let the client draw the conclusion. In practice: ask "What stands out?" rather than telling the client what it means.
Out-of-session work drives change. Readings, homework and self-monitoring are central, not optional. In practice: review every assignment and explain why each one matters.
Teach a general problem-solving method, not a fixed skills menu. The steps are: identify triggers and consequences, generate options, pick the best, make a plan, test it, review it. In practice: the content comes from the client's own situations.
Small steps. Break action plans into small, checkable steps. In practice: if a plan cannot be tried this week, make it smaller.
Take a long-term, relapse-prevention view. Change is often slow and uneven; slips are learning opportunities, not failures, but never predict that a client will slip. In practice: use the fire-drill framing.
Measure, compare, reflect. The same instruments are repeated (BSCQ, Where Are You Now Scale, goal evaluation, decisional balance) so clients can see and explain their own change. In practice: always ask "How did you get from there to here?"
Keep reviews to the big picture. Review logs for major patterns and events, not day by day. In practice: protect time for the session's main task.
Brief by default, more on request. Four sessions, then the client decides whether to continue. In practice: present the end point at assessment and keep the door open.
Clients summarise each session. Each session ends with the client naming what stood out. In practice: in groups, leaders speak last and reinforce positive behaviour.
In groups, members are agents of change. Solutions come from the group, not only from the leaders. In practice: look for things members have in common, draw others in, and invite peer support for changes.
Group safety comes from explicit rules with stated reasons. Confidentiality is the most important rule. In practice: review each rule and its rationale at the first group.

4. Intervention inventory

The inventory has four parts: A, assessment and measurement tools that double as interventions; B, the session-specific interventions; C, the MI techniques the authors list for use throughout; D, procedures specific to groups. All example language is the guide's own illustrative wording unless marked as a quote. Instruments are described, not reproduced. Use the published versions from the book or the NSU site.

A. Assessment and repeated-measure interventions

4.1 Motivational opening and treatment orientation (assessment)

Purpose / when: At the start of the assessment, to start in an MI style and set expectations for a brief, homework-based treatment.
Steps: (1) Open with open-ended questions about what brought the client in and what they hope to get from treatment. (2) Explain what the assessment involves and how long it will take. (3) Explain confidentiality and get signed informed consent. (4) Describe GSC: time-limited (assessment plus four semistructured sessions, more if needed); readings, homework and self-monitoring between sessions; feedback drawn from the assessment; the client learns a problem-solving approach and takes responsibility for the change plan; progress review and a decision about continuing at Session 4; a therapist call one month after the last session. (5) Close by asking what stood out, inviting questions and booking Session 1 [source: Therapist Handout 3.1].
Example language (illustrative): "Before we get into forms, what made now the time to come in?" / "This is a short program. You'll do a lot of the work between our meetings, and the decisions about your goals are yours."
Watch for: Interrogation drift during data collection; keep reflecting between measures. It is working when the client can say back, in their own words, what the program involves and who decides the goal.

4.2 Standardised severity and history measures (AUDIT, DAST-10, Drug Use History Questionnaire)

Purpose / when: At assessment, to describe severity and history and to give data for the Session 1 feedback.
Steps: (1) Collect a core background and problem history; its format is set by the agency or therapist. (2) Give the AUDIT for alcohol and/or the DAST-10 for drugs. (3) Complete the Drug Use History Questionnaire, which the handout pairs with a card sort. The mechanics of the card sort are not given in the sources [uncertain]. (4) Score the measures and enter the scores into the feedback summary [source: Therapist Handout 3.1; AUDIT and DAST-10 scoring-feedback forms listed on the NSU documents page].
Example language (illustrative): "These questions are the same ones used in large surveys, so next time I can show you where you fit compared with other people."
Watch for: Under-reporting when the client fears consequences; restate confidentiality and its limits. Use the questionnaires' published items and scoring; do not paraphrase the items.

4.3 Timeline Followback (TLFB), 90 days before treatment

Purpose / when: At assessment, to build a day-by-day picture of alcohol and/or drug use over the 90 days before treatment. It feeds the frequency and quantity feedback and the before-and-during comparison at Session 4.
Steps (alcohol version): (1) On a calendar, mark today and write in yesterday's date; leave today and later days blank. (2) Work backwards from yesterday, one day at a time. (3) Convert all drinking to standard drinks (a typical beer, glass of wine or shot of spirits counts as one). (4) Record a number for every day, including zeros, and add mixed beverages together into one daily total. (5) Use holidays and personal events (birthdays, trips, parties) as memory anchors. (6) Accept best estimates when exact recall fails. Accuracy matters more than perfection [source: Therapist Handout 3.2]. A separate drug version exists (Therapist Handout 3.3). Its recording rules (e.g., coding by substance) are not described here [uncertain].
Example language (illustrative): "Let's start with yesterday and work back. Anything on the calendar, like a birthday or a long weekend, that helps you remember?" / "If you're not sure, give me your best guess. A good estimate is fine."
Watch for: Patterns the client did not expect (e.g., weekend clusters); note them for feedback, not for confrontation. It is working when the calendar is complete with no blank days.

