FRAMES Approach

Six elements have been identified that were present in brief clinical trials, and the acronym FRAMES was coined to summarize them (Miller and Sanchez, 1994). These elements are defined as the following:

• Feedback regarding personal risk or impairment is given to the client following assessment of substance use patterns and associated problems.
• Responsibility for change is placed squarely and explicitly on the client (and with respect for the client's right to make choices for himself).
• Advice about changing--reducing or stopping--substance use is clearly given to the client by the clinician in a nonjudgmental manner.
• Menus of self-directed change options and treatment alternatives are offered to the client.
• Empathic counseling--showing warmth, respect, and understanding--is emphasized.
• Self-efficacy or optimistic empowerment is engendered in the client to encourage change.

Figure 2-1 lists 32 trials and their FRAME components, as reviewed by Bien and colleagues (Bien et al., 1993b). Since the FRAMES construct was developed, further clinical research and experience have expanded on and refined elements of this motivational model. These components have been combined in different ways and tested in diverse settings and cultural contexts. Consequently, additional building blocks or tools are now available that can be tailored to meet your clients' needs.

Decisional Balance Exercises

The concept of exploring the pros and cons--or benefits and disadvantages--of change is not new and is well documented in the literature (Colten and Janis, 1982; Janis and Mann, 1977). Individuals naturally explore the pros and cons of any major life choices such as changing jobs or getting married. In the context of recovery from substance use, the client weighs the pros and cons of changing versus not changing substance-using behavior. You assist this process by asking your client to articulate the good and less good aspects of using substances and then list them on a sheet of paper. This process is usually called decisional balancing and is further described in Chapters 5 and 8. The purpose of exploring the pros and cons of a substance use problem is to tip the scales toward a decision for positive change.

The actual number of reasons a client lists on each side of a decisional balance sheet is not as important as the weight--or personal value--of each one. For example, a 20-year-old smoker might not put as much weight on getting lung cancer as an older man, but he might be very concerned that his diminished lung capacity interferes with playing tennis or basketball.

Discrepancies Between Goals and Current Behavior

One way to enhance motivation for change is to help clients recognize a discrepancy or gap between their future goals and their current behavior. You might clarify this discrepancy by asking, "How does your drinking fit in with having a happy family and a stable job?" When an individual sees that present actions conflict with important personal goals such as health, success, or family happiness, change is more likely to occur (Miller and Rollnick, 1991). This concept is expanded in Chapters 3 and 5.

Flexible Pacing

Every client moves through the stages of change at her own pace. Some will cycle back and forth numerous times between, for example, contemplating change and making a commitment to do so. Others seem stuck in an ambivalent state for a long time. A few are ready to get started and take action immediately. Therefore, assess your client's readiness for change. By determining where the individual has been and is now within the stages of change, you can better facilitate the change process.

The concept of pacing requires that you meet your clients at their levels and use as much or as little time as is necessary with the essential tasks of each stage of change. For example, with some clients, you may have to schedule frequent sessions at the beginning of treatment and fewer later. In other cases, you might suggest a "therapeutic vacation" for a client who has to take a break before continuing a particularly difficult aspect of recovery. If you push clients at a faster pace than they are ready to take, the therapeutic alliance may break down.

Personal Contact With Clients Not In Treatment

Motivational interventions can include simple activities designed to enhance continuity of contact between you and your client and strengthen your relationship. Such activities can include personal handwritten letters or telephone calls from you to your client. Research has shown that these simple motivation-enhancing interventions are effective for encouraging clients to return for another clinical consultation, to return to treatment following a missed appointment, to stay involved in treatment, and to increase adherence (Intagliata, 1976; Koumans and Muller, 1965; Nirenberg et al., 1980; Panepinto and Higgins, 1969). This concept is discussed in Chapter 7.

Express Empathy

Empathy "is a specifiable and learnable skill for understanding another's meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning" (Miller and Rollnick, 1991, p. 20). An empathic style

• Communicates respect for and acceptance of clients and their feelings
• Encourages a nonjudgmental, collaborative relationship
• Allows you to be a supportive and knowledgeable consultant
• Sincerely compliments rather than denigrates
• Listens rather than tells
• Gently persuades, with the understanding that the decision to change is the client's
• Provides support throughout the recovery process

Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client's unique perspective, feelings, and values. Your attitude should be one of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected. Motivational interviewing is most successful when a trusting relationship is established between you and your client.

