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JANE CASE STUDY SCENARIO

Preparation (previously referred to as Determination) is the stage when the client realizes that the behavior is having enough of a negative impact to warrant at least a slight change. The client is now ready to begin taking steps to actively change the target behavior. At this stage the client develops a specific plan. Oftentimes, clients will develop a change plan only after carefully examining their strengths, resources, and activities to determine what will help, and what may hinder, the change process ( Solomon & Fioritti, 2002 ). The counselor, in this stage of change, plays a vital role in supporting change talk—that is, helping the client clarify and continue to articulate the value of potentially changing the target behavior ( Mason, 2009 ).

Case Study

Jane speaks with her physician and gets a referral to a treatment center that specializes in problematic drinking. She makes an appointment to see a counselor after finding out that her insurance will cover treatment. She reads a bit of material on alcohol dependence, and asks some family and friends for their assistance and emotional support. She selects her support team carefully as she does not want “support” from anyone who will ridicule her or make her feel inept. What might Jane’s counselor say or do to help Jane feel the nonjudgmental support she is seeking at this pivotal stage of change?

Jane has created a change plan and has begun to act on her plan. She is now moving into the Action stage.

The Action stage is when the change plan is implemented. The counselor’s role during this stage is to help the client remember why he or she decided that change was necessary. The client’s role is to continue implementing the change plan and to call upon his or her support system for help as needed. This stage can be exciting for the client, counselor, and support system members who want to see the client’s behavior change. However, it can also become overwhelming, as change affects multiple areas of a client’s life. To help prevent the client from becoming overwhelmed or discouraged, counselors focus on increasing the client’s self-efficacy ( Miller & Rollnick, 2012 ).

Self-efficacy is a person’s belief about his or her ability to accomplish a task ( Bandura, 1993 ). According to self-efficacy theory, self-efficacy is a key predictor of performance ( Tucker, Olson, & Frusti, 2009 ). In this case, it is the addicted person’s belief about whether or not he or she can reduce or eliminate the addictive substance, and the thoughts and behaviors associated with the addiction. Counselors practicing Motivational Interviewing will focus on enhancing self-efficacy throughout the entirety of the therapeutic relationship, but will focus even more specifically on a client’s efficacy as action steps are taken.

Further, counselors with clients at this stage of change need to focus even more carefully on the quality of the therapeutic relationship and strength of the client-counselor alliance. Clients in these latter stages of change typically report stronger therapeutic alliances than clients at earlier stages and this factor appears to be quite crucial in helping a client maintain motivation to change ( Emmerling & Whelton, 2009 ).

Case Study

Before attending her first counseling session, Jane decides that she would like to cut back to half of a glass of wine a day. She is able to reduce to one glass (sometimes two) and is quite proud of her accomplishment. When Jane attends her first counseling session, she and her counselor discuss the plan to reduce to half a glass. Jane’s counselor suggests that they enlist the help of her physician so that she is also under medical management to help with withdrawal effects. Jane’s counselor asks her to discuss the support and strengths she has employed to be able to reduce her drinking thus far. The counselor helps Jane focus on her accomplishments to date, rather than on any setbacks or feelings of being overwhelmed she may be experiencing. Further, they will discuss the potential impact of continuing to drink even half a glass a day. Jane may decide it is a better idea to abstain entirely. What are the counselor’s key duties at this stage in order to help Jane meet her goals?

Once the target behavior has changed and the action plan is complete, the client moves into the Maintenance stage of change. This stage is aptly named in that its sole focus is on maintaining the new, positive behaviors. Counselors at this stage will continually work with clients to maintain new behaviors in the face of cravings and relapse cues. Clients who engage in obsessive or catastrophic thinking in regards to their cravings may be more likely to relapse sooner rather than later ( Nosen & Woody, 2009 ), so counselors focus regularly on addressing cravings and cues with clients.