4.4 Readiness ruler

Purpose / when: At assessment (and at any point), to gauge readiness to change and draw out reasons.
Steps: (1) Ask the client to rate readiness to change on a 1–10 scale, now and at some earlier time. (2) Ask what accounts for any shift. (3) Ask what would move the number higher. (4) Re-rate later, because readiness changes [source: Therapist Handout 3.1; Motivational Techniques and Skills handout].
Example language (illustrative): "On a 1 to 10, how ready are you right now? … Why a 6 and not a 3? … What would it take to get to a 7?"
Watch for: Asking "why not higher?" invites defence; ask why the number is not lower. It is working when the client gives their own reasons for change.

4.5 Where Are You Now Scale

Purpose / when: At assessment, Session 2 and Session 4, so clients can track and put into words their own progress.
Steps: (1) The client rates current use on a 10-point scale running from most serious concern (1) to no longer a concern (10). (2) At Sessions 2 and 4, show or remind the client of the earlier rating(s). (3) Ask how they got from the earlier number to the current one. (4) If there has been no change, ask what has got in the way or what it would take to move up one or two points. (5) In groups, point out shared experiences and invite praise from peers [source: Therapist Handouts 4.4, 5.2, 5.4].
Example language (illustrative): "At the assessment you were at 3; today you say 6. What did you do to get there?"
Watch for: Clients who rate high while their logs show little change; explore the discrepancy with curiosity (see 4.33). It is working when the client explains the change by pointing to their own actions.

4.6 Brief Situational Confidence Questionnaire (BSCQ) and profile feedback

Purpose / when: Measures confidence to resist heavy drinking or drug use across eight high-risk situation categories. Given at assessment, fed back as a profile at Session 2, repeated in Session 3, and compared at Session 4.
Steps: (1) Give the BSCQ (Appendix D of the book) at assessment. (2) Turn the answers into a profile graph; NSU's graphing spreadsheet can do this. The eight categories are unpleasant emotions, physical discomfort, pleasant emotions, testing personal control, urges and temptations, conflict with others, social pressure to use, and pleasant times with others. (3) At Session 2, give the client the profile and ask them to compare its low-confidence peaks with the two trigger situations from their homework. (4) Name the profile with the book's shorthand labels (e.g., Good Times; Good Times/Social Pressure; Negative Affective; Testing Personal Control; Affective; Undifferentiated Flat) so it is easy to remember. (5) Ask why it matters to know where heavy use is most likely. (6) At Session 3, give the BSCQ again in session, asking the client to answer for how they feel today. (7) At Session 4, show the assessment and Session 3 profiles side by side and ask what changed and what led to it [source: Therapist Handouts 4.3, 4.4, 5.2; Table 4.2].
Example language (illustrative): "The low points on this graph are the situations you felt least sure about. Do they match the two situations you wrote about?" / "Your confidence with conflict went up a lot. What made the difference?"
Watch for: A flat profile (no clear peak), which the book links to daily, habitual use; focus on routine and daily structure. It is working when profile peaks match the client's own trigger list and confidence rises in the targeted categories.

4.7 Decisional balance exercise

Purpose / when: Homework after the assessment; reviewed in Session 1; revisited in Session 4. It makes ambivalence explicit and brings the costs of changing to the surface so they can be planned for.
Steps: (1) Give the decisional balance handout: a 2×2 grid of benefits and costs, for changing and for not changing. It has a worked example and a final page asking for the client's most important reason to change. (2) In Session 1, ask what the client got out of doing it. (3) Use open questions, reflections and summaries to explore the benefits of use, its less desirable sides, and the benefits and costs of changing. (4) Spend time on the costs of changing, because they set up the later planning to avoid or reduce them. (5) In groups, cover short- and long-term effects, what surprised members, and members' reasons for use and obstacles to change. (6) At Session 4, ask about new good or less good things and whether any expected costs actually happened. Clients often report that the downsides they feared did not occur [source: Client Handout 3.1; Therapist Handouts 4.1, 4.4, 5.1, 5.4].
Example language (illustrative): "What did you notice when you saw it all on one page?" / "You listed losing your Friday crowd as a cost of changing. That sounds like something we'll want to plan around."
Watch for: Clients who list only costs of use (telling you what you want to hear); ask about what they get from using. It is working when both sides are represented and the client names a reason for change that is clearly their own. A weighted version and adolescent and eating versions exist on the NSU site but are not drawn on [uncertain].

4.8 The five-million-dollar question

Purpose / when: Session 1, at the end of the decisional balance review, to establish that change is hard but a matter of choice.
Steps: (1) Ask whether the client would stop using for one day if paid a very large sum (the handout uses five million dollars). (2) When the client says yes, draw out what that means: the issue is not whether they can change but what it would take. (3) Ask about their personal "price", meaning what would tip the balance toward changing now. (4) Stress that changing is a choice and move on to what would make it happen [source: Therapist Handouts 4.1, 5.1; Client Handout 3.1].
Example language (illustrative): "So for the right reason, you could do it. What would your real-life reason need to look like?"
Watch for: Clients who hear this as "so you're choosing to be ill"; keep the tone curious, not accusing. It is working when the client names a concrete thing that would tip the balance.

