Reframing Recovery: Developmental Considerations for Maintaining Change

72 Journal of Addictions & Offender Counseling • October 2011 • Volume 32

© 2011 by the American Counseling Association. All rights reserved.

Reframing Recovery: Developmental Considerations for Maintaining Change

Gerard Lawson, Simone F. Lambert, and Charles F. Gressard

Lasting recovery for clients can be challenging to establish in addictions counsel-ing. Through the combination of 2 approaches, motivational interviewing and developmental counseling and therapy, client treatment can be refined to promote transformative change and long-lasting recovery.

When clients with addiction issues come to counseling, the counselor can help them explore and ultimately change their behaviors. Facilitating behavioral change is crucial and often the easiest measures of success in counseling. However, maintaining that change, avoiding relapse, and enter-ing recovery are the more significant outcomes for the client. According to the U.S. Department of Health and Human Services’ Center for Substance Abuse Treatment (2005), “Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life” (p. 1). Within recovery, the duration of abstinence is positively correlated with enhanced coping skills, stable housing, social and spiritual support, and self-efficacy associated with preventing relapse (Dennis, Foss, & Scott, 2007).

Addictions treatment can be a frustrating process. Clients often make advances, then relapse and lose the progress previously accomplished. Dennis, Scott, and Funk (2003) suggested that clients who struggle with chronic addiction issues may cycle through substance use, treatment, recovery, and relapse for nearly a decade. Often this results in multiple treatment admissions. Thus, changing behavior is often just the beginning, not a sufficient endpoint. As a result, counselors must be aware of both the behavioral change itself and the accompanying growth in other areas of clients’ lives that may assist them to maintain that change and enter lasting recovery. By combining the strengths of two proven approaches, motivational interviewing (MI) and developmental counseling and therapy (DCT), we address the following issues in addictions treatment: how to help clients change and how to help them maintain that change.

The literature demonstrates counseling efficacy; meta-analyses have dem-onstrated that individuals benefit from the counseling process when they are trying to overcome life’s challenges (Wampold, 2000). In addition, coun-selors have learned more about how individuals change and have identified counseling factors that best meet specific needs of clients (Lambert & Barley,

Gerard Lawson and Simone F. Lambert, School of Education, Virginia Tech; Charles F. Gressard, Counselor Education Program, College of William and Mary. Correspondence concerning this article should be addressed to Simone F. Lambert, School of Education, Virginia Tech, 7054 Haycock Road, Falls Church, VA 22043 (e-mail: [email protected]).

Journal of Addictions & Offender Counseling • October 2011 • Volume 32 73

2001). There is also a need to focus on the type or degree of change that clients experience. Particularly when the overall treatment goal is a specific behavioral change, such as addictive behavior, counselors must help manage both the behavioral change and the maintenance of that change. The first-order change of problem solving or alleviating symptoms (Murray, 2002) could be the cli-ent establishing abstinence. Maintaining the behavioral change (i.e., stability of abstinence or reduced usage) leads to a second-order change defined by “a resolution of the problem” (Fraser & Solovey, 2007, p. 15). According to Fraser and Solovey (2007), second-order change is a necessary component of long-lasting transformation and an indicator that counseling has been truly effective. The next section focuses on the impact of second-order changes in clients struggling with addictive behaviors seeking recovery.

Second-Order Change in Addictions Counseling

Three different perspectives are provided as examples of the integration of the process of second-order change in addictions counseling. Brown (1985) introduced a developmental model of recovery based on the work of Piaget. This approach included clear references to the second-order change required for meaningful long-term recovery. In this developmental model, recovery is an ongoing process of construction and reconstruction of the individual’s identity and view of the world. Brown suggested that as development and growth continue, the client’s focus on alcohol wanes and then shifts to self-exploration and the formation of a new identity no longer organized around substances. Thus, the individual requires fewer behavioral or cognitive coping mechanisms, because the focus has shifted to living a fuller life, not merely avoiding alcohol. Similarly, Bewley (1995) described a second-order change in addictions counseling as meta-recovery, which she defined as “recovery from recovery” (p. 3). Bewley suggested that individuals who are successful in working a 12-step program eventually will transcend addiction-focused recovery and see their world from a qualitatively new and healthy perspective.

