Chapter 6 From Preparation to Action: Getting Started
 
Strong commitment alone does not guarantee change. Unfortunately, enthusiasm does not make up for ineptness... Commitment without appropriate coping skills and activities can create a tenuous action plan... Anticipation of problems and pitfalls appears to be a solid problem-solving skill. DiClemente, 1991

At the end of the preparation stage, clients make a plan for change to guide them into the action stage. This chapter focuses on negotiating this specific change plan with clients. Changing any long-standing, habitual behavior requires preparation and planning. As your clients move from contemplating to actually implementing change in their lives, they are in an intermediate stage in which they increase their commitment to change by exploring, clarifying, and resolving their ambivalence and making a decision to act.

In the transtheoretical model, this stage is known as preparation. Clients must see change as in their best interest before they can move into action. The negative consequences of ignoring the preparation stage can be a brief course of action followed by rapid return to substance use.

During the preparation stage, your tasks broaden. Where before you were using motivational strategies to increase readiness--the goals of the precontemplation and contemplation stages--now you will use these strategies to strengthen your client's commitment and help this person make a firm decision to change. Clients who are committed to change and who believe change is possible are prepared for action.

Clients and clinicians in the preparation stage are equipped with important knowledge from the personalized feedback of assessment information described in Chapter 4. The activities and strategies described in Chapter 5 were intended to solidify your client's commitment to change and set the stage for developing a plan for moving into action. Clients should now have a clearer picture of how their substance use affects many aspects of their lives, and they should have begun to recognize some of the consequences of continued use.

In addition, many clients sense the hopeful possibilities inherent in the growing therapeutic alliance. If you have exercised the principles of motivational interviewing, your clients should recognize that they are in a safe environment for exploring their feelings and thoughts about change and that they are in control of the change process.

This chapter explains how and when to negotiate a change plan with the client and suggests ways to ensure a sound plan--by offering the client a menu of options, contracting for change, identifying and lowering barriers to action, enlisting social support, and helping the client anticipate what it will be like to participate in treatment.

Recognizing Readiness To Move Into Action

As clients proceed through the preparation stage, be alert for signs of their readiness to take action. Clients' recognition of important discrepancies in their lives is an uncomfortable state in which to remain for long; thus change should be initiated to decrease discomfort, or clients may retreat to using defenses such as minimizing or denying.

Mere vocal fervor about change, however, is not necessarily a sign of determination to change. Clients who are vehement in declaring their readiness may be desperately trying to convince themselves, as well as you, of their commitment (DiClemente, 1991).

The following are several confirming signs of readiness to act:

Decreased resistance. The client stops arguing, interrupting, denying, or objecting.

Fewer questions about the problem. The client seems to have enough information about his problem and stops asking questions.

Resolve. The client appears to have reached a resolution and may be more peaceful, calm, relaxed, unburdened, or settled. Sometimes this happens after the client has passed through a period of anguish or tearfulness.

Self-motivational statements. The client makes direct self-motivational statements reflecting openness to change ("I have to do something") and optimism ("I'm going to beat this").

More questions about change. The client asks what she could do about the problem, how people change once they decide to, and so forth.

Envisioning. The client begins to talk about how life might be after a change, to anticipate difficulties if a change were made, or to discuss the advantages of change.

Experimenting. If the client has had time between sessions, he may have begun experimenting with possible change approaches (e.g., going to an Alcoholics Anonymous [AA] meeting, reading a self-help book, stopping substance use for a few days) (Miller and Rollnick, 1991).

When you conclude that a client is becoming committed to change, determine what is needed next by asking a key question (see Chapter 5). You might say, "I can see you are ready for a change. How would you like to proceed?" If the client indicates that she wishes to pursue treatment with your help, you can begin negotiating a plan for change.

