Comparing Therapeutic Treatment Goals Across Settings for Those in or At-Risk for Substance Use Treatment in West Alabama

Site 1: Urban FQHC

The urban FQHC offered outpatient services to individuals with or at risk for substance use concerns in a primary care medical setting or via telehealth. Patients were recruited by a clinical champion on site based on predetermined diagnostic risk factors, including substance misuse, chronic pain, depression, anxiety, or trauma history. The clinical champion varied across time yet typically was a social worker or social work trainee who facilitated integrated, interprofessional care.

Site 2: Rural FQHC

The rural FQHC offered MAT using suboxone for individuals with opioid use disorder between January 2020 and December 2022 when this program was discontinued due to lack of sustainable funding. In order to continue in the MAT program, clients at this site were required to attend individual psychotherapy sessions to receive their suboxone medicine and remain in the program. Typically, these services were provided by our clinical psychology trainees, who participated in interprofessional treatment team meetings for the MAT program.

Site 3: Urban Community Substance Use Treatment Facility

The third site was a 3.01 urban residential community substance use treatment facility (CRF) with an average length of stay between 60 and 90 days and offered low intensity residential services to individuals recovering from a SUD. While some residents were court-mandated to attend treatment, others enrolled voluntarily. During the day, residents worked or volunteered at local organizations and in the evenings, they attended individual or group therapy, relapse prevention, psychoeducation, or occupational education classes. Individuals at this site were referred for assessment and, potentially, individual psychotherapy by the clinical champion, a licensed independent social worker and director of clinical services.

Treatment Goals

The Bern Inventory of Treatment Goals (BiT-T) is an evidence-based framework for classifying psychotherapy goals, originally developed using cluster analysis in a large university counseling center sample. ³² Using cluster analysis to identify common themes in treatment among clients, the original BiT-T classified 5 goal types, 26 goal categories, and 52 subcategories. The 5 goal types included (1) coping with specific problems and symptoms, (2) interpersonal goals, (3) overall well-being and functioning, (4) existential concerns, and (5) personal growth. The BiT-T, tested on a large sample of over 1000 participants, displays good interrater reliability (mean K goal types = 0.79 and for goal categories = 0.76). ³² It was chosen as an initial coding scheme because it offers a comprehensive, empirically derived structure for organizing client treatment goals, making it a strong foundation for adapting goal categories to substance use treatment settings.

In the current study, the BiT-T was used as a framework and modified to reflect the needs of adults at risk for or receiving substance use treatment in community-based settings (see Table 2). The iterative process of qualitative coding informed and supported the modification of the BiT-T within this sample of clients in psychotherapy at the substance use treatment facilities and is described in the Data Analyses section.

The modified BiT-T maintained the 5 goal types described above and omitted the following goal categories due to limited endorsement across the current treatment settings: obsessive thoughts and compulsive behaviors, eating behaviors, and sexuality. Furthermore, the following subcategories were incorporated into the modified framework to account for the common experiences of clients across the current treatment settings: comorbidity of severe mental illness, transportation challenges, history of or current legal involvement, or incarceration, relationships with their own parents or grandchildren, not otherwise specified relationships (e.g., sponsors, peers, or site-specific support team), and helping loved ones with their own recovery. The original Bern inventory “existential issues” category was renamed “exploration of self.” The goals within this category focused on clients’ recovery journey and included intentions to process their life history and consider their future, contemplate issues related to their spirituality, and reflect on their struggles with intense feelings. A new subcode of negative affectivity was added. These modifications were made to ensure that the BiT-T captured common psychosocial concerns that are particularly salient for adults receiving or potentially needing substance use treatment in community-based settings.

Overview of Psychosocial Treatment Goals by Site

Across all settings, goals related to coping with substance use or associated problems, such as the use of substances due to chronic pain, were most frequently documented. The emphasis of specific psychosocial goals, however, varied by site, likely due to the differing stages of change characterizing individuals’ substance use and treatment goals (e.g., at risk for substance use, in active treatment for substance use, maintenance of recovery goals after a period of active treatment for substance use). At the urban CRF focused on recovery maintenance, goals often centered on substance use and addiction, work and education, and rebuilding daily structure during residential recovery. At the rural FQHC-MAT clinic wherein active treatment for addiction occurred, goals frequently combined substance use and cravings with anxiety, somatic concerns, and multiple life stressors. At the urban FQHC where many clients were at risk for substance use and were referred from the clinical champion and primary care physicians, goals often focused on coping with chronic pain and other somatic problems, in addition to fears/anxiety and substance-related concerns. Interpersonal, well-being, exploration of self, and personal growth goals appeared across all settings but with differing emphases, as described below.

