Administer Reasons for Quitting Questionnaire; Evaluate Reasons for Seeking Treatment
Using Motivational Interviewing Strategies
Sessions 1 and 2 rely heavily on the motivational interviewing strategies described in Miller and Rollnick (2002). Motivational interviewing is a technique used in motivational enhancement therapy (MET). The counselor assesses the client’s motivation by using motivational interviewing strategies, which include asking open-ended questions, listening reflectively, affirming the client, summarizing the client’s views of change, eliciting self-motivational statements, recognizing and addressing resistance, recognizing readiness for change, and identifying discrepancies (see CSAT 1999b). Once the client’s stage is identified, the counselor uses these strategies to support continued progress through the stages.
Close- Vs. Open-Ended Questions
Close-ended questions are an efficient way of obtaining information quickly; however, they allow the client to be passive, answering each question and quietly waiting for the next. The interviewer is in control, and the interviewee responds to each cue. Open-ended questions encourage the client to express himself or herself and to adopt an active role in his or her treatment. Exhibit V-2 presents examples of both types of questions.
Exhibit V-2. Examples of Close- and Open-Ended Questions
• How old were you when you first smoked marijuana?
• Was it offered to you by a family member?
• How old were you when you began using it daily?
• Have you ever had a bad experience with marijuana?
• When did you first think you had a marijuana problem?
• Tell me about your early experiences with marijuana.
• How did your marijuana use change over time?
• Please describe some of your recent experiences with marijuana.
• What was it that made you think you had a problem with marijuana?
A reflection can take the form of simply repeating the client’s words or paraphrasing his or her comments. Sometimes the reflection adds to what the client has said as a way of testing a counselor’s hunch. The skilled listener using reflective listening skills can help the client explore his or her thoughts and feelings:
Miguel (M): I’ve tried to quit before but have never made it for longer than a month.
Counselor (C): Keeping it going has been hard.
M: Yeah. I can’t help feeling pessimistic about what will happen if I try it again.
M: My wife is pressuring me to quit. I’ve got to want to do it for me if this is going to work.
C: Pressure from your wife is distracting you from tuning in to your needs about quitting.
M: It’s almost as if I resist because I want to feel that she doesn’t control my life.
M: My buddies say they’ll support me if I decide to quit, but knowing that they’re getting high will make me feel left out.
C: You’d like to figure out a way to stay connected to these friends and stop smoking.
M: I guess I’ve been thinking that’s not possible.
A double-sided reflection captures two opposing sides to an individual’s ambivalence:
Linda (L): I know I’m getting high too much, but it’s summer and I want to have fun before school starts.
C: On the one hand, you don’t want to miss having fun during the summer, but on the other hand, you’re thinking that you use too often.
Affirmation of the Client
Admitting drug dependence, seeking help by enrolling in a program, summoning the courage to change, and undertaking other aspects of overcoming a dependence are tremendously difficult. The counselor can be supportive by frequently offering genuine compliments and expressions of awareness:
C: You’ve been thinking about quitting for a long time, and now you’re taking the first steps. I’m guessing you feel good about that.
C: Telling your father that you needed counseling for a marijuana problem must have been difficult.
C: Deciding to give up the extra income that came from selling pot wasn’t a minor decision. It requires a real commitment to leave that behind.
Summarizing the Client’s Views of Change
As the client reveals facets of his or her thinking about change, the counselor can be supportive by summarizing key issues. Hearing the counselor consolidate the client’s statements helps the client become aware and ready to resolve his or her mixed motivations:
C: If I understand you correctly, you’re aware of reasons for changing but you’re thinking of other reasons not to quit. On the side of quitting are being a good role model for your children and overcoming a tendency to procrastinate. On the side of not quitting are your fears that you’ll lose friends and won’t make it for long. Have I got it right? What are your thoughts about this?