4.9 Goal statement and goal evaluation (importance, confidence, readiness)

Purpose / when: Completed as homework after the assessment and again after Session 3, and reviewed in Sessions 1 and 4. The client sets a self-chosen goal and examines how important it is and how confident they feel.
Steps: (1) Give the abstinence goal evaluation form (alcohol or drugs) or the goal-choice form (alcohol). On the goal-choice form the client chooses abstinence or moderation; for moderation, the client writes a maximum number of drinks on a drinking day, a maximum number of drinking days per week, situations where drinking is acceptable, and situations where they will not drink. (2) The client rates importance and confidence on 0–100 scales and answers follow-up questions about obstacles, competing priorities and how realistic the goal is. (3) A 2×2 grid of low/high importance against low/high confidence helps the client reflect. (4) In Session 1 (abstinence goals), ask why the ratings are as high as they are rather than lower, and what might interfere. (5) For moderation goals, have the client state the goal and how they arrived at it, check how realistic it is, and go through the low-risk guidelines and contraindications (4.10). (6) For low confidence, ask what would need to happen to raise the number. Expect some clients to rank other priorities (health, work) above this goal, and use that to explore what matters to them. (7) At Session 4, compare the new and original goals and ratings and ask what drove any shift. Check whether recent use matches the new goal [source: Client Handout 3.5; Therapist Handouts 4.1, 4.3, 4.4, 5.1, 5.4].
Example language (illustrative): "You gave importance an 80. What puts it that high?" / "Walk me through how you landed on three drinks, two nights a week."
Watch for: A goal that does not match the logs; raise it neutrally. In Session 1, frame abstinence reasons as choices, not traits ("I can't because I'm an addict"). It is working when goal, ratings and logs come into line over time.

4.10 Low-risk drinking guidelines and contraindication guidance

Purpose / when: Session 1 (and whenever a moderation goal is chosen), so that the client's choice of a low-risk goal is informed.
Steps: (1) Explain that people with contraindications to drinking should not drink at all. (2) Name the contraindications listed in the Sobells' self-help handout: medical conditions where alcohol is not advised (e.g., diabetes, liver problems); pregnancy or trying to conceive; medications that interact with alcohol (check with a physician); and legal or social reasons to abstain (e.g., probation, a partner's wishes) [source: Aids for Changing Your Drinking on Your Own, 2013]. (3) Give printed low-risk guidelines. The Session 1 therapist handout lists no more than 3 drinks a day, no more than 4 drinking days a week, no more than one drink per hour, and no drinking in high-risk situations [source: Therapist Handout 4.1]. The 2013 self-help handout instead cites sex-specific daily and weekly limits from the US National Institute on Alcohol Abuse and Alcoholism (NIAAA). The two sources differ; use the version your setting endorses and current national guidance [uncertain]. (4) Ask whether the client has drunk at low levels without problems, and discuss situations where even low-level drinking is risky. (5) If the goal goes beyond the guidelines, acknowledge the difference and ask how the client might reduce further. In groups, invite peers to comment on the risks [source: Therapist Handouts 4.1, 5.1].
Example language (illustrative): "Can I share the guidelines we use, and you tell me how they fit with what you wrote?" / "Your plan is a bit above these limits. What would it look like to bring it closer?"
Watch for: A client choosing moderation despite a contraindication: restate the medical information, involve their physician, and record the advice given [synthesis]. Signs of significant physical dependence (e.g., withdrawal symptoms): arrange medical assessment before any change in use [synthesis].

4.11 Self-monitoring logs (use and urges)

Purpose / when: From the assessment through Session 4 and beyond. The logs keep a running record of alcohol or drug use (and urges) against the goal, and they open every session.
Steps: (1) At assessment, give the alcohol or drug self-monitoring log and explain that clients record use and urges. Detailed completion instructions are in separate NSU documents that are not drawn on [uncertain]. (2) At the start of each session, ask an open question about the week, then go to the logs. (3) Keep to major events and patterns, not a day-by-day account. (4) Have the client link the week's use to their goal. (5) Copy or record the data; it feeds the comparison at Session 4. (6) When there is a major change or a hard situation handled without use, have the client describe it in their own words, reflect it, and ask how they feel about it (in groups, ask the group) [source: Therapist Handouts 3.1, 4.1, 4.3, 4.4, 5.1–5.4].
Example language (illustrative): "Give me the headline of your week, then we'll look at the log." / "Saturday you were at the party and stopped at two. How did you pull that off?"
Watch for: Logs filled in all at once just before the session (they are uniform and lack detail); ask when entries were made and suggest logging at the time of use [synthesis]. It is working when logs come back complete and the client uses them to spot their own patterns.

B. Session-specific interventions

4.12 Personalised normative feedback (Session 1)

Purpose / when: Session 1, to help the client see that their current use is not typical and that continuing it predicts problems, without lecturing.
Steps: (1) Before the session, compile the TLFB, questionnaires and calendar into the alcohol or drug feedback summary and highlight key points. (2) Explain that the summary shows where the client's use falls compared with other people. (3) Go through weekly use against the peer-comparison graphs (pie charts). (4) Go through the AUDIT or DAST-10 severity score at the end of the summary. (5) Ask what stands out and what surprises them. (6) If the client is surprised by the severity score, go back over their specific answers together. (7) In groups, have each member comment on their charts. The book notes that drinkers are often surprised by how heavy their use is compared with the general population, and drug users by how few people use certain drugs [source: Therapist Handouts 4.1, 5.1].
Example language (illustrative): "This chart puts your weekly drinking next to adults in general. What do you make of where you land?" / "You look surprised by the score. Want to go back over the answers that added up to it?"
Watch for: Defensiveness ("the norms don't apply to me"); reflect it and ask permission before adding information (4.22). It is working when the client draws the conclusion themselves ("I didn't realise I was that far above").