Coping with Specific Problems and Symptoms

This category focused on client-reported symptoms or difficulties related to specific mental and physical health issues (e.g., depressive symptoms, coping with somatic problems), health behaviors (e.g., substance use and addiction), and life domains (e.g., housing problems, problems with work and education). Coping with specific problems and symptoms emerged as the most commonly documented goal category across all 3 settings, reflecting the centrality of substance use and associated difficulties in client’s treatment plans, particularly at active substance use treatment sites (e.g., the urban CRF and the rural FQHC-MAT clinics). Many clients discussed experiences with fear or anxiety related to different situations in their lives that impacted daily functioning. For example, 1 client “identified a large part of herself does not want to stop or slow down out of fear,” with her therapist working collaboratively, “to break down her fears about taking a break” from addiction. Complex trauma histories were common within this population, with clients expressing interest in processing traumatic events to develop more effective coping strategies. One therapist described using the book The Body Keeps the Score with a client, highlighting how trauma affects various systems and avoidance perpetuates negative patterns.

At the urban CRF, work and education goals were especially prominent alongside fears/anxiety and coping with trauma, consistent with clients’ efforts to rebuild daily roles while addressing long-standing emotional difficulties. A therapist working with a client stated she “discussed his personal goals that may be interrupted by continued substance use, including obtaining his GED” and reviewed the concept of mindfulness and how its skills can aid “in maintaining sobriety.”

At the rural FQHC-MAT clinic, goals frequently combined substance use challenges with financial concerns, work barriers, and somatic complaints. One client expressed that she “wanted to go back to work, but she learned she would lose her Social Security benefits if she did this” and so “she decided to not go back to work, which caused concern, as she fears that if she cannot fill her time, she will experience increased cravings.”

Uniquely, at the urban FQHC, coping with somatic problems predominated, reflecting the chronic pain focus of many referrals. One client reported “experiencing pain in several different parts of her body and continued migraines” and with her therapist they “discussed ways to continue engaging in pleasurable and meaningful activities despite the pain.” Taken together, while substance use remained foundational across settings, the constellation of accompanying goals mirrored each site’s client population and recovery stage.

Interpersonal Goals

This category captured clients’ efforts to navigate relationships central to their recovery, including parenting roles, family connections and multigenerational families, intimate partnerships, and broader social networks. Relationship goals appeared consistently across all 3 settings, underscoring how interpersonal priorities shaped clients’ recovery trajectories. Overall, parenting emerged as a dominant theme across sites, anchoring many clients’ motivation for sustained recovery and representing a common concern of midlife development. Many clients discussed parenting roles and relationships with their children as central to their treatment. For example, a client from the urban FQHC reported that, “her daughter recently obtained her driver’s license. [The client] commented that she was proud of her daughter and felt further motivated to ‘get it together’ and continue saving money to buy her own car. . . .”

At the rural FQHC-MAT clinic, clients often focused on disclosing recovery struggles to family while managing emotional reactions. A client expressed discomfort discussing stress and anxiety with her daughter and fiancé, concerned about their reactions to her struggles with recovery. Another client described, “telling her sister that she was in the MAT program and attending counseling. She said she had been worried about how her sister would take the news, but she was surprised that her sister was actually supportive and thought it was good for her to be talking to someone.”

At the urban CRF, intimate partner relationships predominated as a central goal, possibly due to the residential nature of this treatment setting wherein clients were not living with their family members. For example, a client, “recounted having arrived early to the couple’s most recent court date, only to receive multiple ‘belligerent’ phone calls from her husband regarding the appointment’s time/location, followed by the announcement that he had wrecked his vehicle in route. [The client] referred to this incident as ‘the straw that broke the camel’s back’ in justifying her termination of the relationship.”

At both of the FQHCs, connectedness and intimacy were emphasized as integral components of recovery, illustrated by a client, “reporting he is trying to work on himself more throughout his recovery journey, describing how he is going to church weekly, involved in a peer support group, going to the gym, and drinking more water.” Across settings, parenting provided essential motivation for change, while relationship priorities (e.g., partner versus community support) reflected each site’s recovery context. For example, the culture of rural communities reflected by the rural FQHC illustrated concern about disclosures and reactions from loved ones. The residential treatment program revealed concerns about partner separation, while the urban FQHC indicated focus on social support more generally.