DiClemente (2003) offered another perspective on second-order change in the addictions treatment process, particularly in the maintenance stage of recovery. The maintenance stage is when the individual has been able to abstain from alcohol or other drugs for a sustained period and avoiding substances is less of a daily struggle. DiClemente described this process as becoming an ex-addict, or shifting away from addictive behavior and toward (a) a new identity separate from the addiction and (b) a permanent exit from the stages of change. In other words, a successful ex-addict re-establishes an identity separate from the drug. DiClemente (2003) noted, “In order to sustain recovery, new behaviors and reinforcing experiences must become part of a new way of living in the world” (p. 190). Thus, the models of DiClemente (2003), Brown (1985), and Bewley (1995) suggested that a new and fulfilling way of living in the world and a new identity are the hallmarks of second-order change in addictions treatment. We propose that second-order change should be the ultimate goal of addictions coun-


seling. Therefore, the next section presents the two counseling approaches mentioned earlier, MI and DCT, which together assists clients in integrating maintained change into their worldview and lifestyle.

Strategies for Maintaining Change

Two approaches exist at the forefront of counseling research. The MI ap-proach is well established in the literature and is noted as effective when treating addictive disorders (Burke, Arkowitz, & Menchola, 2003; Carroll et al., 2006; Hettema, Steele, & Miller, 2005; Vasilaki, Hosier, & Cox, 2006). Alternatively, DCT has a body of literature supporting its efficacy in helping clients establish new and more effective strategies for living (Barrio Minton & Myers, 2008; Ivey, Ivey, Myers, & Sweeney, 2005; Marszalek & Myers, 2005; Rigazio-DiGilio & Ivey, 1990). These two counseling approaches comple-ment each other, and counselors may find avenues for more fully meeting the needs of their clients through the synthesis of these two approaches. In addition, both approaches can help clients achieve second-order change. We discuss each approach individually and then as a synthesis.

MI Approach

MI is a counseling approach with its roots in the transtheoretical or stages of change model (DiClemente & Velasquez, 2002). The significant contribu-tion of the transtheoretical model includes the focus on how people change. Prochaska, DiClemente, and Norcross (1992) found that change occurred within specific processes, levels, and stages of readiness. In terms of counsel-ing applications, the stages of change were helpful in conceptualizing how best to support a client in moving toward behavioral change. The stages of change describe an individual’s readiness to recognize and take action on a specific behavioral goal. Table 1 describes the five stages of change: precontemplation, contemplation, preparation, action, and maintenance.

Prochaska et al. (1992) provided a visual characterization of the stages of change as a spiral in which individuals move upward from one stage to the next. However, it should be noted that at any point along the way the individual may exit the spiral and regress to a lower stage of readiness. This regression generally indicates a lack of commitment to continue the process and can be seen as unresolved ambivalence about the changes to be made. The transtheoretical approach is especially helpful because it charts the course for individuals who, with or without counseling, struggle to make some change in their behavior. The adaptation of this theoretical approach to a specific counseling model held great promise for helping clients change their troubling behaviors.

Miller and Rollnick (2002) noted that the transtheoretical model of change and their MI approach developed together and have proved to be excellent complements to each other. For instance, MI includes specific interventions that alternately support and challenge the client’s understanding of the problem behavior and that are chosen on the basis of the client’s readiness for change


(Britt, Blampied, & Hudson, 2003). Miller and Rollnick (2002) specifically stated that “MI aims to alter how the client sees, feels about, and means to respond to the problematic behaviour” (p. 194). The principles that serve as the foundation of the MI approach include the positions that (a) motivation for change must come from the client, (b) ambivalence toward change is normal, (c) resistance to change reflects on the counselor and not on the client, and (d) the counselor’s role is one of a partner rather than an expert (Miller & Rollnick, 2002). These principles come together in a number of tenets and techniques applied by counselors to shift clients toward the maintenance stage.

Throughout the process of MI, counselors must express empathy for clients and their struggles; the counselor must not judge the client but rather should listen with respect and seek to understand the client’s experience (Miller & Rollnick, 2002). In addition to the relational component of empathy, Miller and Rose (2009) described other factors of MI as including “the interpersonal spirit of MI, and a technical component involving differential evocation and reinforcement of client change talk” (p. 527). Genuine client change talk de-velops through counselors listening for discrepancies between the client’s perception of the impact of the behavior and the client’s hopes or life goals.