4.13 Identifying triggers: reading and exercise

Purpose / when: Assigned at Session 1 and reviewed at Session 2, so the client can identify their personal high-risk situations and the consequences of use.
Steps: (1) Assign the Identifying Triggers reading (about 10 minutes). It covers: triggers can be unexpected events, situations the person seeks out, positive or negative emotions, or ongoing stresses; immediate positive consequences reinforce use while negative ones may come later; the problem-solving sequence from understanding to action; and a long-term view of change. (2) Assign the exercise: describe the two highest-risk situations for use in the past year in detail (where, when, who, what happened), and the consequences that followed. (3) At Session 2, check the client's understanding of the reading and have them describe each trigger. (4) Link the triggers to the BSCQ profile (4.6). (5) In groups, have each member describe one trigger, then point out common triggers (e.g., anger) and invite others to respond. (6) Tell the client that in the next step they will build options for these situations [source: Client Handout 4.5; Therapist Handouts 4.1, 5.1, 5.2].
Example language (illustrative): "Take me through the first one as if I were there. Where were you, who was around, what happened just before?" / "And afterwards, what did it cost you, that night and the next week?"
Watch for: Vague triggers ("stress"); push for a specific, recent example. It is working when each trigger is specific enough to plan around.

4.14 Mt. Change: the long-term, relapse-prevention view and slips

Purpose / when: Introduced through the Session 2 reading and revisited at Session 4. It sets realistic expectations so that a slip does not become a full return to use.
Steps: (1) Ask what the reading means by taking a long-term view and expecting bumps in the road. (2) Use the Mt. Change image: people climb by different routes and at different speeds, and both direct and winding routes can reach the top. (3) Explain that slips can happen and should be interrupted early and learned from. Use the fire-drill comparison: you hope there will be no fire but you practise anyway. Do not imply the client will slip. (4) If a slip is reported, ask what triggered it, what was different this time, how others have handled slips, and how else it could be seen besides failure. (5) At Session 4, ask what a realistic perspective on change now means to the client. Listen for "change is often slow" and "slips are something to learn from so I can keep going" [source: Therapist Handouts 4.4, 5.2, 5.4; Client Handout 4.5]. The Mt. Change diagram itself could not be read (the PDF has no text) [uncertain about its exact content].
Example language (illustrative): "Think of it like a fire drill. We're not expecting a fire, but it helps to know where the exits are." / "If Saturday was a slip rather than a fall, what's the lesson in it?"
Watch for: All-or-nothing thinking after a slip ("I've blown it"); respond straight away with the learning frame. It is working when the client describes a slip in terms of its trigger and next steps rather than self-blame.

4.15 Developing new options and action plans (problem solving)

Purpose / when: Assigned at Session 2 and reviewed at Session 3. This is the core cognitive-behavioural step: new ways of handling high-risk situations without using.
Steps: (1) Assign the Developing New Options and Plans exercise (about 10 minutes). For each high-risk trigger, the client writes two specific, realistic options, lists the likely positive and negative outcomes of each, ranks them best and second-best, and then writes how they would carry out each option, ideally in smaller steps. (In the group format, members do it for one of their two triggers.) (2) At Session 3, have the client talk through the options for each trigger. (3) Explore which plan makes most sense and why, using open questions, reflections and summaries to examine how feasible it is. (4) Break the chosen plan into small, trackable steps. (5) Ask which situations the client expects before the next session where they could try their options [source: Client Handout 4.8; Therapist Handouts 4.3, 5.2, 5.3].
Example language (illustrative): "Of the two options for Friday drinks after work, which one could you actually do this week? … What's the very first step?"
Watch for: Options that rely only on willpower ("I just won't drink"); ask what they will do instead. Plans that are too big; shrink them. It is working when the client leaves with a specific situation, a chosen option and a first step.

4.16 Options testing and implementation review

Purpose / when: Between Sessions 3 and 4, reviewed at Session 4 (and in any later sessions), to turn plans into real-world practice and learn from the results.
Steps: (1) At the end of Session 3, agree which expected situations will be used to test plans. (2) At Session 4, ask which situations came up where the client used an action plan and how it went. (3) If the plan worked, have the client say what made it work and acknowledge it. (4) If it did not, look at why and choose another option. This last step follows the reading's problem-solving loop (monitor, acknowledge success, re-examine and try other options) [source: Therapist Handouts 4.3, 4.4, 5.4; Client Handout 4.5].
Example language (illustrative): "Did the situation you planned for come up? Tell me what you did." / "That one didn't land. What does it tell you about which option to try next time?"
Watch for: Clients who avoided every trigger situation; avoidance is a valid option, but check whether it can be kept up long term [synthesis]. It is working when the client can describe at least one situation handled differently.

