wanted to,” they might say, “but I don’t really see why I should.” For them, your task is to increase the
perceived importance of change.
It is further possible to be willing and able to change, but still not ready. “I can do it, and it’s
important for me to change, but it’s not the most important thing for me right now.” If a person sees the
importance of change and feels able to do it, what else is needed to reach readiness to do it now? Usually the
problem is that there are higher priorities to be dealt with first. Sometimes it is an event that stands between
the person and this particular change (“Not until after __________”).
As you prepare to make the transition to Phase 2, complete this quick assessment of where your client
stands on these three dimensions. This will be helpful in deciding not only on whether to proceed, but how.
Using the Personal Rulers worksheet, obtain these three ratings:
Importance. Now if I may I’d like to ask you three questions, and for each one I’d like you to give me a rating
on a scale that goes from zero to ten. (Show the client the Personal Rulers worksheet). First of all, how
important do you think it is now for you to make a change in your drinking, if zero means not important at all,
and ten means extremely important. What would you say? [Circle the one number that the client indicates.
Marks between numbers are not allowed.]
Confidence. Now suppose that you have made up your mind to quit drinking. How confident are you
that you could actually do it? Zero is not at all confident, and ten means you are certain you could do
it. How confident would you say you are? [Again circle the number that the client indicates, with the
sheet in front of the client.]
Readiness. Now third, how ready would you say you are now to change your drinking? Zero is not
ready at all, and ten is completely ready. How ready do you think you are? [Circle the client’s rating.]
Here is an important clinical judgment call: Should you proceed directly to Phase 2, or continue to strengthen
motivation for change? As a guideline, any client rating less than a 6 bears further exploration. If there is a
rating of 5 or less on any one of the scales, or if you decide for other reasons that further Phase 1 work is
warranted, proceed to the optional Exploring Motivation Ratings procedure (2.8d). If after you have
explored the client’s ratings with this procedure you believe that further Phase 1 work is needed, two other
optional procedures are also provided: Constructing a Decisional Balance (2.8e) and Reviewing Past
Successes (2.8f). Otherwise proceed directly to Phase 2 (2.8g).
2.8d. Optional: Exploring Motivation Ratings. If the client reports low (<6) ratings or you otherwise
decide that additional Phase 1 work is needed, use this procedure first. You may then decide to use either,
both, or neither of the other two optional strategies that immediately follow (2.8e, 2.8f).
For each of the three ratings that a client gives, there are two open questions that can be asked. Each
of these two questions tends to elicit self-motivational statements, to which you should respond with reflective
listening and summarizing. The following is suggested wording, which may be rephrased in your own
language to suit the clinical situation:
1. Now let me ask you this: Why are you at a (current score
) and not a zero on this scale? [This
question elicits the client’s arguments for importance, ability, or readiness, and empathic listening is
the appropriate response. Question 1 makes no sense, of course, for the rare client whose score is zero,
in which case you should skip to Question 2.]
Reference: Form I
2. And what would it take to get you from a (current score
) to a (higher score
) on this scale? [For the
latter, choose a number that is 1-5 points higher than the client’s current score, but not more than 8.
Question 2 evokes from the client statements about the conditions under which perceived importance,
ability, or readiness could increase, offering you some clues about what is needed in Phase 2 and Phase
3. Again, reflective listening is your primary response to what the client offers. If the client’s rating is
already 8 or higher, skip this question.]
Ask these questions at least for each scale score that is lower than 6 (you may ask them for other scales as
well). When you have completed this, offer a summary reflection that
gathers together the self-motivational statements that emerged
through Question 1, and the if-then statements that emerged with
Question 2. Here is an example of how such a summary might sound.
So pulling all this together, you said that you are around a five on willingness to make a change in
your drinking, and the main reasons why you are that far up the scale are your concern about how
your drinking is affecting your family, and also the problems you have been having with the courts and
your probation officer. Making a change in your drinking might get your PO off your back, and you
think it would probably also help things go better with your spouse and your children. On the second
ruler here, you said that you are very confident - an 8 - that you could quit drinking if you made up
your mind to do it. It’s just that you haven’t really decided yet if you’re willing to do it. And so that’s
reflected in your third rating, a 3, that you are mostly not ready to make any change yet. Does that
sound about right?
