Phase 2: Strengthening Commitment to Change

Recognizing Change Readiness

The strategies outlined above are designed to build motivation, and to help tip the client's decisional balance in favor of change.  A second major process in MET is to consolidate the client's commitment to change, once sufficient motivation is present (Miller & Rollnick, 1991).

Timing is a key issue - knowing when to begin moving toward a commitment to action.  There is a useful analogy to sales here - knowing when the customer has been convinced and one should move toward  "closing the  deal."  Within the Prochaska/DiClemente model, this is the stage of determination, when the balance of contemplation has tipped in favor of change, and the client is ready  for  action  (but  not  necessarily for  maintenance). 

Such a shift is not irreversible.  If the transition to action is delayed too long, determination can be lost.  Once the balance has tipped, then, it is time to begin consolidating the client's decision.

There are no universal signs of crossing over into the determination stage.  These are some changes you might observe (Miller & Rollnick, 1991):

The client stops resisting and raising objections
The client asks fewer questions
The client appears more settled, resolved, unburdened, or  peaceful
The client makes self-motivational statements indicating a decision (or openness) to change
["I guess I need to do something about my drug use."  "If I wanted to kick this, what could I do?"]
The client begins imagining how life might be after a change

Here is a checklist of issues to assist you in determining a client's readiness to accept, continue in, and comply with a change program.  These questions may also be useful in recognizing individuals at risk for prematurely withdrawing from treatment (Zweben et al., 1988):
 
1.  Has  the  client  missed  previous  appointments  or  canceled  prior  sessions  without rescheduling?

2. If the client was coerced into treatment (e.g., for a drunk driving offense), has the client discussed with you his or her reactions to this involuntariness - anger, relief, confusion, acceptance, etc.?

3. Does the client show a certain amount of indecisiveness or hesitancy about scheduling future sessions?

4. Is the treatment being offered quite different from what the client has experienced or expected  in  the  past;  and  if  so,  have  these  differences  and  the client's reactions been discussed?

5. Does the client seem to be very guarded during sessions, or otherwise seem to be hesitant or resistant when a suggestion is offered?

6. Does the client perceive involvement in treatment to be a degrading experience rather than a "new lease on life"?

If the answers to these questions suggest a lack of readiness for change, it might be valuable to explore further the client's uncertainties and ambivalence about drug use and change.  It is also wise to delay any decision-making or attempts to obtain firm commitment to a plan of action.

For many clients, there may not be a clear point of decision or determination.  Often people begin considering and trying change strategies while they are in the later part of the contemplation stage. 

For some, their willingness to decide to change depends in part upon trying out various strategies until they find something that is satisfactory and effective.  Then they commit to change. Thus the shift from contemplation to  action may be a gradual, tentative transition rather than a discrete decision.

It is also important to remember that even when a client appears to have made a decision and is taking steps to change, ambivalence is still likely to be present.  Avoid assuming that once the client has decided to change, there is no longer any need for Phase I strategies. 

Likewise you should proceed carefully with clients who make a commitment to change too quickly or too emphatically. Even when a person seems to enter treatment already committed to change, it is useful to pursue some of the above motivation-building and feedback strategies before moving into commitment consolidation.

In any event, a point comes when you should move toward strategies designed to consolidate commitment.  The following strategies are useful once the initial phase has been passed, and the client is moving toward change.

Asking Key Questions

One useful strategy in making the transition from Phase 1 to Phase 2 is to provide the kind of summary statement described earlier, summing up all of the reasons for change that the person has given, while also acknowledging remaining points of ambivalence.  At the end of this summary, ask a key question such as:

What do you make of all this?
Where does this leave you in terms of your drug use? What's your plan?  What are you thinking you will do?
I wonder what you're thinking about your drug use at this point.
Now that you're this far, I wonder what you might do about these concerns.

Discussing a Plan

The critical shift for the therapist is from focusing on reasons for change (Phase 1; building motivation) to strengthening commitment and negotiating a plan for change (Phase 2).  The client may initiate this transition by stating a need or desire to change, or by asking what he or she could do.  Alternatively, you may trigger this transition with a key question.

Your goal during Phase 2 is to elicit from the client (and SO) some ideas and ultimately a plan for what to do about the client's drug use.  It is not your task at this point to prescribe a plan for how the client should change, or to teach specific skills for doing so. 

The overall message is: "Only you can change your drug use, and it's up to you."  Further questions may help: "How do you think you might do that?  What do you think might help?" and to the SO, "How do you think you might help him/her?"  Reflecting and summarizing continue to be good therapeutic responses as more self- motivational statements and ideas are generated.