Negotiating a Plan for Change

Creating a plan for change is a final step in readying your client to act. A solid plan for change enhances your client's self-efficacy and provides an opportunity to consider potential obstacles and the likely outcomes of each change strategy before embarking. Furthermore, nothing is more motivating than being well prepared--no matter what the situation, a well-prepared person is usually eager to get started. A sound change plan can be negotiated with your client by the following means:

Offering a menu of change options
Developing a behavior contract
Lowering barriers to action
Enlisting social support
Educating your client about treatment

Chapter 5 describes the process of exploring clients' goals as a way of enhancing commitment and envisioning change. The change plan can be thought of as a roadmap to realizing those goals. Some clients begin spontaneously suggesting or asking about specific things they can do to change. You can prompt others to make suggestions by asking key questions such as, "What do you think you will do about your drinking/drug use?" or "Now that you've come this far, I wonder what you plan to do?" (see Chapter 5 for a list of key questions).

Clients will create plans that reflect their individual concerns and goals. Most plans are not limited to stopping or moderating substance use, and ensuring success is the central focus of the plan. The plan can be very general or very specific, and short term or long term. Indeed, some clients may be able to commit only to a very limited plan, such as going home, thinking about change, and returning on a specific date to talk further. Even such a restricted and short-term plan can include specific steps for helping the client avoid high-risk situations as well as specific coping strategies for the interim.

Some clients' plans are very simple, such as stating only that they will enter outpatient treatment and attend an AA meeting every day. Other plans include details such as handling transportation to the treatment facility or arranging alternative ways to spend Friday nights. As discussed below, specific steps to overcome anticipated barriers to success are important components of many change plans. Some plans lay out a sequence of steps. For example, working mothers with children who must enter inpatient treatment may develop a sequenced plan for arranging for child care and training temporary replacements for their jobs before entering treatment.

Although the change plan is the client's, creating it is an interactive process between you and the client. One of your most important tasks is to ensure that the plan is feasible. When the client proposes a plan that seems unrealistic, too ambitious, or not ambitious enough, a process of negotiation should follow.

The following areas are ordinarily part of interactive discussions and negotiations:

Intensity and amount of help needed--for example, the use of only self-help groups, enrolling in intensive outpatient treatment, or entering a 2-year therapeutic community

Timeframe--a short- rather than a long-term plan and a start date for the plan

Available social support--including who will be involved in treatment (e.g., family, Women for Sobriety, community group), where it will take place (at home, in the community), and when it will occur (after work, weekends, two evenings a week)

Sequence of subgoals and strategies or steps in the plan--for example, first to stop dealing marijuana, then stop smoking it; to call friends or family to tell them about the plan, then visit them; to learn relaxation techniques, then to use them when feeling stressed at work

How to address multiple problems--for example, how to deal with legal, financial, and health problems

Clients may ask you for information and advice about specific steps to incorporate in the plan. Provide accurate and specific facts, and always ask whether they understand them. Eliciting responses to such information by asking, "Does that surprise you?" or, "What do you think about it?" can also be helpful in the negotiation process.

How prescriptive should you be when clients ask what you think they should do? Providing your best advice is an important part of your role. It is also appropriate to provide your own views and opinions, although it is helpful to insert qualifiers and give clients permission to disagree.

Other techniques of motivational interviewing, such as developing discrepancy, empathizing, and avoiding argument, remain as useful during these negotiations as they are at all other stages of the change process. Guard against becoming overly focused on the negotiations and on the plan such that you forget to use these strategies. Acknowledge and affirm the client's effort in making the plan.

Some clients have found the Change Plan Worksheet (see Figure 6-1) a useful tool in focusing their attention on the details of the plan.

The following is a list of considerations for completing the worksheet (Miller et al., 1995c):

The changes I want to make are... Be specific. Include goals that are positive (wanting to increase, improve, do more of something), and not just negative goals (stop, avoid, or decrease a behavior).

My main goals for myself in making these changes are... What are the likely consequences of action or inaction? Which motivations for change are most compelling?

The first steps I plan to take in changing are... How can the desired change be accomplished? What are some specific, concrete first steps? When, where, and how will the steps be taken?