Although empathy is the foundation of a motivational counseling style, it "should not be confused with the meaning of empathy as identification with the client or the sharing of common past experiences. In fact, a recent personal history of the same problem area...may compromise a counselor's ability to provide the critical conditions of change" (Miller and Rollnick, 1991, p. 5). The key component to expressing empathy is reflective listening.

If you are not listening reflectively but are instead imposing direction and judgment, you are creating barriers that impair the therapeutic relationship (Miller and Rollnick, 1991). The client will most likely react by stopping, diverting, or changing direction. Twelve examples of such nonempathic responses have been identified (Gordon, 1970):

1. Ordering or directing. Direction is given with a voice of authority. The speaker may be in a position of power (e.g., parent, employer) or the words may simply be phrased and spoken in an authoritarian manner.
2. Warning or threatening. These messages are similar to ordering but they carry an overt or covert threat of impending negative consequences if the advice or direction is not followed. The threat may be one the clinician will carry out or simply a prediction of a negative outcome if the client doesn't comply--for example, "If you don't listen to me, you'll be sorry."
3. Giving advice, making suggestions, or providing solutions prematurely or when unsolicited. The message recommends a course of action based on the clinician's knowledge and personal experience. These recommendations often begin with phrases such as, "What I would do is...."
4. Persuading with logic, arguing, or lecturing. The underlying assumption of these messages is that the client has not reasoned through the problem adequately and needs help to do so.
5. Moralizing, preaching, or telling clients their duty. These statements contain such words as "should" or "ought" to convey moral instructions.
6. Judging, criticizing, disagreeing, or blaming. These messages imply that something is wrong with the client or with what the client has said. Even simple disagreement may be interpreted as critical.
7. Agreeing, approving, or praising. Surprisingly, praise or approval also can be an obstacle if the message sanctions or implies agreement with whatever the client has said. Unsolicited approval can interrupt the communication process and can imply an uneven relationship between the speaker and the listener. Reflective listening does not require agreement.
8. Shaming, ridiculing, labeling, or name-calling. These messages express overt disapproval and intent to correct a specific behavior or attitude.
9. Interpreting or analyzing. Clinicians are frequently and easily tempted to impose their own interpretations on a client's statement and to find some hidden, analytical meaning. Interpretive statements might imply that the clinician knows what the client's real problem is.
10. Reassuring, sympathizing, or consoling. Clinicians often want to make the client feel better by offering consolation. Such reassurance can interrupt the flow of communication and interfere with careful listening.
11. Questioning or probing. Clinicians often mistake questioning for good listening. Although the clinician may ask questions to learn more about the client, the underlying message is that the clinician might find the right answer to all the client's problems if enough questions are asked. In fact, intensive questioning can interfere with the spontaneous flow of communication and divert it in directions of interest to the clinician rather than the client.
12. Withdrawing, distracting, humoring, or changing the subject. Although humor may represent an attempt to take the client's mind off emotional subjects or threatening problems, it also can be a distraction that diverts communication and implies that the client's statements are unimportant.

Ethnic and cultural differences must be considered when expressing empathy because they influence how both you and your client interpret verbal and nonverbal communications.

Develop Discrepancy

Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes for the future. Your task is to help focus your client's attention on how current behavior differs from ideal or desired behavior. Discrepancy is initially highlighted by raising your clients' awareness of the negative personal, familial, or community consequences of a problem behavior and helping them confront the substance use that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.

Separate the behavior from the person and help your client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current substance use patterns. This requires you to listen carefully to your client's statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlight this concern to heighten the client's perception and acknowledgment of discrepancy.

Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perceive discrepancy is sometimes called the "Columbo approach" (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client's problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).

Tools other than talking can be used to reveal discrepancy. For example, show a video and then discuss it with the client, allowing the client to make the connection to his own situation. Juxtaposing different media messages or images that are meaningful to a client can also be effective. This strategy may be particularly effective for adolescents because it provides stimulation for discussion and reaction.