Note. Stages of change adapted from “In Search of How People Change: Applications to Ad-dictive Behaviors,” by J. O. Prochaska, C. C. DiClemente, and J. C. Norcross, 1992, American Psychologist, 47, pp. 1102–1114. Copyright 1992 by the American Psychological Association.

Table 1

Transtheoretical Model of Change Stage Combined With Motivational Interviewing

Precontemplation stage

Contemplation stage

Preparation stage

Action stage

Maintenance stage

Transtheoretical Model of Change Stage

Client description

Motivational Interview approach

Is unaware of the problem and minimizes the significance or impact of behavior

Recognizes that something relating to the problem be-havior might need to change and is ready to examine the situation

Strategizes about how might some change occur regard-ing the problem behavior

Implements plan and makes the changes sought, which may involve limiting the behavior or abstaining from it all together

Successfully changed the behavior and/or continued to modify the behavior to maintain the specific goals set

Very nondirective or personcentered approach with the goal of keeping the client returning and reducing any resistance to talking about the behavior in question

More directive to help the client resolve ambivalence about whether to undertake some change

More directive, at times even behavioral in preparation and action stages, as the counselor helps to identify possible areas for change and strategies that may be effective if the client decides to move forward

Not applicable


Often resistance to change prevents clients from achieving these goals, thus MI counselors use a technical skill, “rolling with resistance” (Miller & Moyers, 2006, p. 9), that uses the clients’ momentum to help them achieve a different understanding of the problem and resolve ambivalence in their own time. When problem behaviors become entrenched over years, the process of even deciding to change can be daunting. Counselors working in the motivational spirit support self-efficacy throughout the process by highlighting the clients’ ability to achieve goals and enhancing their feelings of self-efficacy (Miller & Rollnick, 2002). Often MI counselors will reframe past relapse experiences as practice rather than failures and help clients to understand lessons from previ-ous experiences that will serve them well as they address their current goals.

Although the skills and strategies of the MI approach are important, the key to effective motivational counseling is the counselor’s style and practice in working with the client (Miller & Rose, 2009). Counselors must align themselves with the client’s goals and be careful not to allow their own values to enter into the equation. MI stresses the personal responsibility of the client in determining how and what to change (Miller & Rollnick, 2002) and promotes a cooperative and coequal working relationship be-tween client and counselor designed to generate solutions to behavioral problems. This collaborative relationship sets the stage for transformation through the development of a change plan and the commitment of clients to implement their plan and achieve their goals (Miller & Moyers, 2006).

Although MI is an effective technique on its own for increasing recovery behaviors, it never was meant to be used in isolation (Miller & Moyers, 2006). Treatment efficacy can be improved when MI is combined with other theories (Burke et al., 2003). Miller and Rose (2009) stated that counselors can enhance the effectiveness of MI by using it in conjunction with other active treatment methods. Table 1 lists proposed considerations in the selection of treatment interventions to be used in conjunction with MI on the basis of the client’s current stage of change.

By counselors matching clients where they are in terms of readiness for change and building trust and rapport, the MI approach provides clients with the opportunity to experiment with new ideas and possibilities. Some of these possibilities may be positive radical changes in their life that would be consistent with second-order changes. MI, if done well, provides the cli-ent struggling with an addiction the space to consider the unthinkable—an identity and life without drugs or alcohol. In doing so, the client can choose to maintain change. In summary, counselors can use MI along with other approaches, such as DCT, to assist clients in sustaining their choice for a new identity and new lifestyle not centered around an addiction.

DCT Approach

DCT (Ivey, 1986; Ivey et al., 2005) addresses client difficulties through a strength-based coconstructivistic approach. Based in the developmental progression described by Piaget, DCT was designed to help clinicians to


understand their clients’ perspective of the world and to intervene with clients in the developmental style that is most meaningful for clients (Barrio Minton & Myers, 2008; Ivey et al., 2005). The DCT model of development involves four styles, which are differentiated from Piaget’s stages because they are unrelated to age and because the DCT model suggests that no one stage is better than another (Ivey et al., 2005). The styles are sensorimotor/elemental, concrete/situational, formal/reflective, and dialectic/systemic. A description of each of the styles is given in Table 2. The DCT model suggests that counselors can best serve clients either by helping them maximize the coping skills available to them within their current style or by helping them move to a different style (Ivey et al., 2005). These approaches are termed horizontal development and vertical development. The goal of horizontal development is to build skills within an individual’s current system of making meaning, which begins when the counselor can understand how the individual sees and relates to the world and other people. The goal of vertical development is to increase skills beyond an individual’s current system of making meaning, which is achieved by mismatching the therapeutic intervention and preferred style (Ivey et al., 2005). In the initial stages of treatment when rapport building and understanding the client’s story are