2.8e. Optional: Constructing a Decisional Balance. If there is additional Phase 1 work to do in order
to enhance motivation for change, a useful follow-up strategy is to ask the client (and SSO) to consider the
pros and cons of change. Use the Decisional Balance Worksheet for this purpose. As an introduction, say
something like this:
Sometimes it’s helpful to consider the pros and cons of making a change. This is where people often
get stuck. They may think about one reason why a change might be good, then they think about
something they like about drinking, and after going back and forth a couple of times they just stop
thinking about it altogether. Ever had an experience like that? (Listen and reflect if the client offers
an example of ambivalence.)
What I’d like to do is to get a clear picture of the pros and cons as you see them. First of all, what do
you see as the advantages of continuing to drink as before, the way you have been? We’ll come back
to this in more detail later, but in general what are the things that you’ve liked about drinking the way
you have been? (Fill in the upper left box of the worksheet. If the client states motivations
appropriate other boxes on the worksheet, print them in the appropriate spaces.)
Besides the things you enjoy about drinking, there may also be some disadvantages that come to mind
when you think about changing your drinking. What are those? What might be some not-so-good
things about changing your drinking? Fill in the lower left box.)
Reference: Form J
Now how about the other side. What are some of the not-so-good
things about drinking for you? [This question may suffice, but
you can also ask follow-up questions such as:
In what ways have you or other people been concerned about your drinking?
What have you noticed about how your drinking has changed over the years?
What hassles have you had related to your drinking?
You may also ask “in what ways . . .” questions (or ask for examples or elaborations) pertinent to
problems reported by the client on the DrInC questionnaire. If a SSO is present you can ask what he or
she has noticed. Spend time eliciting self-motivational statements here, and respond with reflective
listening. Fill in the upper right box of the worksheet.]
Finally, what might be some advantages or benefits of making a change in your drinking? In
what ways might that be a good thing? (Again, elicit and reflect self-motivational statements.
Fill in the lower right box.)
Reflecting, summarizing, and reframing remain appropriate responses throughout this module. Complete the
Decisional Balance procedure with a summary reflection that draws together the themes of pros and cons,
placing particular emphasis on self-motivational statements.
2.8f. Optional: Reviewing Past Successes. For some clients, the primary impediment to motivation
for change is shaky self-efficacy. They understand the importance of change (e.g., see the negative
consequences of their drinking) but are not confident of their ability to change. They are willing to change, but
question whether they are able. When low confidence is an impediment to motivation, it can be helpful to
review how the client and others have changed successfully in the past. Begin by asking the client to recall
times when she or he decided to make a change and did so successfully. Here is some sample language:
I know that you’re not really sure at this point whether you are ready to change your drinking. Part of
this seems to be that you are not sure if you could do it, if you could succeed. Maybe the best place to
start is with what has worked for you in the past. Think about some times in your life where you
decided to make a significant change and you did it. It might be something you made up your mind to
do, or a habit you broke, or something you learned how to do. When have you made significant
changes like that in your life? . . . . . . What other changes have you made? When have you taken
charge of your life?
Elicit several examples, and look for changes that were of the client’s own initiative (rather than being
imposed) and about which the client seems to feel happy or proud. Then for these explore what the client did
that worked, and how similar personal skills or strengths might be applied in changing alcohol use. Respond
with empathic listening, particularly reflecting client statements about personal ability to change. Rather than
asking baldly, “How did you do it?” it may be helpful to have the client walk you through what changed and
how it happened. How did the change process start - what triggered it? What did the client do? What
difficulties were encountered? How did the client overcome them? How does the client explain his or her
success? What does this imply about the client’s personal strengths and skills? Avoid jargon here, and use the
client’s own language.
THERAPIST: I’m particularly interested in the time when you were able to get out of the abusive
relationship. Tell me about that.
CLIENT: Well, I just got tired of being afraid all the time, and I decided that I wanted something
better for myself. One night he beat he up really bad, and as I was lying there crying, I just promised
myself that was the last time he was ever going to do that to me.