4.17 Comparative progress feedback (Session 4)

Purpose / when: Session 4, to let the client see and explain their own change across all measures.
Steps: (1) Before the session, prepare the before-and-during comparison. For alcohol: percentage of drinking days in the 90 days before treatment against during treatment, and drinks per drinking day for the same periods. For drugs: percentage of days of use. (2) Prepare the BSCQ comparison (assessment vs Session 3). (3) In session, give the use comparison and ask how use has changed. (4) Revisit the goal (compare ratings and the goal statement and revise if needed) and the decisional balance (4.7). (5) Give the BSCQ comparison and ask what led to the changes in confidence. (6) Revisit Mt. Change (4.14). (7) Have the client complete the Where Are You Now Scale and compare it with the assessment and Session 2 ratings (4.5) [source: Therapist Handouts 4.3, 4.4, 5.4].
Example language (illustrative): "Before treatment you were drinking on about two-thirds of days; during these weeks it's been about a quarter. How did you do that?"
Watch for: Clients who play down real gains; reflect the data back and ask how they feel about it. Little or no change: see Section 5. It is working when the client gives their own explanation of the change and a plan to keep it going.

4.18 Request for Additional Sessions and the one-month aftercare call

Purpose / when: The form is assigned at Session 3 and reviewed at Session 4; the call comes about one month after the last session. Together they make sure brief treatment ends on purpose, with a route back in.
Steps: (1) At Session 3, explain that the next session is the last scheduled one. Give the Request for Additional Sessions form: the client marks whether they want more sessions, how many, and what they hope to achieve. In the group format, extra sessions are individual. (2) At Session 4, review the form. If more sessions are requested, schedule them and record the number and reasons (in groups, meet individually with members who asked). (3) Make sure the client knows how to contact the program. (4) Tell the client you will call in about a month to check progress, support the changes made, and book more sessions if needed. (5) Make the call [source: Therapist Handouts 4.3, 4.4, 5.3, 5.4].
Example language (illustrative): "Some people feel ready to go it alone after today; others want a few more sessions. What did you decide, and what would you want from them?"
Watch for: Requests for more sessions that come from anxiety rather than a clear aim; agree specific goals for any extra sessions [synthesis].

4.19 "What stood out" close and homework reminder

Purpose / when: The end of every session (and the assessment). The client summarises the session and commits to the homework.
Steps: (1) Ask what stood out for the client today. (2) Go over the homework and why it matters. (3) Book the next session. In groups, each member and then each leader names one thing that stood out; leaders go last and reinforce positive behaviour they saw; volunteers start, or a leader calls on a member. Remind members to attend, call if they will miss a session, keep self-monitoring, and bring logs and homework; a leader phones the day before the group [source: Therapist Handouts 4.1, 4.3, 5.1–5.3].
Example language (illustrative): "We covered a lot today. What's the one thing you're taking away?"
Watch for: A takeaway that differs from what you thought the main point was; that tells you what the client found meaningful. Use it next session.

4.20 Spouse sessions (directed social support variant)

Purpose / when: An optional research variant for married clients whose spouse is willing to take part.
Steps (as reported): The spouse attends two individual sessions in which counselling procedures are explained. In the directed-support version, the spouse is encouraged to support change actively and to respond to relapses in line with a relapse-prevention model. Outcomes were the same as natural support [source: Sobell, Sobell & Leo 2000 abstract]. Session content beyond the abstract was not found [uncertain].
Example language (illustrative): "If there's a slip, what response from you would help them get back on track rather than give up?"
Watch for: Spouses who become monitors or enforcers; steer them toward support and toward treating a slip as something to learn from [synthesis].

C. Motivational techniques used throughout

The NSU "Motivational Techniques and Skills" handout lists these as the MI tools woven through every GSC session. The readiness ruler is covered at 4.4 [source: Motivational Techniques and Skills handout].

4.21 Affirmations

Purpose / when: To build confidence by recognising strengths, successes and effort to change; useful whenever the client reports an effort or success.
Steps: (1) Name a specific strength or effort. (2) Keep affirmations sincere and fairly infrequent; overly enthusiastic praise sounds fake.
Example language (illustrative): "You kept the log even on the weeks it was uncomfortable to write down. That takes honesty."
Watch for: Praise that sounds like cheerleading. It is working when the client builds on what you affirmed.

4.22 Advice and feedback, given neutrally

Purpose / when: To give information (norms, risks, guidelines) without setting off defensiveness, especially during feedback (4.12) and when discussing guidelines (4.10).
Steps: (1) Ask permission. (2) Find out what the client already knows. (3) Give the information neutrally, e.g., in comparison with national norms, and highlight the benefits of change. (4) Respect a "no". (5) Avoid scare tactics and lectures, which tend to produce surface agreement.
Example language (illustrative): "What have you heard about how alcohol interacts with your medication? … Would it help if I added what I know?"
Watch for: Quick, flat agreement; it may mean the client is going along with you. Follow up with an open question.

4.23 Asking permission

Purpose / when: Before raising a sensitive topic.
Steps: Ask whether the client is willing to talk about the topic before going into it; people are more open when they are asked rather than told.
Example language (illustrative): "Would it be OK if we looked at how this has been affecting your relationship?"
Watch for: Asking permission and then ignoring the answer. Honour a "not now" and come back to it later.