You can help your client perceive discrepancy on a number of different levels, from physical to spiritual, and in different domains, from attitudinal to behavioral. To do this, it is useful to understand not only what an individual values but also what the community values. For example, substance use might conflict with the client's personal identity and values; it might conflict with the values of the larger community; it might conflict with spiritual or religious beliefs; or it might conflict with the values of the client's family members. Thus, discrepancy can be made clear by contrasting substance-using behavior with the importance the clients ascribe to their relationships with family, religious groups, and the community.

The client's cultural background can affect perceptions of discrepancy. For example, African-Americans may regard addiction as "chemical slavery," which may conflict with their ethnic pride and desire to overcome a collective history of oppression. Moreover, African-Americans may be more strongly influenced than white Americans by the expressed values of a larger religious or spiritual community. In a recent focus group study with adolescents, African-American youths were much more likely than other youths to view cigarette smoking as conflicting with their ethnic pride (Luke, 1998). They pointed to this conflict as an important reason not to smoke.

Avoid Argument

You may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If you try to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not you, who voices arguments for change, progress can be made. The goal is to "walk" with clients (i.e., accompany clients through treatment), not "drag" them along (i.e., direct clients' treatment).

A common area of argument is the client's unwillingness to accept a label such as "alcoholic" or "drug abuser." Miller and Rollnick stated that

[T]here is no particular reason why the therapist should badger clients to accept a label, or exert great persuasive effort in this direction. Accusing clients of being in denial or resistant or addicted is more likely to increase their resistance than to instill motivation for change. We advocate starting with clients wherever they are, and altering their self-perceptions, not by arguing about labels, but through substantially more effective means (Miller and Rollnick, 1991, p. 59).

Although this conflicts with some clinicians' belief that clients must be persuaded to self-label, the approach advocated in the "Big Book" of Alcoholics Anonymous (AA) is that labels are not to be imposed (AA, 1976). Rather, it is a personal decision of each individual.

Roll With Resistance

Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, viewpoint is that resistance is a signal that the client views the situation differently. This requires you to understand your client's perspective and proceed from there. Resistance is a signal to you to change direction or listen more carefully. Resistance actually offers you an opportunity to respond in a new, perhaps surprising, way and to take advantage of the situation without being confrontational.

Adjusting to resistance is similar to avoiding argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible, and divert or deflect the energy the client is investing in resistance toward positive change.

How do you recognize resistance? Figure 3-2 depicts four common behaviors that indicate that a client is resisting treatment. How do you avoid arguing and, instead, adapt to resistance? Miller and colleagues have identified and provided examples of at least seven ways to react appropriately to client resistance (Miller and Rollnick, 1991; Miller et al., 1992). These are described below.

Support Self-Efficacy

Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires you to recognize the client's strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial that you as the clinician also believe in your clients' capacity to reach their goals.

Discussing treatment or change options that might still be attractive to clients is usually helpful, even though they may have dropped out of other treatment programs or returned to substance use after a period of being substance free. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, "one day at a time," may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients' sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how substance use progresses to abuse or dependency. Making the biology of addiction and the medical effects of substance use relevant to the clients' experience may alleviate shame and guilt and instill hope that recovery can be achieved by using appropriate methods and tools. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

Ask Open-Ended Questions

Asking open-ended questions helps you understand your clients' point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, help you avoid making premature judgments, and keep communication moving forward (see Figure 3-3).

Listen Reflectively

Reflective listening, a fundamental component of motivational interviewing, is a challenging skill in which you demonstrate that you have accurately heard and understood a client's communication by restating its meaning. That is, you hazard a guess about what the client intended to convey and express this in a responsive statement, not a question. "Reflective listening is a way of checking rather than assuming that you know what is meant" (Miller and Rollnick, 1991, p. 75).

Reflective listening strengthens the empathic relationship between the clinician and the client and encourages further exploration of problems and feelings. This form of communication is particularly appropriate for early stages of counseling. Reflective listening helps the client by providing a synthesis of content and process. It reduces the likelihood of resistance, encourages the client to keep talking, communicates respect, cements the therapeutic alliance, clarifies exactly what the client means, and reinforces motivation (Miller et al., 1992).

