Chapter 5 From Contemplation to Preparation: Increasing Commitment

Contemplation is often a very paradoxical stage of change...[and] ambivalence can make contemplation a chronic [and extremely frustrating] condition... Clearly, interest [in change] is not commitment... Ambivalence is the archenemy of commitment and a prime reason for chronic contemplation.

Helping the client to work through the ambivalence, to anticipate the barriers, to decrease the desirability of the problem behavior, and to gain some increased sense of self-efficacy to cope with this specific problem are all stage-appropriate strategies. DiClemente, 1991

This chapter describes strategies to increase clients' commitment to change by enhancing their decisionmaking capabilities. Central to most of the strategies is the process of eliciting and exploring through open-ended questioning and reflective listening skills, as described in earlier chapters. The chapter begins with a discussion of extrinsic (external) and intrinsic (internal) motivation, describing ways to help clients connect with internal motivators to enhance decisionmaking and thereby commitment.

The second section focuses on decisional balancing strategies--effective ways to explore the benefits and costs of change and clients' values about changes they might make. The third section highlights the importance of personal choice and responsibility as clients get closer to making a decision to change.

Exploring and setting goals can also be effective in strengthening commitment, primarily because the process of envisioning what one's life would be like after change has been accomplished may strongly tip the decisional balance toward positive change. Finally, the important role of self-efficacy in client goal-setting is reemphasized.

Although these strategies are introduced here in linear fashion, with each process of exploration unfolding from the last, in discussions with clients these processes can occur simultaneously or in a different order from that used here. For example, clients may begin to set goals or formulate a specific change plan (see Chapter 6) while continuing to explore their ambivalence (see Figure 5-1).

Changing Extrinsic to Intrinsic Motivation

To help your clients prepare for change, seek to understand the range of both extrinsic and intrinsic motivators that have brought them to this point. Many clients move through the contemplation stage acknowledging only the extrinsic motivators that push them to change--and that brought them to treatment. As discussed in Chapter 4, many different external motivators may cajole or coerce clients into treatment, including a spouse, an employer, a physician, or family and criminal courts.

Although extrinsic motivators can be useful in bringing a client into treatment and increasing retention, self- or intrinsic motivation is important for substantive and abiding change.

Intrinsic motivation often begins at the point when clients recognize the discrepancies between "where they are" and "where they want to be." An intensive exploration of life goals and deep-seated values can be a way to strengthen internal motivation. Some clients, as they mature, cast off the rebelliousness or apparent nonchalance of adolescence to explore more existential concerns such as, Where am I going? and Who am I?

In searching for answers, clients often reevaluate past mistakes and activities that were self-destructive or harmful to others. You can encourage this soul-searching through reflective listening. Then, through motivational strategies, you can promote the client's recognition of discrepancies between the current situation and hopes for the future. As described in earlier chapters, this awareness of disparities often creates a strong desire to improve. This is an essential source of self-motivation for positive change.

Sometimes intrinsic motivation emerges from role conflicts and family or community expectations. For example, a mother who has lost custody of children because of substance use may have a strong motivation to fulfill her role as a good mother. Other clients' chronic substance use severs cultural or community ties; they stop going to church or neglect culturally affirmed roles such as helping others or serving as role models for young people.

A yearning to reconnect with cultural traditions as a source of identity and strength can be a powerful motivator for some clients, as can the desire to regain others' respect. Positive change also leads to improved self-image and self-esteem.

Helping clients change extrinsic to intrinsic motivation is an important part of helping them move from contemplating change to deciding to act. Start with the client's current situation and find a natural link between existing external motivators and intrinsic ones the client may not be aware of or find easy to articulate. Through sensitive and respectful exploration, untapped intrinsic motivation may be discovered even in clients who seem unlikely to become self-motivating.

In addition to standard practices for motivational interviewing, several other strategies are useful for identifying and strengthening intrinsic motivation. First, show curiosity about your clients. Show interest and maintain this attention over time. Because clients' desire to change is rarely limited to substance use, they may find it easier to talk about changing other behaviors. Most clients have concerns about several functional areas of their lives and wish they could reconnect with the community, improve their finances, find work, or fall in love.

Many are highly functional and productive in some aspects of their lives and take great pride in special skills, knowledge, or other competencies they do not want to jeopardize. Do not wait for clients to talk spontaneously about their troubles or capabilities. Show interest and ask about how their substance use affects these aspects of their lives. Even with clients who do not acknowledge any problems, question them about their lives to show concern and thus strengthen the therapeutic alliance.

Another useful strategy is to reframe clients' negative statements about perceived coercion by re-expressing their resentment with a positive connotation. A classic example is to reinterpret a client's hostility toward a threatening wife as a manifestation of his continued caring and investment in the marriage, which is pushing him to resolve and change the problem behavior and save the relationship.

Clients who were openly coerced into entering treatment pose a special challenge. With these clients, identify and strengthen intrinsic motivation so that change can come from within, rather than from external threats. Not only can external threats provoke resistance, but any achieved change may collapse if the threatened contingencies do not happen--if, for example, the threat of divorce or separation is not carried out by the wife when her husband's drinking resumes, or a parole officer does not revoke a client's freedom when the released offender fails to continue treatment.