Communicating Free Choice

An important and consistent message throughout MET is the client's responsibility and freedom of choice.  Reminders of this theme should be included during the commitment-strengthening process:

It's up to you what you do about this. No one can decide this for you.
No one can change your drug use for you.  Only you can do it.
You can decide to go on using just as you have been, or to make a change.

Consequences of Action and Inaction

A useful strategy is to ask the client (and SO) to anticipate what the result would be if the client continued using as before.  What would be the likely consequences?  It may be useful to make a  written list of the possible negative consequences of not changing.  Similarly, the anticipated benefits of change can be generated by the client (and SO).

For a more complete picture, you could also discuss what the client fears about changing. What might be the negative consequences of giving up drugs, for example?  What are the advantages of continuing to use as before?  Reflection, summarizing, and reframing are appropriate therapist responses.

One possibility here is to construct a formal "decisional balance" sheet, by having the client generate (and writing down) the pros and cons of change options.  What are the positive and negative aspects of continuing to use drugs as before?  What are the possible benefits and costs of making a change?

Information and Advice

Often clients (and SOs) will ask for key information, as important input for their decisional process.  Such questions might include:

What is likely to happen to me if I quit cold turkey? Do drug problems run in families?
How addicted am I?
Does marijuana damage the brain? What's a safe level of use?
If I quit using, will these problems improve? Could my sleep problems be due to my drug use?

The number of possible questions is too large to plan specific answers here.  In general, however, you should feel free to provide accurate, specific information that is requested by clients and SOs.  It is often helpful to ask for the client's response to any information that you provide:  Does it make sense to you?  Does that surprise you?  What do you think about it?

Clients and SOs may also ask you for advice.  "What do you think I should do?"  It is quite appropriate to provide your own views in this circumstance, with a few caveats.  It is often helpful to provide qualifiers and permission to disagree.  For example:

If you want my opinion, I can certainly give it to you, but you're the one who has to make up your mind in the end.

I can tell you what I think I would want to do in your situation, and I'll be glad to do that, but remember that it's your choice.  Do you want my opinion?

Being just a little resistive or "hard to get" in this situation can also be useful:

I'm not sure I should tell you.  Certainly I have an opinion, but you have to decide for yourself how you want to handle your life.  I guess I'm concerned that if I give you my advice, then it looks like I'm the one deciding instead of you.  Are you sure you want to   know?

Within this general set, feel free to give the client your best advice as to what change should be made, specifically with regard to:

What change should be made in the client's drug use
The need for the client and SO to work together
General kinds of changes that the client might need to make in order to support changes in drug use (e.g., find new ways to spend time that don't involve drugs)

When it comes to "how to's," it is often best not to prescribe specific strategies or attempt to train specific skills at the outset.  Instead try turning the challenge back to the client (and SO):

How do you think you might be able to do that? What might stand in your way?
You'd have to be pretty creative [strong, clever, resourceful] to find a way  around that.  I
wonder how  you could do it.

Again, you may be asked for specific information as part of this process (e.g., "I've heard about a drug that you can take once a day and it keeps you from using.  How does it work?"). Accurate and specific information can be provided in such cases.

A client may well ask for information that you do not have.  Do not feel obliged to know all the answers.  It is fine to say that you do now know, but will find out.  You can offer to research a question and get back to the client at the next session, or by telephone.

Abstinence and Harm Reduction

Not all clients choose, as their goal, to abstain totally from all psychotropic drugs.  The goal of change is, in fact, a choice that each client must and does make.  Within an MET style, it is not up to you to "permit" or "let" or "allow" clients to make choices.  The choice is theirs to make, and you cannot make it for them.

There are, of course, some persuasive reasons to consider drug abstention:

1. Successful abstinence is a safe choice.  If you don't use drugs, you can be sure that you won't have problems (e.g., legal violations, AIDS risk, health damage) because of your drug use.

2. There are good reasons to at least try a period of abstinence (e.g., to find out what it's like to live without drugs, and how you feel; to learn the ways you have become dependent on drugs; to break your old habits; to experience a change and build some confidence; to please your spouse, etc.)

3. No one can guarantee a "safe" level of drug use (including alcohol use) that will cause you no harm.

At  the  same  time  many  clients,  at  least  initially,  find  a  goal  of  complete  abstention unacceptable,  or  view  it  as  unattainable.  Therapist insistence in such cases may only increase resistance and risk of drop-out. 