THERAPIST: You decided you had had enough of that - too much.
CLIENT: Right. I mean, I was terrified, too, and I didn’t know what I would do. I didn’t have a job,
or any place to go, but I knew I had to get out of there.
THERAPIST: So even though you couldn’t see very far ahead, and you were pretty afraid, you knew
you wanted something better for yourself, and you started on your way. What did you do?
CLIENT: I waited until he went out, and then I called the women’s shelter. They were really good to
me. I was out of there within an hour, before he got back. He never knew what happened to me.
THERAPIST: So once you made up your mind that you wanted a better life, you took action. You
knew who to call for help, and you got it! You really trusted in something. What was it?
CLIENT: I guess I just trusted in myself, and that there were people out there who would help me.
THERAPIST: You’re a pretty strong person in some ways.
CLIENT: In some ways, yes.
THERAPIST: What are some of those strengths? . . . .
This short dialogue illustrates how through open questions and reflective listening you can elicit self-
motivational statements to strengthen the client’s sense of hope and optimism, building on past experience. It
may also be helpful to describe how others have succeeded in making changes similar to that which the client
is contemplating. In one form, you can describe the generally very positive outcomes for people who set out to
change their drinking and related problems. In the long run, most people do succeed in escaping from alcohol
dependence, even though it often takes a series of attempts. You can describe the range of different
approaches that have been successful for others in the past, reflected in part in the menu of options contained
in Phase 3. Be familiar with the very favorable outcomes of treatment for alcohol problems (Hester & Miller,
1995; Project MATCH Research Group, 1997a, 1998a) and more generally of efforts to change addictive
behavior (Miller & Heather, 1998; Sobell & Sobell, 1992). Look for ties between approaches that have
worked for others and what the client tells you about his or her own past successes. Emphasize that there is a
large variety of things to try, and that the chances are excellent that the client will find something that works,
even if it’s not on the first try.
2.8g. Closing Phase 1.
Whether or not you have used optional modules (2.8 d,e,f) in Phase 1, bring this phase of treatment to
a close with a transitional summary, followed by a structuring statement such as this:
Now that we’ve spent some time talking about the “why” of change, I’d like, if you’re willing, for you
to help me get a clearer picture of how drinking has fit into your life in the past. We can also start
considering here the “how” of change - what you think you might want to do.
If the client is still reluctant, ask whether he or she is willing to move ahead to the next step, which is exploring
some of the reasons for drinking (i.e., the functional analysis). Emphasize the client's personal choice and
control here, that whatever you do together, it will always be the client's decision what, if anything, to do about
Use the Phase 1 Completion Checklist to document your completion of the above steps. If Phase 1
continues beyond Session 2, continue to complete the checklist in Session 3. Remember also to log every
session on the Session Record Form (see 2.6g).
If Phase I continues to Session 3, you should also give the Working Alliance Inventory (WAI) at the
end of Session 3. Ask your client to complete it and give it to the clerk or Project Coordinator, sealed in the
provided envelope. The WAI should not be returned directly to you and you should not be present when the
client is completing it.
2.9. Interim Homework Assignments
Some clients will come into treatment much more ready to change than others. For these clients,
Phase 1 is likely to be somewhat shorter. Even so, clients in the preparation or action stage may seem a bit
restless to “get going” as you move through the processes of Phase 1 and Phase 2.
One way to address this eagerness is to provide a home task assignment at the end of the second or
even first session if you are fairly sure the client is ready for it. The assignment must be consistent with one of
the modules of CBI, but this still allows for considerable latitude. You could, for example, invite a client to
visit a mutual-help group meeting (3.5c), or sample an enjoyable alcohol-free activity (5.8). It would be
possible to start a client on mood monitoring (5.6) or completing a referral to an agency that provides a needed
service (4.3). Choose an assignment that is consistent with where you anticipate treatment will be going, based
on what you already know about your client. The SSO may or may not be involved in this assignment, though
it is often a good place to start in initiating SSO support.
As with any home task assignment, always follow up on the assigned task at the beginning of the next
session. This communicates that you place importance on your client’s effort and progress in between
Developing a Plan for
Treatment and Change
Documents you may be interested
Documents you may be interested