Using the information on Carl and the below-mentioned interview, what are four supported intervention components to consider as part of a treatment plan for Carl?

Carl: A 32-year-old man began to drink heavily after he was honorably discharged from the military.  He has been drinking very heavily and nearly continually for the past 10 years, with blackouts, frequent arrests for public intoxication, and injuries in barroom brawls.  He has received 3 DUIs and has lost several jobs due to drinking.  He has been unable to reduce or stop drinking. Whenever he starts to "dry out," he feels anxious, nauseous, and has hand tremors – so he starts drinking again to alleviate these experiences.
INTERVIEWER: I appreciate you giving me information on your drinking habits, Bryan. Did you get a chance to see the feedback sheet I prepared for you and your wife?

BRYAN: I read it.

INTERVIEWER: What are your thoughts on it?

BRYAN: Well, I was surprised to see that I drink more than, what, 85% of people?

INTERVIEWER: Yeah, based on a comparison to the population in general.

BRYAN: I knew I drank, but I didn't know how it compared.

INTERVIEWER: You look bothered by that.

BRYAN: Well, I don't like it. But, how do you know the rest of the country just doesn't drink much? I mean, maybe they just don't drink at all. Doesn't necessarily mean it's bad.

INTERVIEWER: That's true. It just says that 85% percent drink less. It doesn't say anything about whether that's bad.

BRYAN: Yeah, well, I'm sure it's not good.

INTERVIEWER: So, seeing how much you drink in comparison to others doesn't mean it's bad, but you probably feel like it probably is for other reasons?

BRYAN: I don't know. Some of the other stuff on the sheet kind of got me.

INTERVIEWER: What stuff hit you like that?

BRYAN: Well, I didn't realize that my wife felt the way she did about it. You know she's never said anything like that to me before, she's just pretty much been angry.

INTERVIEWER: She hasn't voiced this other stuff to you before? What did she say that hit you so hard?

BRYAN: The stuff about losing me. Losing the guy she married.

INTERVIEWER: I can see it upset you. How does it make you feel?

BRYAN: Ashamed. Like I'm not the guy she married anymore.

INTERVIEWER: Being the guy she married is obviously important to you.

BRYAN: Of course it is. It used to be. I'm not so sure about that now.

INTERVIEWER: You don't know if it's important anymore?

BRYAN: No, it is. I mean, I'm just not that guy anymore. I've changed

INTERVIEWER: It's important to you to be that guy, but you're struggling to be that guy now.

BRYAN: Yeah, I mean, I used to be the strong one, the go-getter, the we can do anything guy. You know what I mean?

INTERVIEWER: I do. Why aren't you that way now?

BRYAN: Drinking. I pretty much check out with the drinking.

INTERVIEWER: You seem disappointed.

BRYAN: Yeah, in myself.

INTERVIEWER: Bryan, sometimes our motivation to get things back comes from the negatives that happen to others as a result of our drinking. This one seems important to you.

BRYAN: It is. I don't like this part of it. I don't like disappointing her like this.

INTERVIEWER: I can see that. When we first talked about looking at these consequences, positive and negative, we said that we might keep the ones that meant a lot, separate them out. Is this one of them?

BRYAN: Yeah. When I think of this it makes me want to change, get back to what I was.

INTERVIEWER: OK, I'll put that one aside. How about we go over the rest of this sheet the same way, see what we find?

BRYAN: Boy, that sounds like fun.

INTERVIEWER: I know. You don't have to if you don't want to. These are your decisions.

BRYAN: No, I don't mean it. We probably should.

INTERVIEWER: All right. You had mentioned some possible positive consequences to quitting. Which ones come to mind now?

BRYAN: Well, I feel crappy most of the time. I think quitting would probably help me feel better. I mean, the only time I feel good is when I first start drinking. The rest of the time I'm dead, tired all the time, strung out.

INTERVIEWER: You'd indicated some concerns about your health.

BRYAN: Well, I'm starting to wonder about it, but I haven't gone to the doctor because I'm afraid of what he might tell me.

INTERVIEWER: What concerns do you have?

BRYAN: Well, I don't have the stamina I used to have. I wonder about how drinking is affecting my heart and my liver. And then there the stomach pains that come and go, and I wonder if that's related to something serious from my drinking? So do you think I should go to the doctor just to get the answers?