Well-Being and Functioning

This category addressed clients’ efforts to maintain mental stability, physical health, and daily functioning through exercise, relaxation techniques, body comfort, and structured routines. Well-being goals appeared consistently across settings, though specific priorities reflected each site’s client population and recovery stage. For instance, stability and comfort goals (e.g., body image, weight concerns, and routine maintenance) appeared across sites but with less emphasis than other well-being priorities. A client at the urban CRF reported feeling depressed but informed his therapist that he started volunteering at a local agency and noticed “it felt good to leave. . .and stay busy.” Another client acknowledged how limited he felt in his life due to his addiction and recognized loss, stating “there is so much . . . not experienced . . . due to being ‘trapped’ in his addiction,” highlighting sobriety’s role in expanding life opportunities.

At the rural FQHC and urban CRF wherein clients received active treatment for substance misuse, mindfulness and relaxation techniques predominated as tools for managing cravings and emotional stability. Clients sought structured practices to combat depression, recognizing opportunities afforded by sobriety. One client shifted from using alcohol to cope with stress to engaging in self-care activities, like going on walks, while another sought to improve health behaviors, “to feel better physically and mentally.”

At the urban FQHC, improving physical activity took precedence, consistent with the chronic pain focus of many referrals. Clients prioritized movement alongside mental health goals to manage somatic symptoms and maintain daily functioning. Altogether, well-being priorities mirrored recovery contexts. Mindfulness and relaxation were most salient for active addiction management at the rural FQHC and urban CRF, whereas physical activity for pain management was documented the most at the urban FQHC.

Exploration of Self

This category described clients’ reflections on their recovery identity, life history, future aspirations, and spiritual growth. Self-exploration goals appeared across all treatment sites, though with varying emphasis that reflected clients’ stages of recovery. Spirituality also emerged prominently here, potentially reflecting the culture of substance use recovery in the Deep South.

At the urban CRF, reflecting on past experiences, present recovery, and future aspirations were salient themes for treatment, marking self-reflection as central to residential recovery. One therapist described a client who, “. . .spent a long time seeing herself as ‘the Addict,’” with the therapist challenging this passive self-label and reflecting that the client has a choice in this moment to redefine her identity.

At the rural FQHC, clients focused on creating new sober environments and identities, possibly due to the small community social systems of rural areas. One client shared, “. . .living in [redacted] is not much different from where he lived before. . .but it all depends on how he spends his free time and who he spends his time with. He recognized that he has to create his own world now and surround himself with sober and motivated people.” Another client reflected how, “he is taking on more responsibilities in his church to help with his recovery.”

Self-exploration appeared less frequently at the urban FQHC but remained meaningful for clients processing identity shifts alongside chronic pain management. Across settings, self-exploration marked clients’ evolving recovery identities. For example, treatment goals at the rural FQHC evoked environmental and spiritual reconnection and clients at the urban CRF chose to reconstruct their identities during treatment for substance use and addiction.

Personal Growth

This category focused on clients’ emotional and personal development, including identifying and striving for personal desires and monitoring progress. Personal growth goals appeared across all treatment settings, reflecting clients’ efforts to build emotional resilience and agency in recovery.

At the urban CRF, recognizing and pursuing aspirations were central goals, in addition to taking responsibility and practicing self-control. One therapist noted, “Pt and I discussed recent steps she has taken towards her goals (. . ., got driver’s license) and aspirations for the future (becoming peer support specialist. . .).” Another therapist described a male client’s acknowledgment of overreacting and subsequent apology to staff, highlighting accountability as key to residential recovery.

At the rural FQHC, emotion regulation and stress management predominated among clients in active addiction treatment for opioid use disorder. Clients used tools like stress diaries to build emotional resilience while navigating cravings and life stressors.

At the urban FQHC, self-esteem, self-confidence, and self-acceptance took precedence, consistent with chronic pain clients processing identity alongside somatic goals for treatment. These clients prioritized building positive self-regard as foundational to sustain recovery or prevent addiction. Overall, personal growth priorities aligned with the unique recovery contexts of each site. For residents at the urban CRF, aspirations and accountability seemed to play an integral role in their motivation for treatment and decision to participate in the program. Emotion regulation during active treatment was important for the clients at the rural FQHC.