This process has a tremendous amount of flexibility, and you can use reflective listening to reinforce your client's positive ideas (Miller et al., 1992). The following dialog gives some examples of clinician's responses that illustrate effective reflective listening. Essentially, true reflective listening requires continuous alert tracking of the client's verbal and nonverbal responses and their possible meanings, formulation of reflections at the appropriate level of complexity, and ongoing adjustment of hypotheses.

Clinician: What else concerns you about your drinking?

Client: Well, I'm not sure I'm concerned about it, but I do wonder sometimes if I'm drinking too much.

Clinician: Too much for...?

Client: For my own good, I guess. I mean it's not like it's really serious, but sometimes when I wake up in the morning I feel really awful, and I can't think straight most of the morning.

Clinician: It messes up your thinking, your concentration.

Client: Yes, and sometimes I have trouble remembering things.

Clinician: And you wonder if that might be because you're drinking too much?

Client: Well, I know it is sometimes.

Clinician: You're pretty sure about that. But maybe there's more...

Client: Yeah, even when I'm not drinking, sometimes I mix things up, and I wonder about that.

Clinician: Wonder if...?

Client: If alcohol's pickling my brain, I guess.

Clinician: You think that can happen to people, maybe to you.

Client: Well, can't it? I've heard that alcohol kills brain cells.

Clinician: Um-hmm. I can see why that would worry you.

Client: But I don't think I'm an alcoholic or anything.

Clinician: You don't think you're that bad off, but you do wonder if maybe you're overdoing it and damaging yourself in the process.

Client: Yeah.

Clinician: Kind of a scary thought. What else worries you?

Summarize

Most clinicians find it useful to periodically summarize what has occurred in a counseling session. Summarizing consists of distilling the essence of what a client has expressed and communicating it back. "Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on" (Miller and Rollnick, 1991, p. 78). A summary that links the client's positive and negative feelings about substance use can facilitate an understanding of initial ambivalence and promote the perception of discrepancy. Summarizing is also a good way to begin and end each counseling session and to provide a natural bridge when the client is transitioning between stages of change.

Summarizing also serves strategic purposes. In presenting a summary, you can select what information should be included and what can be minimized or left out. Correction of a summary by the client should be invited, and this often leads to further comments and discussion. Summarizing helps clients consider their own responses and contemplate their own experience. It also gives you and your client an opportunity to notice what might have been overlooked as well as incorrectly stated.

Affirm

When it is done sincerely, affirming your client supports and promotes self-efficacy. More broadly, your affirmation acknowledges the difficulties the client has experienced. By affirming, you are saying, "I hear; I understand," and validating the client's experiences and feelings. Affirming helps clients feel confident about marshaling their inner resources to take action and change behavior. Emphasizing their past experiences that demonstrate strength, success, or power can prevent discouragement. For some clients, such as many African-Americans, affirmation has a spiritual context. Affirming their inner guiding spirit and their faith may help resolve their ambivalence. Several examples of affirming statements (Miller and Rollnick, 1991) follow:

• I appreciate how hard it must have been for you to decide to come here. You took a big step.
• I think it's great that you want to do something about this problem.
• That must have been very difficult for you.
• You're certainly a resourceful person to have been able to live with the problem this long and not fall apart.
• That's a good suggestion.
• It must be difficult for you to accept a day-to-day life so full of stress. I must say, if I were in your position, I would also find that difficult.

Elicit Self-Motivational Statements

Engaging the client in the process of change is the fundamental task of motivational interviewing. Rather than identifying the problem and promoting ways to solve it, your task is to help the client recognize how life might be better and choose ways to make it so.

Remember that your role is to entice the client to voice personal concerns and intentions, not to convince him that a transformation is necessary. Successful motivational interviewing requires that clients, not the clinician, ultimately argue for change and persuade themselves that they want to and can improve. One signal that the client's ambivalence and resistance are diminishing is the self-motivational statement.