The human tendency is to revert to an earlier stage of change and the target behavior is likely to return in times of stress or discouragement, especially given that addictions have deep roots below consciousness ( Sheeran, Gollwitzer, & Bargh, 2013 ). Counselors will view this reversion as resistance and will continue to engage the client in motivational interviewing. Relapses into former behaviors are viewed as a normal part of the change process, and their importance ought to be minimized. That is, rather than dwelling on the relapse as a “setback,” clients can view it as an informative and typical event in the change process. The relapse is viewed as a signal that some additional action may need to be considered; the client and counselor can respond accordingly.

Case Study

Jane has decided to fully abstain from drinking and is approaching six months of sobriety. She is actively using many of the techniques she learned in treatment and makes use of her sponsor and a support group. Jane has a strong sober support system and a recovery plan that details her steps to maintaining sobriety. Further, she has a relapse prevention plan and has listed the daily tasks she will engage in to actively prevent relapse. She is aware that she may relapse, but also has a plan in case that happens. She has shared these plans with her family and close friends so that she has extra support in times of need.

It is important to realize that the stages of change are not time limited. That is, some stages may last only hours while others last for years. Sometimes a stage may be skipped altogether. Consider the following example:

John has been arrested for driving under the influence of an illegal substance. He subsequently lost his job, his girlfriend broke up with him, and his family feels disgraced. John wishes he never tried cocaine and wants to rid it from his life. Upon his release from jail, he decides immediately to enter treatment so as to break his cocaine addiction. In this case, John moves directly into the Preparation stage without spending time in the Contemplation stage. The Preparation stage is quite short-lived and he moves into Action as quickly as he can.

The stages of change are important in motivational interviewing because they help counselors determine the most appropriate techniques to use. Before using any motivational interviewing techniques, though, it is important that counselors fully understand the dynamics of change, the interpersonal nature of resistance, and the effect motivational interviewing can have on the change process.

JOHN CASE STUDY SCENARIO

It was a fine day, and John had finished work early after receiving a highly positive annual appraisal from his boss. He decided to walk home from work. He varied his usual route so as to stroll through the local park, enjoying the warm sun, the trees in blossom, and the sounds of children playing ball. He felt good about life, and his days of alcoholic drinking seemed far away. As he walked out of the park he passed a bar where he used to drink. Knowing that he did not want to drink anymore, but remembering that his old friends would be wondering what had happened to him, he went in to see how they all were “just for old time’s sake.” Once there, they ignored his pleas that he no longer drank alcohol and bought him a “proper man’s drink.” Telling him they were angry he hadn’t called on them for weeks, they said that they’d let bygones be bygones if only he joined them for “just one drink.” Telling himself that there was nothing else he could do under the circumstances, John gave in. Within only a few hours the barman refused to serve him any more on grounds of his obviously drunken behavior. When he got home, his wife was also angry, so he knew that he had “no choice” but to go to the home of another of his drinking friends, where he spent the night consuming yet more alcohol.

Decisions to walk home rather than take a bus, or to choose one route rather than another, are “seemingly irrelevant” to the mental processes of alcoholism. However, with hindsight, such decisions can set in motion an inexorable process of movement toward a relapse due to environmental triggers. Such relapses are often later viewed as “unavoidable.” After all, what could John do once he was back in the bar, with all his old friends insisting that he drank alcohol?

Much of what has been said earlier is relevant to this example. John could have been aware that his feelings of well-being and success were as much an HRS as any disappointment in life. Had he also rehearsed a range of realistic strategies with which to resist pressures from his drinking friends, he might have been more likely to emerge from the bar without having had a drink. More importantly, he might have recognized that simply going into the bar was an extremely bad idea in the first place. However, the overall problem here was that an unconscious chain of decisions was being forged that made relapse almost inevitable. Because the decisions were seemingly irrelevant, and because their true purpose was partly or completely unconscious, John was able to argue that events had caught him off guard. However, having once recognized such patterns of decision making (and most addicts are readily able to think of examples), it becomes extremely difficult to continue engaging in them without making conscious decisions. Once the process has become conscious, SIDs lose much of their power and the client can bring relapse prevention strategies into play.