Note. From Developmental Counseling and Therapy: Promoting Wellness Over the Life Span, by A. E. Ivey, M. B. Ivey, J. Myers, & T. Sweeney, 2005, pp. 206–207. Boston, MA: Lahaska Press. Copyright 2005 by Wadsworth, a part of Cengage Learning, Inc. Adapted with permission.

Table 2

developmental Counseling and Therapy (dCT) and Suggested Interventions

Sensorimotor/elemental

Concrete/situational

Formal/reflective

Dialectic/systemic

dCT Style Client description Intervention

Is especially in touch with the sensory (sounds, smells, sights, touch, taste) world and is very much in the here and now

Experiences life in very structured, linear terms of cause and effect, but without much ability to reflect on the experience

Begins to reflect on his or her experiences in more abstract terms and takes multiple perspectives of the experiences

Is able to think about thinking and has the ability to take multiple, contextual perspec-tives on life experiences

Very structured and body-based interventions

• acupuncture • bodywork • meditation • relaxationtrainingLinear, structured interventions • 12-stepsupportgroups • behavioralandnarrative

interventions

Less structured interventions, which allow for reflection

• personcentered • psychodynamiccognitive

therapiesSystemic therapies that allow

for a broader view of the client’s relationships

• family • socialchange • multicultural


critical, DCT enables counselors to match interventions to the needs of the client on the basis of the client’s preferred developmental style. Thus, the initial therapeutic focus is on horizontal development. Vertical development tends to be a later emphasis in the counseling process.

Likewise, we propose that the DCT approach offers a unique perspective on the dynamics of addiction and recovery by using clients’ preferred de-velopmental style in determining the appropriate goals and intervention for each client. For example, a client whose primary means of relating is with a sensorimotor style will tend to focus on the physical and sensory experi-ences of the drug. This client focuses on avoiding withdrawal symptoms and maintaining pleasure, such as a high. Treatment goals would include decreas-ing withdrawal symptoms while identifying other sources of pleasure that are not a part of the addiction. A client who prefers the concrete/situational style will be more inclined to rationalize his or her addiction. This client may not take responsibility for the addiction and instead may shift responsibility onto other individuals or situations. An appropriate intervention here may be to look at faulty thinking and empower the client to take ownership of the recovery process. Both sensorimotor and concrete styles are common preferred styles, in particular with clients in early stages of recovery.

The DCT approach characterizes the formal/reflective style and the dialectic/systemic styles as part of the abstract world of ideas and thinking (Ivey et al., 2005). Certainly, clients with substance abuse problems can access this world, but it is our position that their access will be limited, especially at the begin-ning stages of recovery. The formal/reflective style requires the ability to think about self, to reflect on what happened to self, and to examine experiences from multiple perspectives. Because of the narrowing of one’s worldview through addiction, individuals may be able to take multiple perspectives, but these perspectives will continue to be filtered through the primary lens of maintaining substance use. The dialectic/systemic style is characterized by the ability to think contextually, to access multiple perspectives regularly, and to think more altruistically (Ivey et al., 2005). When individuals who are abusing drugs appear to act altruistically, there is often a greater motivation in their own self-interest that underlies those acts. For example, a substance-abusing husband may give his wife a gift certificate to a day spa, noting the amount of time and energy it takes for her to raise the children. On the surface, this may seem like an act of generosity, but in the husband’s mind it is also building goodwill for the next time there are problems created by his drug use. When no longer governed by their addiction, clients can be more successful using the formal or dialectic style. However, we suggest this typically occurs only once recovery is well established.

