Table 3 Categories and themes generated from clinical excerpts of clients’ chief concerns, case closing summaries, and progress notes which illustrate their recovery

Uncovering personal identities

Identifying and forming a cohesive personal narrative

Clients shares about their roles in their birth and/or affinal families (e.g son, husband, partner) as well as other identities they choose to describe themselves with (e.g people who use drugs, gay man).

• Juggling “multiple selves”.

• Identified fear of being “soft” and “yielding”, and desire to honour father’s disciplining

• Examining values in coming out to family

• Feels guilt over drug use: “Let my parents and family down” (CC)

Losing motivation and drive

Feeling lonely or isolated

When clients mention that they feel isolated or alone, and want to work through their thoughts and feelings in relation to loneliness. This may also be the case when clients still interact with others within their social circle.

• Acknowledged emotional avoidance, fear of loneliness.

• Unable to talk to friends about his addiction, no one understand his addiction situation (CC)

• Lost, loneliness, low self-esteem, Family recently found out he is seeing a psychiatrist (CC)

• To address fear of being alone, wanting to be around people (CC)

• Feels lonely, need to develop support system (CC)

Feeling hopeless about recovery

When clients express emotions related to a combination of negative life events, and thought patterns, particularly those of self-blame and expressing the idea that circumstances are unchangeable.

• Addressed harsh self-criticism over “bad self”

• Losing motivation to change

• Explored ambivalence about change

• "I want to stop using substance completely but I don't think it is even possible” (CC)

• Feelings of despair…Concerns about therapeutic progress (PN)

• Losing motivation to change (PN)

Lack of belonging with others

When clients express their want to be present with others (example: friends, family, partner) without sacrificing who they are. This also implies that there is a mutual agreement between the social group’s wants to be present with the clients.

• Need to review relapse management and relationship with peer supporter.

• Planned new resources in social support and stabilisation

• Acknowledged value of collaboration

• Want to find a community that he can be himself. (CC)

• Client celebrated his achievements in the last 9 months, and also identified needs for love & belonging currently not satisfied due to him not taking action to rebuild his relationship. (CCS)

• Client mentioned that he felt more fulfilled and at ease with himself, and is in a relationship where he feels love and closeness. (CCS)

Overcoming struggles

Attempting to make peace with their past experiences (either using drugs or traumas)

When clients process through feelings and emotions from past negative experience or traumas. In doing so, these past experiences do not greatly impact current experiences

• Honoured integration of good/bad new/old parts

• Examined childhood trauma, and self-image as “monster” with dark side

• Client was able to identify importance of experiential contact with emotions and was able to engage in healthy confrontation and processing of emotions in response to grief and early traumatic experiences (CCS)

• Client was able to process his childhood trauma and reduce the frequency of negative thoughts associated with guilt and self-blaming. (CCS)

• Reflected on how past traumas and present triggers affect decision and wanted to have longer “clean” time to be credible enough in order to serve the recovery community. (CCS)

Self-development

• Self-security

• Self-awareness

• Self-esteem

• Self-efficacy

When clients share about some things that they hope to work on, in order to better themselves

*Self-security:

When the clients express the want to have an open and non-judgmental acceptance of their own weakness.

*Self-awareness:

When clients express that they want to better identify their state and emotions in the present moment.

*Self-esteem:

When clients assess people and what they have accomplished to their values and goals and express their wants to boost their confidence and self-esteem.

*Self-efficacy:

When clients express their want to be self-sufficient or self-sustaining to reach specific goals.

Lack of self-security

• Psychoeducation on self-acceptance and motivation. Challenging good/bad new/old dichotomy

• Amplified ambivalence over self-acceptance

• Increased self-blame

Improving self-awareness:

• Developing curiosity about behaviours.

• Recognised less avoidance of sorrow and more “slowing down”

Building self-esteem:

• Re-valued humour, honesty, freedom.

• Experiencing joy in values.

Self-efficacy

• Self-compassion practice for self and other

• Balanced self-doubt with self-kindness and humour.