4.24 Normalising

Purpose / when: When shame or defensiveness is showing, to reduce both.
Steps: Tell the client that difficulty with change is common.
Example language (illustrative): "Most people find the first few weeks of changing harder than they expected. You're not unusual."
Watch for: Normalising the use rather than the struggle. It is working when the client relaxes and discloses more.

4.25 Open-ended questions

Purpose / when: All the time, so the client tells their story and does most of the talking.
Steps: Ask questions that cannot be answered yes or no; avoid strings of closed questions that feel like an interrogation.
Example language (illustrative): "How have things been since we last met?"
Watch for: The ratio of your talking to theirs.

4.26 Reflective listening

Purpose / when: All the time, to show understanding, build empathy, and help the client voice their own reasons for change.
Steps: (1) Listen closely. (2) Paraphrase content and feeling. (3) If your guess is wrong, the client will usually correct it; take the correction as information.
Example language (illustrative): "So part of you is worried about your health, and part of you can't picture weekends without it."
Watch for: Reflections that are really leading questions. It is working when the client goes further in response.

4.27 Summaries

Purpose / when: To pull key points together, including both sides of ambivalence; to close a topic or session; to redirect a client who talks a lot.
Steps: Collect several of the client's statements, put both sides of the ambivalence into one summary, and end on the change side.
Example language (illustrative): "Let me see if I've got it: drinking helps you unwind and fits your social life, and you're also tired of the mornings and worried about your liver results. You've started to wonder whether cutting back could give you the good parts without the cost."
Watch for: Summaries that leave out the client's reasons for using; they will feel one-sided.

4.28 Eliciting change talk

Purpose / when: To draw out the client's own reasons for change.
Steps: (1) Ask what would happen if nothing changed, and what would be different if it did. (2) For clients who are struggling, offer support. (3) For clients with little wish to change, ask them to consider best-case and worst-case outcomes. Session 1 guidance for ambivalent clients adds: name both sides, ask about the likely effects of continued use over the next year, and ask what one thing would need to happen to stop [source: Therapist Handout 4.1].
Example language (illustrative): "If things carried on exactly as they are for another year, what would that look like?"
Watch for: Pushing faster than the client is ready to go; if you hear more "yes, but", ease off.

4.29 Pros and cons in conversation (decisional balancing)

Purpose / when: In session, whenever ambivalence is present (separate from the written exercise at 4.7).
Steps: Ask about the benefits and drawbacks of the current behaviour, then reflect the ambivalence back so the client can weigh it up.
Example language (illustrative): "What does drinking do for you? … And the less good side?"
Watch for: Arguing for one side; your job is to reflect both.

4.30 Confidence ratings

Purpose / when: To assess and build self-efficacy, alongside goal evaluation (4.9) and the BSCQ (4.6).
Steps: Have the client rate confidence to change on a 1–10 scale. If the rating is 7 or below, ask what would raise it.
Example language (illustrative): "You said 5. What would need to happen for it to be a 6 or 7?"
Watch for: Unrealistically high confidence with no plan; check it against the goal form's question about whether the confidence rating is realistic.

4.31 Supporting confidence

Purpose / when: When clients doubt they can change.
Steps: Ask about changes the client has already made (in this or another area) and how they did it, then ask how they feel about those changes.
Example language (illustrative): "You stopped smoking years ago. What did you do then that might help now?"
Watch for: The client brushing off past successes; reflect them and stay with them.

4.32 Paradoxical statements

Purpose / when: With clients making little progress who may not realise they are falling short.
Steps: (1) Gently and sincerely question whether now is the right time to change; this often leads clients to argue for change themselves. (2) If the client still does not want to change, suggest a short break with a follow-up check-in.
Example language (illustrative): "I wonder whether this just isn't the right time for you to take this on. What do you think?"
Watch for: Sarcasm or manipulation; use this only if you genuinely mean it. Not for clients at high risk [synthesis].

4.33 The "Columbo" approach to discrepancies

Purpose / when: When the client's words and actions do not match (e.g., goal vs logs, ratings vs use).
Steps: Ask curious, non-judgemental questions that let the client notice and resolve the gap. End the question on the side of change, because people tend to expand on the last part of what they hear.
Example language (illustrative): "Help me understand. The log shows four heavier nights, and you've also told me that cutting back matters a lot to you right now?"
Watch for: A tone that turns into confrontation. It is working when the client explains the gap and moves toward the change side.

D. Group-format procedures

4.34 Pregroup planning

Purpose / when: 15–20 minutes before every group (longer before the first), to improve retention and cohesion.
Steps: (1) Review the assessment data, or the previous group. (2) For the first group: learn each member's first name and key facts and note them briefly on cards (e.g., age, problem type and duration, consequences, medical issues, referral reason). Draw a seating chart and fill in names as people arrive. Set chairs in a circle with the two leaders' chairs opposite each other. (3) Prepare each member's materials (feedback, BSCQ profiles, new homework, scales). (4) Decide which leader leads each topic [source: Therapist Handouts 5.1–5.4].
Example language: not applicable.
Watch for: Leaders who are under-prepared fall back on lecturing.