These clients must choose positive change of their own free will because change makes good sense and is desired, not because a punishment might be exacted if a violation is detected.

Linking Family, Community, and Cultural Values to a Desire for Change

Working with a group of Hispanic men in the Southwest who were mandated into treatment as a condition of parole and had spent most of their lives in prisons, we found that as these men aged, they seemed to tire of criminal life. In counseling, some expressed concerns about losing touch with their families and culture, and many articulated a desire to serve as male role models for their sons and nephews. They all wanted to restore their own sense of pride and self-worth in the small community where many of their families had lived for generations.

Newly trained in motivational interviewing, we recognized a large, untapped reservoir of self-motivation in a population that we had long before concluded did not want help. We had to change our previous conceptions of this population as not wanting treatment to seeing these men as requesting help and support to maintain themselves outside of the prison system and in the community.

Tipping the Decisional Balance

In moving toward any decision, most people weigh the costs and benefits of the action being contemplated. In behavioral change, these considerations are known as decisional balancing, a process of cognitively appraising or evaluating the "good" aspects of substance use--the reasons not to change, and the less good aspects--the reasons to change. Research on self-change has shown that many people who have successfully modified addictive behaviors view this appraisal process as important to the resolution of their substance use problems (Sobell et al., 1996b).

At some point in the decisionmaking process, the decisional balance is redistributed, and a decision is made. The objective in moving a client toward positive change, of course, is to help that person recognize and weigh negative aspects of substance use so that the scale tips toward beneficial behavior. In examining ways in which people make major life changes, Baumeister described the inner process that seems to occur when the decisional balance is weighted toward change as a "crystallization of discontent" (Baumeister, 1994).

He notes that it involves a conscious linking, perhaps for the first time, of perceptions regarding costs, problems, and other undesirable features of a situation. This conscious linking of negative aspects changes the person's perception of a situation "so that a broad pattern of dissatisfaction and shortcoming is discerned." See Chapter 8 for tools to use in decisional balancing exercises.

How do you shift the balance to the side of positive change and away from the status quo or negative change? Sobell and colleagues identified four overall objectives in using exercises to shift decisional balance with clients (Sobell et al., 1996b). The intent of such exercises, which weigh substance use and change separately, is to

Accentuate or in a subtle manner make salient from the client's perspective the costs of the client's substance use.

Lessen, when possible, the perceived rewards of substance use.

Make the benefits of change apparent.

Identify and attenuate, if possible, potential obstacles to change.

Summarize Concerns

If you have successfully elicited a client's concerns while providing personalized feedback after an assessment (see Chapter 4) or while exploring intrinsic and extrinsic motivations, you have gathered important information for influencing your client's decisional balance. You have a working knowledge, and perhaps even a written list, of issues and areas about which the client has negative feelings and which are important intrinsic motivators.

A first step in helping the client to weigh the pros and cons is to organize the list of concerns and present them to the client in a careful summary that expresses empathy, develops discrepancy, and weights the balance toward change. Because it is important to reach agreement on these issues, the summary should end by asking whether your client agrees that these are her concerns.

Explore Specific Pros and Cons

Weighing benefits and costs of substance use and of change is at the heart of decisional balance work. Some clinicians find it helpful to ask the client to write out a two-column list. This can be done as homework and discussed during the session, or the list can be generated during a session. Some programs use a worksheet for listing pros and cons preprinted on two-copy carbonless paper so that clients can take one copy home and leave the other with the clinician for later use or revision during future sessions.

A written list helps some clients quantify the factors going into the decision. Seeing a long list of reasons to change and a short list of reasons not to may finally upset the balance. On the other hand, a long list of reasons not to change and a short list of reasons to change can indicate how much work still must be done and can avert premature decisionmaking. Quantity is not the only determinant.

Many clients find that one or two reasons not to change counterbalance the weight of a dozen reasons to change, creating powerful ambivalence. Knowledge about the true strength of each opposing force is important. Remember, too, that the reasons for and against continuing substance use--or the positive and negative aspects of change--are highly individual and emotional rather than rational. Factors that shift the balance toward positive change for one person may scarcely matter to another. Moreover, the value or weight given to a particular item in this inventory of pros and cons is likely to change over time.

Whether or not you use a written worksheet, always listen carefully when clients express ambivalence and highlight their reasons for opposing change or thinking change is impossible. Encouraging clients to openly clarify and state their attraction to substances can be fruitful because they seldom have a chance in treatment programs to examine what they like or enjoy about substance use.

In addition, asking clients to express what they like about substance use (e.g., that it is enjoyable, sociable, exciting) establishes rapport and reassures the client of your nonjudgmental perspective. Starting with positive aspects of substance use also seems to lead clients spontaneously to discussing what is less good about substance use (Saunders et al., 1991).