Four types of motivational statements can be identified (Miller and Rollnick, 1991):

• Cognitive recognition of the problem (e.g., "I guess this is more serious than I thought.")
• Affective expression of concern about the perceived problem (e.g., "I'm really worried about what is happening to me.")
• A direct or implicit intention to change behavior (e.g., "I've got to do something about this.")
• Optimism about one's ability to change (e.g., "I know that if I try, I can really do it.")

Figure 3-4 illustrates how you can differentiate a self-motivational statement from a countermotivational assertion. You can reinforce your client's self-motivational statements by reflecting them, nodding, or making approving facial expressions and affirming statements. Encourage clients to continue exploring the possibility of change. This can be done by asking for an elaboration, explicit examples, or more details about remaining concerns. Questions beginning with "What else" are effective ways to invite further amplification. Sometimes asking clients to identify the extremes of the problem (e.g., "What are you most concerned about?") helps to enhance their motivation. Another effective approach is to ask clients to envision what they would like for the future. From there, clients may be able to begin establishing specific goals.

Figure 3-5 provides a useful list of questions you can ask to elicit self-motivational statements from the client.

Establish Rapport and Trust

Before you raise the topic of change with people who are not thinking about it, establish rapport and trust. The challenge is to create a safe and supportive environment in which the client can feel comfortable about engaging in authentic dialog. One way to foster rapport is first to ask the client for permission to address the topic of change; this shows respect for the client's autonomy.

Next, tell the client something about how you or your program operates and how you and the client could work together. This is the time to state how long the session will last and what you expect to accomplish both now and over a specified time. Try not to overwhelm the new client at this point with all the rules and regulations of the program. Do specify what assessments or other formal arrangements will be needed, if appropriate. If there are confidentiality issues (discussed in more detail later in this chapter), these should be introduced early in the session. It is critical that you inform the client which information will be kept private, which can be released with permission, and which must be sent back to a referring agency.

Because you are using a motivational approach, explain that you will not tell the client what to do or how and whether to change. Rather, you will be asking the client to do most of the talking--giving her perspective about both what is happening and how she feels about it. You can also invite comments about what the client expects or hopes to achieve.

Then ask the client to tell you why she has come or mention what you know about the reasons, and ask for the client's version or elaboration (Miller and Rollnick, 1991). If the client seems particularly hesitant or defensive, one strategy is to choose a topic of likely interest to the client that can be linked to substance use. A clue to such an interest might be provided by the referral source or can be ascertained by asking if the client has any stresses such as illness, marital discord, or overwork. This can lead naturally into questions such as "How does your use of...fit into this?" or "How does your use of...affect your health?" Avoid referring to the client's "problem" or "substance abuse," because this may not reflect her perspective about her substance use (Rollnick et al., 1992a). You are trying to understand the context in which substances are used and this client's readiness to change. Of course, if you discover that she is contemplating or committed to change, you can move immediately to strategies more appropriate to later change stages (see Chapters 5 and 6).

An important point to state at the first session is whether or not you will work with a client who is obviously inebriated or high on drugs at the counseling sessions. You are not likely to receive accurate and reliable information from someone who has recently ingested a mind-altering substance (Sobell et al., 1994). Many programs administer breath tests for alcohol or urine tests for drugs and reschedule counseling sessions if substances are detected at a specified level or if a client appears to be under the influence (Miller et al., 1992).

Explore the Events That Precipitated Treatment Entry

The emotional state in which the client comes to treatment is an important part of the gestalt or context in which counseling begins. Clients referred to treatment will exhibit a range of emotions associated with the experiences that brought them to counseling--an arrest, a confrontation with a spouse or employer, or a health crisis. People enter treatment shaken, angry, withdrawn, ashamed, terrified, or relieved--often experiencing a combination of feelings. Strong emotions can block change if you, the counselor, do not acknowledge them through reflective listening. The situation that led an individual to treatment can increase or decrease defensiveness about change.

It is important that your initial dialog be grounded in the client's recent experience and that you take advantage of the opportunities provided to increase motivation. For example, an athlete is likely to be concerned about his continued participation in sports, as well as athletic performance; the employee may want to keep her job; and the driver is probably worried about the possibility of losing his driving license, going to jail, or injuring someone. The pregnant woman wants a healthy child; the neglectful mother probably wants to regain custody of her children; and the concerned husband needs specific guidance on convincing his wife to enter treatment.