It is helpful here to keep in mind the emerging "harm reduction" perspective in drug abuse treatment: basically, that any step in the right direction is a step in the right direction. 

A change from needle sharing to using clean needles is an important risk reduction.  A change from intravenous use to oral or nasal administration further reduces risk.  A shift from more dangerous to less dangerous drugs is an improvement.  A reduction in frequency and quantity of use represents progress.

What goals, then, can be considered as harm reduction, short of immediate, permanent cold turkey cessation of all drug use?  The more specific question here is: What kind of change(s) is the client willing to pursue with which drugs? 

Some "warm turkey" options include: (1) a trial period of abstention, (2) a gradual tapering of use toward abstention, and (3) a trial period of reduced use
(Miller & Page, 1991).  Shifting from more to less hazardous drugs or use patterns is also a feasible goal.

It  is  important  to  be  clear,  here,  that  you  are not  advocating  continued  use  of  illicit substances.  Your overall goal in counseling is to help the user move away from harmful drug use, including illegal drug use.

In certain cases, you may feel particular responsibility to encourage abstinence, if the client appears to be leaning in a different direction.  Again, this must be done in a persuasive but not coercive manner, consistent with the overall tone of MET.  ("It is your choice, of course. 

I want to tell you, however, that I'm worried about the choice you're considering, and if you're willing to listen, I'd like to tell you why I'm concerned. . .").  Among the reasons for advising against a non-abstinence goal are:

* legal risks involved in the use of illicit substances
* medical conditions that contraindicate any use
* psychological problems likely to be exacerbated by use
* strong external demands on the client to abstain
* pregnancy
* use/abuse of medications that are hazardous in combination
* a history of severe problems and dependence

Clients who are unwilling to discuss immediate and long-term abstinence as a goal might be more responsive to intermediate options, such as a short-term (e.g., 3-month) trial abstinence period.

Handling Resistance

The same principles used for defusing resistance in the first phase of MET also apply here. Reluctance and ambivalence are not challenged directly, but rather can be met with reflection or reframing.  Gently paradoxical statements may also be useful during the commitment phase of MET. One form of such statements is permission to continue unchanged:

Maybe you'll decide that it's worth it to you to keep on using the way you have been, even though it's costing  you.

Another form is designed to pose a kind of crisis for the person by juxtaposing two important and inconsistent values:

I wonder if it's really possible for you to keep using and still have your marriage, too.

The Change Plan Worksheet

The Change Plan Worksheet (CPW) is to be used during Phase 2, to help in specifying the client's action plan.  You can use it as a format for taking notes as the client's plan emerges.  Do not start Phase 2 by filling out the CPW. 

Rather the information needed for the CPW should emerge through the motivational dialogue described above.  This information can then be used as a basis for your recapitulation (see below).  Use the CPW as a guide, to ensure that you have covered these aspects of the client's plan:

The changes I want to make are...  In what ways or areas does the client want to make a change?  Be specific.  It is also wise to include goals that are positive (wanting to begin, increase, improve, do more of something), and not only goals that could be accomplished through general anesthesia (to stop, avoid, or decrease behaviors).

The most important reasons why I want to make these changes are...  What are the likely consequences of action and inaction?  Which motivations for change seem most impelling to the client?

The steps I plan to take in changing are...  How does the client plan to achieve his/her goals?  How could the desired change be accomplished?  Within the general plan and strategies described, what are some specific, concrete first steps that the client can take?  When, where, and how will these steps be taken?

The ways other people can help me are...  In what ways could other people (including the significant other, if present) help the client in taking these steps toward change?  How will the client arrange for such support?

I will know that my plan is working if...  What does the client hope will happen as a result of this change plan?  What benefits could be expected from this change?

Some things that could interfere with my plan are...  Help the client to anticipate situations or changes that could undermine the plan.  What could go wrong?  How could the client stick with the plan despite these problems or setbacks?

Preprinted Change Plan Worksheet forms are available for use by MET therapists.  These are carbonless copy forms, so that you can write or print on the original and automatically have a copy to keep in the client's file.  Give the original to the client, and retain the copy for the file.
 
CHANGE PLAN WORKSHEET

The changes I want to make are:

The most important reasons why I want to make these changes are:

The steps I plan to take in changing are:

The ways other people can help me are: Person Possible ways to help

I will know that my plan is working if:

Some things that could interfere with my plan are:
 
Recapitulating

Toward the end of the commitment process, as you sense that the client is moving toward a firm decision for change, it is useful to offer a broad summary of what has transpired (Miller & Rollnick, 1991).  This may include a repetition of the reasons for concern uncovered in the Phase 1 (see "Summarizing"), as well as new information developed during Phase 2. 