Some things that could interfere with my plan are... What specific events or problems could undermine the plan? What could go wrong? How will the client stick with the plan despite these particular problems or setbacks?

Other people could help me in changing in these ways... What specific things can another person do to help the client take the steps to change? How will the client arrange for such support?

I will know that my plan is working if... What will happen as a result of taking the different steps in the plan? What benefits can be expected?

It can be helpful to estimate your client's readiness and self-efficacy for the changes that your client lists in the plan. For example, on a scale from 1 to 10 (1 = no confidence, 10 = most confidence), the client may rate himself as a "9" in regard to readiness for a making a particular change in behavior, but only as a "4" on self-efficacy. This could help you guide your client about where to start on the change plan.

Offering a Menu of Change Options

Researchers and clinicians working in the motivational framework find that one way to enhance motivation is to offer clients a choice from a variety of treatment alternatives. For example, a client who will not go to AA may go to a meeting of Rational Recovery or Women for Sobriety, if such groups are available.

A client who will not consider abstinence may be more amenable to a "warm turkey" approach (Miller and Page, 1991), as described in Chapter 5. Encouraging clients to learn about treatment alternatives and to make informed choices enhances commitment to the change plan. Choices can be about treatment options or about other types of services.

No single approach to treating substance abuse works equally well for all clients. Determining what works best for whom and under what conditions can be a difficult undertaking. Evidence of treatment effectiveness is becoming increasingly specialized and, to some extent, more confusing, as more elements are added to evaluation formulas, including client characteristics, outcome measures, therapist qualities, treatment components, and quality of implementation.

Familiarity with the available treatment facilities in your community and with the relevant research literature pertaining to optimal choices for the types of clients you see is enormously helpful in providing your clients with appropriate options. It is also useful to know about the range of community resources in other service areas, such as food banks, job training programs, special programs for patients with coexisting disorders, and safe shelters for women in abusive relationships.

A clinician who knows not only program names but also contact persons, program graduates, typical space availability, funding issues, eligibility criteria, and program rules and idiosyncrasies is an invaluable resource for clients. Additionally, knowledge about clients' resources, insurance coverage (or participation in some form of managed care), employment situation, parenting responsibilities, and other relevant factors is obviously crucial in considering alternatives. Information from an initial assessment is helpful, too, in establishing a list of possible treatment options and setting priorities.

Although you may have a wealth of knowledge about local resources, your program's administration has the final responsibility for developing liaisons with other agencies to ensure appropriate referrals for services and for keeping clinicians informed. In many places, a central agency compiles and regularly updates a comprehensive directory of community resources that contains information about services, costs, location, hours of operation, and eligibility criteria.

Every program should have a manual of appropriate referral resources, with cross-references by program type, or should obtain current listings from local, State, or national sources (see Chapter 5 of TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians[CSAT, 1997]). The Internet offers new possibilities for accessing information about community resources and for linking clients with programs and services.

For example, in Washington, DC, a computer system linking criminal justice agencies with substance abuse treatment programs gives up-to-the-minute information about space availability and program changes. Workers in the justice system can set up intake appointments for clients online. Those in rural areas where resources are scarce may find the Internet especially valuable.

As you discuss treatment choices with clients, you can acquaint them with the concepts of levels of care, intensities of care, and appropriate fit. Do not, however, overwhelm them with a complicated description of all possibilities.

Avoid professional jargon and technical terms for treatment types or philosophies. Limit options to several that are appropriate, and describe these, one at a time, in language that is understandable and relevant to individual concerns of clients. Explain what a particular treatment is intended to do, how it works, what is involved, and what clients can expect. Ask clients to postpone a decision about treatment until they understand all the options.

As each option is discussed, ask clients if they have questions and ask for their opinions about how they would handle each alternative. Although the goal is to choose the right approach initially, some clients may choose an option that you believe is inappropriate. Offer advice based on your clinical experience and knowledge of the research. You are searching for change strategies with which to begin, and, ideally, the client will view some appropriate options positively.