Eliciting Self-Motivational Statements
Whereas some clients begin counseling with a strong commitment to stop marijuana use, others have considerable ambivalence that may increase over time. Motivational enhancement sessions help the ambivalent client strengthen his or her determination to quit. It is hoped that these counseling sessions lead the client to recognizing his or her problem (I guess I really have to face that I’m out of control with marijuana), becoming concerned about it (I’m worried about whether I can overcome this), expressing an intention to change (Now’s the time for me to leave this behind), and feeling positive about the prospects of succeeding (I can picture a time when I’ll be clean, and—for once in my life—that seems possible). The counselor elicits expressions of motivation from the client with open-ended questions:
• Recognizing the problem
C: How has your marijuana use gotten in the way of things that are important?
C: What convinces you that marijuana has become a problem?
• Expressing concern
C: What aspects of your marijuana use have made you, or people close to you, worry?
C: What do you imagine could happen if you continued to smoke marijuana the way you have been doing?
• Encouraging intentions to change
C: When you joined our program, you probably had some hope that things would get better. What would improve in your life if your hopes were met?
C: Why should you stop smoking marijuana? Why do you think it’s time to change?
• Expressing optimism
C: What leads you to think that you could succeed in quitting if you decided to do that?
C: Is there a part of you that feels encouraged about changing?
With these questions, the counselor helps the client take ownership of the problem and elicit expressions of readiness to change.
Recognizing and Addressing Resistance
A conventional way of interpreting actions of a client who argues with the counselor, frequently interrupts, or denies that a behavior is a problem is that the individual is not motivated to change.
An alternative view is that the counselor does not understand the client’s thoughts and feelings. When the counselor considers these behaviors a signal that he or she needs to understand the client’s experience better, a confrontation between counselor and client is less likely to occur. The counselor shows that he or she is listening and is not being judgmental. The counselor’s reflections can prompt the client to explore his or her thoughts and feelings:
M: I don’t understand why you folks want everyone to quit smoking dope. Maybe I’d be better off if I just cut back.
C: I hear you saying that it’s important to you to change your marijuana use, but you’re not sure whether stopping completely is best for you right now. I can see that you’re eager to find the best goals.
In this example, the counselor might have offered a defense of the program’s abstinence objectives, listed reasons why the client ought to change, and so forth. Those responses probably would have led the client to become even more resistant. The strategy illustrated above is termed “rolling with resistance,” an approach that conveys the counselor’s acceptance of the client’s point of view and invites the client to be open to a slight variation. In the following examples of this approach, the counselor accepts the client’s comments, conveys empathy for the client’s feelings, and reframes what has been said:
M: Most of the people I know get high. Why is everyone on my back?
C: It’s hard to figure out why you’re getting all this pressure. Kind of makes you wonder how you could be the only one who is having problems with pot.
M: I know I’ll have more energy if I quit, but I need it to relax.
C: On the one hand, you’d benefit from more energy. On the other hand, you’d need to find other ways to relax.
M: I can’t see living for the rest of my life without getting high.
C: Slow down. It’s too early to be talking about forever. Let’s talk about what you’re working on right now.
M: I think a lot about quitting, but I’ve never really tried it.
C: You’ve invested a lot of time and energy in this already.
Recognizing Readiness for Change
Expressions of motivation take a variety of forms. The counselor needs to listen carefully and acknowledge those expressions:
M: I hate having so many people angry at me. Why don’t they get off my back?
C: It’s important to find a way to stop people from being angry with you.
M: One thing that I see happening over and over is my promising that I’ll limit how often I get high, and then I go right ahead and break every one of these promises.
C: You’d really like to stop disappointing yourself.
M: I’ve got three beautiful children, and I don’t want my pot smoking to interfere with my being a good father.
C: An important priority in your life is your role as a father.
Clients who are drug dependent have probably seen their reliance on drugs interfere with important aspects of their lives. The counselor helps the client focus on the costs of continued drug use by pointing them out to the client and seeking the client’s perspectives:
C: I’ve heard you talk about how important it is that your children grow up in a safe and happy home. That’s a goal. But you’ve also talked about not wanting anyone, including your wife, to dictate what you do, and this is causing tension in your home. Relieving this tension is another goal. I wonder what your thoughts are about these two goals.
C: You’ve told me that when you smoke a joint on your lunch break, you have a hard time concentrating at work for the rest of the day. You’ve also said that doing your job well is important so that you can get promoted. I’m a little confused.