However, clients sometimes blame the referring source or someone else for coercing them into counseling. The implication is often that this individual or agency does not view the situation accurately. To find ways to motivate change, ascertain what the client sees and believes is true. For example, if the client's wife has insisted he come and the client denies any problem, you might ask, "What kind of things seem to bother her?" Or, "What do you think makes her believe there is a problem associated with your drinking?" If the wife's perceptions are inconsistent with the client's, you may suggest that the wife come to treatment so that differences can be better understood. Similarly, you may have to review and confirm a referring agency's account or the physical evidence forwarded by a physician to help you to introduce alternative viewpoints to the client in nonthreatening ways. If the client thinks a probation officer is the problem, you can ask, "Why do you think your probation officer believes you have a problem?" This enables the client to express the problem from the perspective of the referring party. It also provides you with an opportunity to encourage the client to acknowledge any truth in the other party's account (Rollnick et al., 1992a).

In opening sessions, remember to use all the strategies described in Chapter 3: Ask open-ended questions, listen reflectively, affirm, summarize, and elicit self-motivational statements (Miller and Rollnick, 1991).

Commend Clients for Coming

Clients referred for treatment may feel they have little control in the process. Some will expect to be criticized or blamed; some will expect you can cure them. Others will hope that counseling can solve all their problems without too much effort. Whatever their expectations, affirm their courage in coming by saying, "I'm impressed you made the effort to get here." Praising their demonstration of responsibility increases their confidence that change is possible. You also can intimate that coming to counseling shows that they have some investment in the topic and an interest in change. For example, you can commend a client's decision to come to treatment rather than risk losing custody of her child by saying, "You must care very much about your child." Such affirmations subtly indicate to clients that they are capable of making good choices in their own best interest.

Agree on Direction

In helping the client who is not yet thinking seriously of change, it is important to plan your strategies carefully and negotiate a pathway that is acceptable to the client. Some are agreeable to one option but not another. You honor your role as a clinician by being straightforward about the fact that you are promoting positive change. It also may be appropriate to give advice based on your own experience and concern. However, do ask whether the client wants to hear what you have to say. For example, "I'd like to tell you about what we could do here. Would that be all right?" Whenever you express a different viewpoint from that of the client, make clear that you intend to be supportive--not authoritative or confrontational. The client still has the choice about whether to heed your advice or agree to a plan. It is not necessary at this early stage in the process to agree on treatment goals.

Assess Readiness To Change

When you meet the client for the first time, ascertain her readiness to change. This will determine what intervention strategies are likely to be successful. There are several ways to assess a client's readiness to change. Two common methods are described below (see Chapter 8 for other instruments to assess readiness to change).

Provide Information About the Effects and Risks of Substance Use

Provide basic information about substance use early in the treatment process if clients have not been exposed to drug and alcohol education before and seem interested. Tell clients directly, "Let me tell you a little bit about the effects of..." or ask them to explain what they know about the effects or risks of the substance of choice. To stay on neutral ground, illustrate what happens to any user of the substance, rather than referring just to the client. Also, state what experts have found, not what you think happens. As you provide information, ask, "What do you make of all this?" (Rollnick et al., 1992a).

It is sometimes helpful to describe the addiction process in biological terms to persons who are substance dependent and worried that they are crazy. Understanding facts about addiction can increase hope as well as readiness to change. For example, "When you first start using substances, it provides a pleasurable sensation. As you keep using substances, your mind begins to believe that you need these substances in the same way you need life-sustaining things like food--that you need them to survive. You're not stronger than this process, but you can be smarter, and you can regain your independence from substances."

Similarly, people who have driven under the influence of alcohol may be surprised to learn how few drinks constitute legal intoxication and how drinking at these levels affects their responses. A young woman hoping to have children may not understand how substances can diminish fertility and potentially harm the fetus even before she knows she is pregnant. A client may not realize how alcohol interacts with other medications he is taking for depression or hypertension.