Again, knowing the client’s preferred DCT style will assist counselors in selecting interventions that match and maximize the client’s functioning within that level (i.e., horizontal development; Ivey & Ivey 2007). A list of suggested interventions based on each DCT style is provided in Table 2. Although one style may be preferred, clients may use various DCT styles during a single session and throughout treatment to make meaning of their


addiction. In fact, counselors should encourage clients to experience other DCT styles by mismatching interventions to foster a new, more complex client perspective (i.e., vertical development; Ivey & Ivey, 2007). Ivey and Goncalves (1988) argued that the goal should be to promote development within and between styles to promote second-order change via vertical development. We propose that by obtaining horizontal and vertical de-velopment, clients will have a fuller understanding of their addiction and achieve long-lasting recovery. Focusing on development as part of treat-ment needs to be a central goal in recovery, because the onset of substance abuse often leads to arrested emotional, social, and intellectual development (Commission on Substance Abuse Among America’s Adolescents, 1997). By addressing these developmental deficits, counselors can establish better understanding and communication with clients, thus fostering stronger rapport and more effective treatment (Wallen, 1992). We propose that long-lasting recovery is in peril when counselors fail to target treatments to match clients’ developmental stage and preferred developmental style.

Synthesis of MI and DCT

The MI and DCT approaches have a number of similarities. Both approaches have demonstrated effectiveness in helping individuals change their be-havior. Both are rooted in humanistic and constructivistic theory, relying on empathy and support for the client to try to understand how the client makes meaning and forms his or her worldview (Ivey et al., 2005; Miller & Rollnick, 2002). We find that both approaches provide a clear roadmap for counselors to follow to tailor interventions based on client variables. Even with the specific questions to ask and techniques to apply using MI and DCT, both approaches put equal emphasis on embracing the spirit of the approach (Ivey et al., 2005; Miller & Rose, 2009).

Despite the many similarities, there are some significant differences be-tween these two approaches. The first major difference is procedural. MI is focused on clients’ readiness for changing their behavior and matches interventions to those internal and external readiness factors (Miller & Rose, 2009). MI begins with the counselor’s nondirective supportive stance. Conversely, DCT uses a specific sequence of questions to identify clients’ developmental preferences to deliver interventions that will resonate with their preferred way of making meaning (Ivey et al., 2005). Thus, DCT begins with a highly structured approach and may shift to a nondirective approach if deemed appropriate for clients. Again, this is the opposite of MI, which becomes more structured as treatment moves forward.

The second major difference between MI and DCT are the focuses of the two approaches. MI assists clients to change their behaviors (Miller & Rose, 2009), yet there is little emphasis on long-term second-order change after clients reach the maintenance stage. “MI was originally conceptualized for helping people move from precontemplation and contemplation, through preparation and on to action. Clients ready for action when they present for treatment are unlikely to need MI” (Miller & Moyers, 2006, pp. 11–12).


We propose that DCT can be used at the maintenance stage to assess where the client is now that the addiction is no longer overruling the client’s meaning-making system. Thus, the client perceives the world differently in the maintenance stage, because here the addiction is managed by the client. At this point, DCT can help to pinpoint an individualized treatment plan with interventions intentionally selected to meet clients where they are at present (Barrio Minton & Myers, 2008). Because behavioral change must take place before recovery can begin, we argue that a synthesis of these two approaches should use the strengths of the MI approach to help change the client’s addictive behavior and the strengths of the DCT approach to help move the client into more permanent recovery.

Implications for Practice

We suggest that the combination of MI and DCT offers a more holistic method of addressing addiction and the individual. This allows clients to explore who they are now in recovery as opposed to only examining who they were while using a substance or engaged in destructive behaviors. Thus, we encourage counselors to first apply MI strategies to assist clients into the maintenance stage, and then to use DCT to understand clients’ worldview going into recovery. We propose that targeting interventions through DCT will foster a longer lasting recovery for the changed client.

Case Vignette

Greg is a 35-year-old Caucasian client who was mandated to attend counsel-ing after receiving his second driving-under-the-influence infraction. (Note. The client is a composite of several clients.) Greg is married, although cur-rently estranged from his wife, and has two children, ages 4 and 6. At the time of the first appointment, Greg is in the precontemplation stage and has no desire for change. At this point, the counselor keeps Greg engaged in counseling by using MI. Although the counselor provides an empathic response to Greg’s story, there are discrepancies between the goals that Greg reports and the actions in which he is engaging. The counselor helps to move Greg into the contemplative stage by helping him consider if any change is needed, while not specifically identifying the substances or ad-dictive behavior. Greg has a choice to maintain the status quo or to embrace the change that might bring about a new way of living; he decides that his current way of making sense of the world is no longer sufficient. The counselor then helps Greg move into the preparation stage and eventually action stage to achieve abstinence and gain a healthier perspective on his alcohol use. Greg is now stable and able to see the world more accurately.

