MODULE 2
DECISION MAKING

Table Of Contents

TABLE OF CONTENTS…………………………………………………………………………	II
MODULE 2: DECISION MAKING ……………………………...................................................	1

	CHECK-IN …………………………….......................................................................................................................	2
	REVIEW PREVIOUS SESSION …………………………….....................................................................................	2
	SET THE AGENDA  ……………………………........................................................................................................	2
	INTRODUCE THE DECISIONAL BALANCE …………………………………………...……...............................	2
Elicit disadvantages of change ……………………………………………………………………………….....  	3
Elicit advantages of change ……………………………………………………………………………………..	3
Summarize the decisional balance ………………………………………………………………………………	4
INTRODUCE THE PERSONAL RULERS WORKSHEET ………………………………………………………...	5
		Discuss importance ……………………………………………………………………………………………...	5
		Discuss confidence ……………………………………………………………………………………..	……….	5 
		Discuss readiness ………………………………………………………………………………………	……….	6
		Responding to low ratings …….…………………………………………………………………………………	6
		Consider ways to increase rating (optional) …………………………………………………….………………	6
		Summarize the rulers …………………………………………………………………………………………….	7
REVIEWING PAST SUCCESS (OPTIONAL)………………………………………………………………………..	7
RECOGNIZING READINESS ………………………………………………………………………………………..	7
CONSOLIDATE COMMITMENT TO CHANGE……………………………………………………………………	7
COMPLETE AGENCY SPECIFIC TASKS ………………..…………………………………………………………	9
SUMMARIZE SESSION ……………………………………………………………………………………………...	9
REVIEW HOME ASSIGNMENT ……..………………………………………………………………………………	9
PREVIEW NEXT SESSION …………………………………………………………………………………………..	9
END SESSION……………….…………………………………………………………………………………………	9

APPENDIX A: SESSION MATERIALS ………………………………………………………………	10

DECISIONAL BALANCE WORKSHEET ……………………………........................................................................	11
PERSONAL RULERS WORKSHEET..………………………………………………………………………………...	12
BENEFITS OF CHANGE WORKSHEET………………………………………………………………………………	13
MODULE 2 SESSION CHECKLIST…………………………………………………………………………………...	14

Module 2: Decision making

The primary objectives of this module are to 1) guide the client through the process of considering the pros and cons of change, 2) enhance importance of, confidence in, and readiness for change, 3) consolidate commitment for change, and 4) consider treatment goals.

=====╣Module Outline╠===========================================

Target Discussion Points

	Check-in
	Review previous session
	Set the agenda
	Review the Decisional Balance Worksheet
	Elicit disadvantages of change
	Elicit advantages of change
	Summarize the decisional balance
	Introduce the Personal Rulers Worksheet
	Discuss importance, readiness, and confidence
	Summarize rulers
	Consolidate commitment to change
	Complete agency-specific tasks
	Summarize session
	Preview next session
	End session

Optional discussion and exercises:
       	Increasing readiness ratings
      	Reviewing past successes
       	Short-term and long-term benefits of change

The therapist’s role in this module is to help the client consider the advantages and disadvantages of making a change, and to elicit a commitment to change.  The amount of time devoted to this module will vary depending on the need for additional work bolstering commitment to change.  Several optional exercises are included in this module to supplement the primary decision-making exercises.  These optional exercises should be used only when clinically necessary.

Check-in
The therapist should conduct a brief check-in to assess how the client has been doing.  Time for discussion of client’s thoughts, questions, or concerns about the session material from the previous week can be taken as needed.

“Welcome back.  It’s good to see you again.  How have you been doing since our last session?”

Review previous session
The therapist should provide some summary of what was covered in the previous session, highlighting the most salient change talk and/or the client’s expressed ambivalence about change.  This review will be similar in content to the review provided at the end of the previous session.

“The last time we met, we spent the majority of our time discussing some of the concerns that have brought you into this treatment.  You have some worries about your health and a clear sense that drinking will eventually cause some problems.  You don’t see any immediate crises in your life because of drinking that would make you want to stop altogether, but you are unsure of how much worse it might get if you don’t take some steps now.”

Set the agenda
After answering any remaining questions from the preceding sections, set the agenda for the session goals, including: (1) explore advantages and disadvantages of change, (2) consolidate commitment to change, and (3) consider treatment goal.

“I have learned mostly about the reasons why you came into this treatment.  Today I would like to learn about what you see as the reasons for considering change and the reasons for not making a change.  I would like to have you consider both sides of this decision and it will be up to you to figure out whether you want to take any steps to change your drinking.  If you do want to take some steps to change your drinking, we can talk about what you have in mind.  How does that sound to you?”

Introduce the Decisional Balance
The Decisional Balance Exercise (Appendix A) is a tool for helping clients explore and resolve ambivalence about change.  The goal of the decisional balance is to have clients consider both the advantages and the disadvantages of making a change in their substance use.  This process may help the clients evaluate their priorities and enhance their commitment to making changes.  When conducting the decisional balance, the therapist should begin by eliciting the advantages of not making a change.

“I would like to start today by asking you to think about both the good and not-so-good things about making a change in your drinking.  The worksheet I have here has two columns.  On one side you can list the not-so-good things about changing, and on the other side you can list the good things about changing.  I think that looking at both sides will help you think about what you want to do.”

Elicit disadvantages of change
Ambivalence about change may be partly maintained by some of the benefits (real or perceived) that may result from substance use.  Although some clients may say “there is nothing good about drinking,” careful exploration may reveal some benefits.  These benefits of using may be the rewarding aspects of substance use (positive reinforcement) or the self-medicating, or numbing aspects of substance use (negative reinforcement).  It is possible that the client may “miss” these benefits if he or she stops using alcohol or drugs, hence leading to some reluctance to change.  As the therapist explores the not-so- good things about change, follow-up questions should be used as needed to elicit a comprehensive list of disadvantages to changing.