• Honoured integration of good/bad new/old parts

Self-security

• Client’s health and wellbeing have improved over the sessions and is starting to accept herself inside and out for who they are (CCS)

• He became more compassionate to his own needs for safety and connection (CCS)

• Client was better able to work on responding to emotions better, and through honesty client was able to be himself, relieving himself from having the need to be someone he is not through lies. (CCS)

• Client remove the facade of upkeeping image and understood the true meaning behind not good enough. (CCS)

Self-awareness

• Client was also aware of his risk-avoidant behaviour in building romantic relationships. (CCS)

• His self-awareness has increased, particularly how his strong values may impact his relationships with others. (CCS)

• Significant improvement in building awareness and managing emotions, resulting in a greater sense of calm and less rebuttal of ideas

Self-esteem

• His self-esteem and confidence have grown and has a greater awareness of how his thoughts influence his emotions and behaviours. He is receiving recognition for his work which has helped his self-esteem. He shared his aspirations and left the last session full of hope and confidence in his ability to achieve these. (CCS)

• Build a support system with fellows at the greenhouse and worked his way to service in the peer support meetings through building rapport and gaining self-esteem. (CCS)

• The client wishes to focus on providing a service to others and continues to build confidence through co- facilitating, and on occasions leading, group sessions at The Greenhouse. (CCS)

Self-efficacy

• Wanted to ask for help but too ashamed to ask around and do not know where also, worried that he goes to wrong place for help authorities. Wanted to find a place without judgement so he can ask for help. (CC)

Setting healthy boundaries

When clients want to create a space where they can love themselves and others simultaneously. This includes taking another person’s feelings into consideration, setting clear limits and showing mutual respect [18].

• Exploring value in relationship boundaries.

• Clarifying relationship boundaries and needs.

• Examined relationship boundaries and expectations in family

• At the end of the 10 sessions, he was functioning well at work and managing to set healthy boundaries within relationships. (CCS)

• Client has also grown in confidence and is setting healthy boundaries in not getting too involved in supporting others which they used to do at the detriment of their own health and wellbeing. (CCS)

• He clarified some relationship boundaries with his partner, by defining his locus of control and expressing his needs more clearly. (CCS)

Effective communication and understanding

When clients express a desire to improve their communication with another person. Clients would ideally exchange thoughts and opinions to the other person so that the message is conveyed and understood with clarity and purpose.

• Clarified ambivalence over partner’s new independence

• Coming out to children

• His ability to communicate more effectively with parents had also improved. (CCS)

• The client is more reflective and patient with others, in particular with his family. (CCS)

• Client was taught coping strategies to build resilience and reduce stress and anxiety levels which included breathing techniques and psycho education on transactional analysis to help with communication with parents. (CCS)

Feelings of discrimination

When clients feel discriminated for being who they are. These can be in relation to their sexual identity, religious affiliations, being HIV positive or as a known person who uses drugs. As a result, they experience feelings of shame, disgrace or dishonour.

• Acknowledged guilt from “objectively disordered” label

• Pressure from others to be “cured”

• Use drug to escape boredom, shame of being Christian and gay (CC)

• To come to terms with sexual orientation and HIV status (CC)

• Wanted to ask for help but too ashamed to ask around and do not know where also, worried that he go to wrong place for help authorities. (CCS)

• Want to be in a relationship, fearful due to HIV status (CC)

Helpful techniques and exercises

When clinicians note down some techniques or exercises that clients work on during the course of counselling

• Psychoeducation on trauma’s impact and therapy process

• Designed experiment in “showing up” when avoidant

• Role-play on responses to pressures

• Psychoeducation on phases of change and termination

• Better coping mechanisms: Meditation, aexercise, dancing, socializing with friends. Internal locus of validation: Daily gratitude to move away from what client doesn’t have. Cognitive defusion: unhook from negative emotions. (CCS)

• Turned towards more meditation and taking heed of space and pace. (CCS)

Preparing for aftercare

Re-evaluating values and goals

When clients reflect on current or past goals in relation to their counselling aims

• Clarifying value of authenticity to self.

• Re-valued “showing up” as vulnerable self for interviews and recovery meetings.

• Was able to experiment with different strategies to manage thoughts, feelings and behaviours with success. Was able to reconceptualise his understanding of his values.

• He also practised and internalised ACT [acceptance and commitment therapy] skills to promote values-guided behaviour.

Preparing for post-therapy

When clients share about their plans and preparations for post-counselling

• Co-designing termination activity.

• Experiencing fear of termination

• Training to become a peer supporter (CCS)

• Client is committed to his work as a peer supporter, which enables him to contribute meaningfully to others and practise living with triggers in his relapse recovery. To manage challenges in this process, he is willing to seek support from other peer leaders. (CCS)

• Client can access other Greenhouse relevant services if needed (i.e., Smart Recovery; Narcotics Anonymous) (CCS)