Greg is ready for a second phase of treatment. Because he has already completed the action phase, the counselor shifts away from MI to work on the maintenance stage. The counselor shifts to DCT to identify Greg’s preferred developmental style. Although Greg is chronologically 35 years


old, he began drinking at age 17, and his present developmental age is similar to that of a teenager. Likewise, through exploration using DCT, the counselor identifies Greg’s preferred developmental style as late concrete. He is beginning to see how his behavior affects others. Greg sees that he is a better parent and spouse when he is not drinking. In fact, his wife is now supportive of his treatment, and the two are living together in the same house again. For Greg, maintaining sobriety has had a huge payoff. The counselor reinforces Greg’s desire to maintain this new identity as a parent who does not abuse substances, because Greg wants to serve as a positive role model for his children.

Next, the counselor helps Greg move into a more lasting recovery by tar-geting vertical development, guiding him into the formal developmental style. The counselor selects a cognitive behavior approach to help Greg reflect on his experiences more abstractly and to consider these experiences from different perspectives. The treatment goal is to reinforce the belief that returning to the previous lifestyle is incompatible with the new person that Greg wants to be. The counselor helps Greg maintain abstinence by supporting his current system of coping and problem solving, as well as challenging Greg to look at the world through a new lens. Although Greg does recognize that there is potential to relapse, he is confident enough to think of his identity and life as separate from alcohol.

Once again, the counselor steers Greg into another developmental level: dialectic/systemic. Greg is able to recognize the impact his drinking had on his wife and children. More important, he is able to see how his sobriety and new way of life affect his family. Greg, along with his wife and children, enters family counseling to develop strategies that the family can imple-ment to support this healthier lifestyle free from alcohol. Greg achieved second-order change and developed a new identity and outlook on life.

Limitations

Both MI and DCT have empirical support for their effectiveness; however, there have not been any studies conducted to examine the syntheses of MI and DCT and the related outcomes for long-term recovery (Barrio Minton & Myers, 2008; Burke et al., 2003; Carroll et al., 2006; Hettema et al., 2005; Ivey et al., 2005; Marszalek & Myers, 2005; Rigazio-DiGilio & Ivey, 1990; Vasilaki et al., 2006). Although caution should be taken in combining these approaches, there is evidence that these two approaches work well in combination with other interventions (Barrio Minton & Myers, 2008; Burke et al., 2003; Miller & Rose, 2009). Counselors who use these two approaches are encouraged to conduct research to determine the effectiveness of this synthesis.

Directions for Research

There needs to be empirical evidence to support our hypothesis that using DCT principles after the MI approach will assist clients who are in an estab-


lished recovery from addiction to maintain the motivation and gain insight to sustain long-lasting recovery. An additional hypothesis to be tested is whether clients who establish ongoing maintenance also achieve second-order change and recovery from addiction. To measure outcomes for sustained recovery, researchers will need to implement longitudinal studies (Dennis et al., 2007). As with any study, examining success rates on the basis of client variables such as racial and ethnic backgrounds will be helpful. In addition, the type of addiction (i.e., substances, process, or multiple addictions) may affect successful outcomes. These answers would assist practitioners in identifying interventions that sustain the maintenance stage of change, so that clients can truly obtain second-order change and a new way of life.

Conclusion

This article presents a perspective on recovery that has not been widely dis-cussed in the addiction literature. We argue that lasting recovery involves a process of second-order change; that is, change that moves beyond manag-ing the behaviors and coping with problems and that challenges clients to examine their core identity. Second-order change affects how individuals experience and make meaning of their world, their experiences, and their relationships, including how they understand themselves.

However, to access the second-order change, the client must be relatively stable in abstinence or early recovery. We suggest that a synthesis of the MI and DCT approaches helps clients achieve and sustain recovery. Our position is that the MI approach should be used for its strengths: helping the client experience and maintain behavioral change. Once the client has reached a stable beginning of recovery, the stage is set for a shift to a DCT approach that specifically targets vertical development, or second-order change, and more lasting recovery.

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Reframing Recovery: Developmental Considerations for Maintaining Change