Information about why substance use is attractive is helpful for judging the client's degree of commitment and sense of self-efficacy. For example, some clients may enjoy little about substance use, and their ambivalence stems from a strong belief that they cannot change. Work with such a client will proceed along different lines than with a client who describes substance use in highly attractive terms and sees little reason to change.

Another reason some clients cling to excessive substance use is pharmacological dependence. Some substances, including high levels of alcohol and barbiturates, have rebound effects of withdrawal that can be not only unpleasant but also dangerous. Tolerance--needing more of the substance to achieve the same effect--also explains why some users of sleeping pills or tranquilizers, for example, increase doses beyond the prescribed level.

Habits developed in relation to drug taking or drinking are another powerful source of attachment to a substance and are difficult to break. The feeling of a glass in the hand when socializing at a party comes to be associated with relaxation and conviviality. Smokers may not know what to do with their hands or want some object in their mouths when they are trying to quit cigarette smoking.

Although your client's initial reasons for wanting to change may be few, each reason is important and should be explored and supported. Because support for change is often linked to a client's intrinsic motivators, reviewing these may elicit more items for the positive side of the balance sheet. As noted earlier, concerns about identity, roles, self-esteem and self-image, and returning to traditional cultural or family values may be linked to specific reasons for change.

Doing a decisional balance exercise with clients has yet another constructive function. Clients are forced to take both sides of the argument about change and articulate the competing sides of their ambivalence. This can be a complex process, however, requiring persistence and reanalysis of each factor several times as clients vacillate between determination and ambivalence.

Normalize Ambivalence

Clients engaged in decisional balance exercises often feel themselves moving closer to a decision--closer to changing long-standing behaviors than they may ever have ventured and, therefore, closer to inner conflict and doubt about whether they can or want to change. An important strategy at this point is to reassure your client that conflicting feelings, uncertainties, and reservations are common.

Essentially, you normalize your client's ambivalence by explaining that many former clients have experienced similar strong ambivalence at this stage, even when they believed they had resolved most of their mixed feelings and were nearing a decision. Clients need your reassurance that many other people who have reached this point and seemed suddenly to lose their nerve have been able to recover their direction by continuing the work of exploration and discussion.

Reintroduce Feedback

As discussed in Chapter 4, personalized feedback following assessment can be very helpful in motivating clients. You can continue to use assessment results to influence clients' decisional considerations. Objective medical, social, and neuropsychological feedback from the assessment prompts many clients to contemplate change.

Reviewing the assessment information can keep clients focused on the need for change. It has been noted that clients may become uneasy when the clinician seems more invested in their changing than they are (DiClemente and Scott, 1997). By reintroducing objective assessment data, you remind clients of their earlier insights about the need for change.

For example, a client may be intrinsically motivated to stop excessive drinking because of health concerns, yet overwhelmed by fear that quitting will prove impossible. Reintroducing feedback from the medical assessment about the risk of serious liver damage or a family history of heart disease could add significant additional weight to the decisional balance.

Examine the Client's Understanding Of Change and Expectations of Treatment

In working toward a decision, it is important to understand what change means to clients and what their expectations of treatment are. Some clients believe that quitting or cutting down means changing their entire life--moving from their neighborhood or severing ties with all their friends, even their family. Some believe they have to change everything overnight--an overwhelming prospect.

Based on friends' experiences with treatment, some may think treatment involves stays of several weeks in an inpatient program or even longer sojourns in a residential treatment facility or that the leader of a therapy group will use confrontational methods in an attempt to "break them down," as in boot camp. Other clients have been in numerous treatment programs and have made many unsuccessful attempts to change. To these clients, the very idea of treatment--of making another attempt to change--connotes failure.

In exploring these meanings and expectations with the client, you will sense what actions might be negotiable and what are not. For example, a client might state that she could never move from her neighborhood, a well-known drug market, because her family is there. Another says he will not consider anything but moderation of his drinking. A third client may just as strongly state that total abstinence and a stay in a therapeutic community are the only options possible because all others have failed.

Exploration of treatment expectations provides an opportunity to introduce information about treatment and to begin a preliminary discussion with clients about available options. When clients' expectations about treatment correspond to what actually happens in treatment, they have better outcomes (Brown and Miller, 1993). Thus, it is never too soon to elicit clients' expectations and begin to educate them about treatment.

Re-explore Values in Relation To Change

Decisional balance exercises offer another opportunity to help clients explore and articulate their values and to make a connection between these values and positive change. Your clients' values will be reflected both in their reasons to change and in the reasons given not to. For example, an adolescent involved in drug dealing with a gang in his neighborhood may let you know that the option of leaving the gang is nonnegotiable because of his loyalty to the other members.

Loyalty and belonging are important values to him, and you can relate them to other groups that can inspire similar allegiance such as a sports team or the military--organizations that create a sense of belonging and reflect his core values. A young woman who comes from a family with a history of hard work and academic achievement may wish to return to those values by finishing high school and becoming financially independent.

Hearing themselves articulate their core values helps your clients increase their commitment to positive change. If they can frame the process of change within the larger context of values shared with their family, community, and culture, they may find it easier to contemplate change.