Use Motivational Language in Written Materials

Remember that the effective strategies for increasing motivation in face-to-face contacts also apply to written language. Brochures, flyers, educational materials, and advertisements can influence a client to think about change. However, judgmental language is just as off-putting in these contexts as it is in therapy. For example, such words as "abuse" or "denial" may be turnoffs. All literature on the counseling services you provide should be written with motivation in mind. If your brochure starts with a long list of rules, the client may be scared away rather than encouraged to come in for treatment. Review written materials from the viewpoint of the prospective client and keep in mind your role as a partner in a change process for which the client must take ultimate responsibility.

Create Doubt and Evoke Concern

As clients move beyond a precontemplation stage and become aware of or acknowledge some problems in relation to their substance use, change becomes an increased possibility. Such clients become more aware of conflict and feel greater ambivalence (Miller and Rollnick, 1991). The major strategy for moving clients from a precontemplation to a contemplation stage is to raise doubts in them about the harmlessness of their substance use patterns and to evoke concerns that all is not well after all.

One way to foster concern in the client is to explore the good and less good aspects of substance use. Start with the client's perceptions about the possible "benefits" of alcohol or drugs and move on a continuum to less beneficial aspects rather than setting up a dichotomy of bad things or problems associated with substance use. If you limit the discussion to negative aspects of substance use, the client could end up defending the substance use while you become the advocate for unwanted change. In addition, the client may not be ready to perceive any harmful effects of substance use. By showing that you understand why the client values alcohol or drugs, you set the stage for a more open acknowledgment of emerging problems. For example, you might ask, "Help me to understand what you like about your drinking. What do you enjoy about it?" Then move on to ask, "What do you like less about drinking?" The client who cannot recognize any of the less good things related to substance use is probably not ready to consider change and may need more information. After this exploration, summarize the interchange in personal language so that the client can clearly hear any ambivalence that is developing: "So, using...helps you relax, you enjoy doing...with friends, and...also helps when you are really angry. On the other hand, you say you sometimes resent all the money you are spending, and it's hard for you to get to work on Mondays" (Rollnick et al., 1992a). Chapter 5 provides additional guidance on working with ambivalence.

You can also move clients toward the contemplation stage by having them consider the many ways in which substance use can affect life experiences. For example, you might ask, "How is your substance use affecting your studies? How is your drinking affecting your family life?" As you explore the effects of substance use in the individual's life, use balanced reflective listening: "Help me understand. You've been saying you see no need to change, and you also are concerned about losing your family. I don't see how this fits together. It must be confusing for you."

Preparation for an Assessment

Findings from an assessment can most readily become part of the therapeutic process if the client understands the practical value of objective information and believes the results will be helpful. Hence, you would most appropriately schedule formal assessments after the client has had at least one session with you so that you can lay the groundwork and determine the client's readiness for change and potential responsiveness to personalized feedback. You then can explain what types of tests or questionnaires will be administered and what information these will reveal. You can also estimate how long this usually takes and give any other necessary instructions. If the client is not considering change and has not acknowledged any concerns or problems with substance use, you can agree that there might not be a problem but that the evaluation is designed to ascertain exactly what is happening. Just like a medical examination, the assessment can pinpoint places where there are--or may be--concerns and where some change might be considered.

Content of an Assessment

A variety of instruments and procedures may be used to evaluate clients. Eight major domains considered comprehensive in scope for assessing clients with primarily alcohol-related problems have been suggested (Miller and Rollnick, 1991). These eight domains are highlighted below.

Personalize and Interpret Feedback About Assessment Results

The presentation and discussion of assessment results can be pivotal for enhancing motivation; thus, structure this session thoughtfully and establish rapport before providing your clients with individual scores from the tests and questionnaires that were administered. First, express appreciation for clients' efforts in providing the information. Ask if there were any difficulties. Inasmuch as answering questions or filling out forms can be revealing in itself, clients may already have a new perception about the role of substances in their lives. You can raise this point by asking, "Sometimes people learn surprising things as they complete an assessment. What were your reactions to the testing?" Make clear that you may need their help to interpret the findings accurately. Encourage them to ask questions: "I'm going to be giving you a lot of information. Please stop me if you don't understand something or want more explanation. We have plenty of time today or in another session, if need be." You may also want to stress the objectivity of the instruments used and give a bit of background, if appropriate, about how they are standardized and how widely they are used. It is also helpful to provide a written summary so that clients can have a copy.