4.35 Group orientation and group rules

Purpose / when: The individual assessment (for group clients) and the first group, to set expectations and build safety.
Steps: (1) At assessment, give the Introduction to Groups handout. Explain that members attend regularly, share about themselves and give feedback and support. Mention that research finds groups as effective as individual therapy, and address concerns. (2) At Group 1, leaders and members introduce themselves. Explain that each member is an agent of change and that solutions come from the group. Ask what each person hopes to gain, normalise discomfort, and ease members in (e.g., two or three words that describe themselves and how they relate to being here). (3) Go through each rule and its reason: confidentiality (the most important); no socialising outside the group; attend on time, stay to the end, call if absent; no alcohol or drugs before group; no discussing absent members; complete and bring homework; participate fully; behave appropriately (take turns, phones off, no yelling) [source: Therapist Handouts 3.1, 5.1; Table 5.3].
Example language (illustrative): "Most of what helps in this room will come from each other, not just from the two of us."
Watch for: Members who seem uneasy about confidentiality; deal with it before going on.

4.36 Round-robin discussions

Purpose / when: The structure for every group topic, so that each member works on the session's task.
Steps: (1) A leader introduces the topic and asks one member to start. (2) Go around the group, keeping reports general. (3) Link members by pointing out what they have in common and inviting peers to comment and support. (4) Leaders choose questions to fit what is happening; they do not need to ask every one. Topics by session: S1 introductions, logs, goal evaluations, feedback, decisional balance; S2 logs, triggers, BSCQ, Where Are You Now Scale; S3 logs, options and action plans; S4 logs, comparative feedback, goals, decisional balance, BSCQ changes, implementing options, Mt. Change, Where Are You Now Scale; every session ends with a wrap-up [source: Table 5.1; Therapist Handouts 5.1–5.4].
Example language (illustrative): "Let's go round with this week's logs. Sam, would you start us off with the big picture?"
Watch for: Rounds that turn into individual therapy in front of an audience; bring others in (4.37).

4.37 Bringing members and topics into the discussion

Purpose / when: Throughout groups, to build cohesion and draw in quiet members [source: Table 5.2].
Steps (the twelve listed moves, paraphrased): (1) Ask who else has had a similar experience. (2) Ask the whole group for its view. (3) Invite everyone to comment on a homework exercise. (4) Ask how the group feels about a member's change, to draw out support. (5) Name one member's struggle and ask how others have handled it. (6) After one suggestion, ask for more. (7) Pose a question that everyone answers in turn. (8) When a member responds harshly, ask the group for other ways of seeing it. (9) Name visible discomfort and invite discussion. (10) Call a time-out when tension rises, look at what is happening, and return to the topic later. (11) After a sensitive disclosure, acknowledge it and ask how others feel. (12) Put nonverbal responses into words (e.g., "I see some nods").
Example language (illustrative): "Jo just described feeling ambushed by a craving at the supermarket. Who else knows that one, and what helped?"
Watch for: The same two or three members carrying the group; use moves 2 and 7 to widen participation.

4.38 Postgroup leader debrief

Purpose / when: 5–10 minutes after every group, to improve the next session.
Steps: Discuss what went well and what did not, note points to highlight next time and notable member behaviour, and prepare materials for the next session (e.g., BSCQ profiles after Group 1; comparative feedback after Group 3) [source: Therapist Handouts 5.1–5.4].
Example language: not applicable.
Watch for: Patterns across sessions (a member drifting, rising tension) that need planning before the next group.

5. Handling problems

Guidance tagged [source] comes from the GSC materials. Guidance tagged [synthesis] is this guide's own, drawn from general MI and CBT practice and current standards of care. The book's chapter on managing difficult clients in groups (ch. 8) is not drawn on [uncertain].

Ambivalent client who will not commit to a goal. Reflect both sides. Ask what continued use is likely to bring over the next year. Ask what one thing would need to happen for them to stop or cut down. Do not set a goal for them [source: Therapist Handout 4.1]. If still undecided, agree a trial period of self-monitoring only, and review it [synthesis].

Stuck: no movement on logs, Where Are You Now Scale or confidence. Ask what has got in the way and what it would take to move up one or two points [source: Therapist Handout 5.2]. Use supporting-confidence questions about past successes (4.31). If progress is still minimal and the client may not see it, use a sincere paradoxical statement about whether now is the right time. If they still do not want to change, offer a short break with a planned check-in [source: Motivational Techniques and Skills handout]. At Session 4, offer more sessions, or step up to a more intensive level of care if use is unchanged or getting worse [synthesis].

Goal exceeds low-risk guidelines. Acknowledge the difference and ask how the client could bring it down. In groups, let peers comment on the risks, noting how low the recommended limits are [source: Therapist Handouts 4.1, 5.1]. If the client goes ahead anyway, agree to track it in the logs and review it against the comparison at Session 4 [synthesis].

Moderation goal despite a contraindication (pregnancy, interacting medication, liver disease, a court order to abstain). Give the information clearly and neutrally, recommend abstinence, involve the physician or other relevant parties with consent, and document the advice. Continue treatment without making abstinence a condition, unless your setting's policy or the law requires it [synthesis; contraindication list from Aids for Changing Your Drinking on Your Own].