Emphasis should be given to the client's self-motivational statements, the SO's role, the client's plans for change, and the perceived  consequences  of changing and not changing.  Use your notes on the Change Plan Worksheet as a guide.  Here is an example of how a recapitulation might be worded:

Let me see if I understand where you are, then.  Last time we reviewed the reasons why you and your husband have been concerned about your cocaine use.  There were a number of these. 

You were both concerned that your drug use has contributed to problems in the family, both between you and with the children.  You were worried, too, about the amount of money you have been spending, and the fact that your use seems to be getting out of control. 

The accident that you had helped you to realize that it was time to do something about your drug use, but I think you were still surprised when I gave you your feedback, just how much in danger you were.
We've talked about what you might do about this, and you and your husband had different ideas at first. 

He thought you should go to C.A., and you thought you'd just cut down on your use on your own.  We talked about what the results might be if you tried different approaches. 

Your husband was concerned that if you didn't make a sharp break with this drug habit, you'd probably slip right back into regular use, and forget what we've discussed here.  You agreed that that would be a risk, and could imagine just blowing it all away to feel high. 

You didn't like the idea of C.A. because you were concerned that people would see you there, even though, as we discussed, there is a strong principle of anonymity.  Where you seem to be headed now is toward trying out a period of not using at all, for three months at least, to see how it goes and how you feel.  If that seems too rough at first, you might want some medication to help you get through the early weeks.

Your husband likes this idea, too, and has agreed to spend more time with you, so you can go and do things together in the evening or on weekends.  You also thought you would get involved again in some of the community activities you used to enjoy during the day, or maybe look for a job to keep you busy.  Do I have it right?  What have I missed?

If the client offers additions or changes, reflect these and integrate them into your recapitulation. Also note them on the Change Plan Worksheet.

Asking for Commitment

After you have recapitulated the client's situation, as above, and responded to additional points and concerns raised by the client (and SO), move toward getting a formal commitment to change.  In essence, the client is to commit verbally to take concrete, planned steps to bring about the needed change.  The closing question (not necessarily in these words) is:

Are you ready, then, to commit yourself to do this?

As you discuss this commitment, also cover the following points:

1. Clarify what, exactly, the client plans to do.  Give the client the completed Change Plan
Worksheet, and discuss it.

2. Reinforce what the client (and SO) perceive to be likely benefits of making a change, as well as the consequences of inaction.

3. Ask what concerns, fears, or doubts the client (and SO) may have, which might interfere with carrying out the plan.

4. Ask what other obstacles might be encountered, which could divert the client from the plan.  Ask the client (and SO) to suggest how they could deal with these.

5. Clarify the SO's role in helping the client to make the desired change.

6. Determine what additional help the client would like to have from you or from other treatment agencies.  If you are terminating your treatment, remind the client (and SO) that there will be a follow-up interview to see how they are doing.

If the client is willing to make a commitment, ask him/her to sign the Change Plan Worksheet and give the client the signed original, retaining a copy for your file.

Some clients are unwilling to commit themselves to a change goal or program.  In cases where a person remains ambivalent or hesitant about making a written or verbal commitment to deal with the drug problem, you may ask the person to defer the decision until a later time. 

A specific time should be agreed upon to reevaluate and resolve the decision.  The hope in allowing clients the opportunity  to  postpone  such decision-making,  is that  the  motivational  processes  will act  more favorably on them over time (Goldstein et al., 1966).  Such flexibility provides clients with the opportunity to explore more fully the potential consequences of change, and prepare themselves to deal with the consequences. 

Otherwise, the client may feel coerced into making a commitment before she or he is ready to take action.  In this case, a client may withdraw prematurely from treatment, rather than losing face over the failure to follow through on a commitment.  It can be better, then, to say something like this:

It sounds like you're really not quite ready to make this decision yet.  That's perfectly understandable.  This is a tough choice for you.  It might be better not to rush things here, not to try to make a decision right now. 

Why don't you think about it between now and our next visit, consider the benefits of making a change and of staying the same.  We can explore this further next time, and sooner or later I'm sure it will become clear to you what you want to do.  OK?

It  can  be  helpful  in  this  way  to  express  explicit  understanding  and  acceptance  of  the  client's ambivalence, as well as confidence in his or her ability to resolve the dilemma.