It is helpful in providing feedback to compare clients' personal scores with normative data or other interpretive information. Clients must understand, for example, that their usual drinking level is above the normal range and that this is predictive of long-term risk for such negative consequences as stroke, liver cirrhosis, breast cancer for women, and all cancers for men (see Figure 4-1). Both the score and the interpretive explanation are important; neither is interesting or motivational in itself. The realization that, for instance, a high score of 23 on the Alcohol Use Disorders Identification Test (AUDIT) indicates heavy--and problematic--drinking can raise questions for clients about what they previously thought was normal behavior (see Figure 4-2). The AUDIT is reproduced in Appendix B.

Although clients are often already given handouts that contain extensive information, even minimal data should be presented in written form with accompanying explanations. Also, use a motivational style in presenting the information. Do not pressure clients to accept a diagnosis or offer unsolicited opinions about what a result might mean. Instead, preface explanations with such statements as, "I don't know whether this will concern you, but..." or "I don't know what you will make of this result, but..." Let them form their own conclusions, but help them along by asking, "What do you make of this?" or, "How do you feel about this?" When soliciting clients' reactions, watch for nonverbal cues such as scowls, frowns, or even tears. Reflect these in statements such as, "I guess this must be difficult for you to accept because it confirms what your wife has been saying" or, "This must be scary" or, "I can see you are having a hard time believing all this" (Miller and Rollnick, 1991).

Finally, summarize the results, including risks and problems that have emerged, clients' reactions, and any self-motivational statements that the feedback has prompted. Then ask clients to add to or correct your summary.

When presented in a motivational style, assessment data alone can move clients toward a new way of thinking about substance use and its consequences. If they still have difficulty accepting assessment results and maintain that consumption levels are not unusual, you can try the "Columbo approach" (see Chapter 3): "I'm confused. When we were talking earlier, there didn't seem to be a problem. But these results suggest there is a problem, and these are usually considered pretty reliable tests. What do you make of this?"

One good example of a format and description of the feedback process can be found in the Personal Feedback Report developed for Project MATCH (Miller et al., 1995c), reproduced in Appendix B. Another is the summary report, Where Does Your Drinking Fit In? (Sobell et al., 1996b) (parts of which are given in Figures 4-1 and 4-2), given to individuals who participate in Guided Self-Change--an assessment and feedback program developed for excessive drinkers who do not view their alcohol consumption as serious enough to warrant formal treatment but do agree to a checkup. The materials are intended to foster self-change by encouraging drinkers to view their alcohol use from a new perspective (Sobell and Sobell, 1998).

For practitioners working in situations that do not allow an extensive drinking assessment, a free, personalized alcohol feedback program is available for use on the Internet. Three researchers (Drs. Cunningham, Humphries, and Koski-Jannes) have developed a program based on the materials used in the Project MATCH Personal Feedback Report (Miller et al., 1995c) and the Where Does Your Drinking Fit In? report (Sobell et al., 1996b). This program can be accessed on the Web site of the Addiction Research Foundation, a division of the Centre for Addiction and Mental Health in Toronto, Canada: www.arf.org. The respondent fills out a brief, 21-question survey about her drinking and submits the data. A personalized feedback report is returned that compares the respondent's drinking to others of the same age, gender, and country of origin (for people living in the United States or Canada). While brief, the feedback program is a useful tool for practitioners to use.

Providing feedback--on clients' level of alcohol or drug use compared with norms, health hazards associated with their level of use, costs of use at the current level, and similar facts--is sometimes sufficient to move precontemplators through a fairly rapid change process without further need for counseling and guidance. Feedback provided in a motivational style also enhances commitment to change and improves treatment outcomes. For example, one study in which persons admitted to a residential treatment center received assessment feedback and a motivational interview found these clients to be more involved in treatment, as perceived by clinicians, than a control group and to have twice the normal rate of abstinence at followup (Brown and Miller, 1993).