Slips between sessions. Ask what triggered the slip, what was different this time, how others have handled slips, and how else it could be seen besides failure. Revisit Mt. Change and the fire-drill framing. Turn the slip into a new trigger for options and action planning (4.15) [source: Therapist Handout 5.2; Client Handout 4.5].

Discrepancy between what the client says and what they do (resistance shown as "yes, but"). Use the Columbo approach (4.33) and end on the change side. Avoid lectures and scare tactics, which produce surface agreement. Back off and reflect if you hear more sustain talk [source: Motivational Techniques and Skills handout].

Defensiveness about feedback or the severity score. Go back over the specific answers that made up the score together. Ask what stands out rather than telling them [source: Therapist Handout 4.1]. Ask permission before adding information (4.22) [source: Motivational Techniques and Skills handout]. If the client disputes the norms, reflect the doubt and ask what would be a fair comparison for them [synthesis].

Homework or logs not done. Explain why each assignment matters; the authors link this to better compliance [source: Table 5.3]. In session, complete a shortened version on the spot (e.g., rebuild the week's log from memory), find the barrier (time, literacy, privacy, forgetting), and shrink the task [synthesis]. Some forms are available in Spanish and as digital logs on the NSU site; for low-literacy clients, read forms aloud [synthesis].

Missed or late sessions. In groups, the rules are: attend every session, arrive on time, call ahead; a leader phones the day before each group [source: Table 5.3; Therapist Handouts 5.1–5.3]. Individually, call after a missed session, ask with curiosity what happened, and reschedule within the week. Treat repeated absence as a sign of ambivalence to explore, not a reason to discharge [synthesis].

Client arrives intoxicated. The group rule is no alcohol or drugs before group, because intoxication disrupts the group and draws its focus [source: Table 5.3]. Speak to the person privately, check whether they are safe to travel, reschedule, and explore the episode at the next contact as a trigger situation [synthesis].

Overwhelm (too many forms, shame at seeing the data). Normalise the difficulty (4.24) [source: Motivational Techniques and Skills handout]. Spread measures across the assessment; prioritise the TLFB, AUDIT/DAST-10 and BSCQ. Present feedback one graph at a time with frequent check-ins [synthesis].

Ruptures (client feels judged or pushed). Name the moment, take responsibility for your part, ask what felt off, and return to asking permission and reflecting. Paradoxical statements and discrepancy questions often trigger ruptures, so use them sparingly and sincerely [synthesis].

Group difficulties: a dominating member, harsh responses, rising tension, sensitive disclosures. Use summaries to redirect a member who talks a lot [source: Motivational Techniques and Skills handout]. Widen participation by asking everyone in turn. Invite other views of a harsh response. Name visible discomfort. Call a time-out and come back to the topic later. Acknowledge sensitive disclosures and ask how others feel [source: Table 5.2]. Address breaches of confidentiality or socialising outside the group by restating the rule and its reason [source: Table 5.3].

Severe dependence or withdrawal risk. GSC was designed for clients who are not severely dependent [source: 1993 book description]. Screen for withdrawal history and medical risk at assessment. Arrange medical assessment (and medically supervised withdrawal where indicated) before any sudden reduction. Consider a more intensive level of care [synthesis].

Suicidal thoughts, self-harm or severe mood symptoms (often surfacing in Negative Affective BSCQ profiles or trigger reviews). Carry out a standard suicide risk assessment and collaborative safety planning. Counsel on lethal means (secure storage or temporary removal of firearms and medications, and limiting the alcohol kept at home during a crisis). Refer or coordinate care for co-occurring disorders, and continue GSC alongside if the client is safe to do so [synthesis].

Mandated clients. Make clear what is reported to the referrer and what stays confidential. Separate the externally required goal from the client's own goal, and use decisional balance to explore the client's own reasons [synthesis].

Polysubstance use. Complete the TLFB and feedback for each substance. Have the client choose which substance to target first, or set a separate goal for each, and use the matching goal-evaluation forms [synthesis].

Adolescents. NSU posts adolescent versions of the decisional balance, a feelings exercise, an "important thing" exercise and a weekly check-in. Their procedures are not described here [uncertain]. Adapt the language, check consent and confidentiality rules for minors, and consider involving parents within those limits [synthesis].

Sources

Sources:

Books and articles cited:

Sobell, M. B., & Sobell, L. C. (1993). Problem drinkers: Guided self-change treatment. Guilford Press (description only).
Sobell, L. C., & Sobell, M. B. (2011). Group therapy for substance use disorders: A motivational cognitive-behavioral approach. Guilford Press (followed via its published handouts; the book text itself is not drawn on).
Sobell, M. B., & Sobell, L. C. (2005). Guided self-change treatment for substance abusers. Journal of Cognitive Psychotherapy, 19(3), 199–210 (abstract only).
Sobell, M. B., Sobell, L. C., & Leo, G. I. (2000). Does enhanced social support improve outcomes for problem drinkers in guided self-change treatment? Journal of Behavior Therapy and Experimental Psychiatry, 31(1), 41–54 (abstract only).
Carballo, J. L., Coloma-Carmona, A., Sobell, L. C., & Sobell, M. B. (2022). Programa de Auto-cambio Dirigido en abuso de alcohol en población española: un estudio de caso. Psicología de la Salud, 8(1) (abstract only).

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