INTERVIEWER: It sounds like you know you should go to the doctor.

BRYAN: Yeah.

INTERVIEWER: So, if I'm hearing you accurately, Bryan, getting your wife's faith in you restored and improving your health are two results of sobriety that motivate you to try to succeed in your recovery. Is that right?

BRYAN: Yes.

INTERVIEWER: What other positive effects of maintaining sobriety might help you stay on course?

ARTHUR E. JONGSMA, JR.: Well, this vignette on motivational enhancement starts off with an assessment form. Tell us a little about that.

TIMOTHY J. BRUCE: Yeah, it's common in this approach to have the client fill out a kind of pre-treatment assessment that describes their drinking habits and explore some of their thoughts and feelings about their drinking. And it's to kind of get--

ARTHUR E. JONGSMA, JR.: Some of the consequences are probed there too?

TIMOTHY J. BRUCE: Sure, and try to get a gauge on where they are at in terms of their motivation. So it's a starting point. They may also, as they did here, if that's allowed, to ask significant others, spouses, and so on what impact it's had.

ARTHUR E. JONGSMA, JR.: To give some input.

TIMOTHY J. BRUCE: Give some input. Compare their drinking to national prevalence rates, things like this, just to give some perspective. And then as you're seeing here, talk about this form.

ARTHUR E. JONGSMA, JR.: The client's reacting to some of that feedback that he got from his wife and from the statistical information that he got off the form.

TIMOTHY J. BRUCE: Yeah, and the therapist-assessor is kind of using these non-directive techniques, looking for what the client's reacting to and kind of exploring that a little bit more. So this is not a directive approach where they're saying you can do this.

ARTHUR E. JONGSMA, JR.: More reflective.

TIMOTHY J. BRUCE: More reflective. But also looking for points of conflict in the client as possibilities for consequences that might motivate them. So, that's what you're seeing here.

ARTHUR E. JONGSMA, JR.: And then the therapist points out the wife's disappointment, zeroes in on that and how that affects the client. What's the point there?

TIMOTHY J. BRUCE: Well, the point is the same as what we were just talking about in the sense that the therapist is looking for something that's attached to the client emotionally. So in other words, is this a consequence that's significant? The 85% thing he was dismissing. Well, maybe nobody else drinks, and all this. This one, he actually is reacting to.

ARTHUR E. JONGSMA, JR.: He's buying into this.

TIMOTHY J. BRUCE: Yes, this actually means something to him. So this therapist is now exploring that a little bit further. And the notion is, what's the point is that this may end up being a consequence of significance that might move him toward more action, you know, this kind of stages the change.

ARTHUR E. JONGSMA, JR.: Increase his motivation to change. We talked about stages of change. This might be one of those that moves him further down that stage of change.

TIMOTHY J. BRUCE: Exactly. That's what he's looking for.

ARTHUR E. JONGSMA, JR.: And then he also talks about the health improvement. That could be another point, a factor that could move him forward in motivation.

TIMOTHY J. BRUCE: So, they're going to look at negative consequences he'd like to avoid. They're going to look at positive consequences he'd like to gain, and so that's where they move later in this vignette.

ARTHUR E. JONGSMA, JR.: Sure. Good. Our next research supported treatment is the Community Reinforcement Approach. If we are to add this to our treatment plan, we could consider objectives such as those that appear on your screen now. The statements start with the client taking the happiness scale and being given feedback about the results. The goals of counseling are developed with a focus on increasing satisfaction in non-drinking aspects of life.

TIMOTHY J. BRUCE: This treatment approach also places emphasis on teaching the client communication, problem solving, and assertiveness skills aimed at increasing satisfaction in non-drinking areas of life, and more effective personal and interpersonal functioning. Homework assignments may be given to strengthen newly learned behavioral skills. A relapse prevention plan is also commonly developed.

ARTHUR E. JONGSMA, JR.: To broaden the client's focus on finding satisfaction apart from drinking activities, the therapist may teach skills necessary for finding or maintaining employment. The therapist may also attempt to help the client identify new areas of recreation and social relationships where satisfaction may be found without substance use. Finally, conjoint sessions may be held to address and resolve relationship issues with the partner and to increase the frequency of their pleasant interactions.