“Let’s start out by talking about some of the not so good things about making a change in your cocaine use.”

“What are the things that you like about marijuana?”

“What are some of the effects that you are not sure you would want to give up?”

“Are there circumstances that you doubt you could tolerate without having a drink?”

“What else do you like about using cocaine?”

“What would you miss if you cut back or quit drinking altogether?”

When the client has identified the majority of disadvantages to changing, the therapist should summarize the list and transition to eliciting the advantages of changing.

“So this is what I have so far.  There are some things about drinking that are enjoyable for you.  Not being able to drink with friends would feel like a sacrifice.  You are unsure about how you would tell people in your life if you decided to quit drinking, and you are worried that people will judge you if they know you are trying to stop.  Sometimes drinking feels necessary to you, particularly around your family on the holidays.  You enjoy the social aspect of drinking with others and sometimes alcohol takes the edge off when you are in some uncomfortable situations.  Have I gotten it right?  Is there anything you would add to this list before we move on to talk about the other side?”

Elicit advantages of change
When eliciting the advantages of making a change in substance use, it is the responsibility of the client to make an argument for change, not the therapist.  The therapist can guide this discussion with evocative questions, but the risk of suggesting advantages to the client is that it may elicit resistance.  If the client is having difficulty generating a list of advantages to change, the Benefits Of Change Worksheet (Appendix A) can be used as needed to facilitate discussion.

“I have a good idea about the not-so-good things about making a change, now let’s look at the other side.  What would be the good things about you making a change in your cocaine use?”

What are some of the things that would change in your life for the better if you cut back or quit using marijuana?”

“If you decided to stop drinking and you were able to do it, what would your life be like?”

“What are the immediate positive changes you might expect if you cut back on your marijuana use?”

“What are the things you would look forward to in your life if you decided to quit using opiates?”

When the client has identified the majority of advantages of changing, the therapist should briefly summarize these advantages.

“This is what I understand so far.  Some of the good things about making a change in your drinking that you look forward to are having more money, not
 feeling guilty about your drinking, and losing weight.  It seems the most important reason for you is related to your self-esteem.  You haven’t been feeling so good
about yourself and the direction your life has been going, and it seems that you are hopeful that quitting drinking will help you get back to feeling good about yourself and happy again.  You also see some long-term benefits of not drinking, like improved health and a better job.  Is there anything you would add?”

Summarize the decisional balance
The therapist should summarize the broad points of what was learned from the decisional balance and encourage the client to draw some conclusions about how the process informs their current thinking about the possibility of change.

“We have looked at both sides of this decision you are considering.  On the one hand, there are things about drinking that you still enjoy and you sometimes feel like you need alcohol to get through unpleasant circumstances in your life.  On the other hand, there are real and immediate positive things that would happen in your life if you decide to quit drinking, and you seem to really want to return to the time in your life when you felt good about yourself and hopeful about the future.  You expect that not drinking would help you get closer to feeling happier in your daily life.”

The therapist should allow the client time to respond to the summary of the decisional balance or if necessary, elicit the client’s reaction to the summary:

“We have been looking at both sides of this decision you are trying to make…I am wondering what your thoughts are about this?”

Introduce the Personal Rulers Worksheet
The Personal Rulers Worksheet (Appendix A) is a tool that can be used to further explore motivation for change (Miller, 2004).  The Rulers is a three-item clinical measure designed to assess: 1) how important it is to the client that he or she changes, 2) how ready the client feels to make a change, and 3) the degree of confidence the client has in his or her ability to change.  Using this scale provides an opportunity to assess, and possibly strengthen, motivation in these three areas.

“We have talked quite a bit about the reasons why you are thinking about making a change in your alcohol use.  I would like to change the focus a bit and ask you to make some ratings about how important it is that you make a change, how ready you feel to make a change, and how confident you are that you can do it.”

“As I ask you these three questions, I’d like you to give me a rating on a scale that goes from 0 to 10.”

Discuss importance

“First, how important do you think it is now for you to make a change in your drinking?  If 0 means not important at all and 10 means extremely important, how important is this to you right now?”

After the client has made a rating, this ruler can be used to elicit change talk regarding importance.

“So right now, making a change in your drinking is fairly important (or a 4 on this scale).  Can I ask, what makes this a 4 which suggests you see this as fairly important compared to a 2 which means it would only be somewhat important?” 
Or “What makes this score so high?”

The therapist should guide this discussion such that the client had the responsibility of making an argument for change.  Allow time for the client to respond, reflect any change talk and then move on to the next ruler.

Discuss confidence

“Suppose that you have made up your mind to quit drinking.  How confident are you that you could actually do it?  Zero is not all confident and 10 means you are certain you could do it.  How confident would you say you are right now?”
After the client has made a rating, this ruler can be used to elicit change talk related to the client’s confidence.  By asking the client to discuss what makes the rating as high as it is, the therapist places the client in the position of arguing for change.

“So right now, you are feeling very confident that you can do this… an 8 on this scale.  Can I ask, what makes this an 8, compared to feeling a little less confident, like a rating of 6?”

As with the importance scale, asking why the rating is as high as it is places the client in the role of making an argument for change.  Summarize the discussion of confidence, affirming client strengths and reflecting client change talk, and move on to the next ruler.

Discuss readiness

“I would like to ask how ready you are to stop drinking right now on a scale of 0- 10.  One means you are not at all ready to make this change and 10 means you are completely ready to make this change.  How do you rate your readiness?”

After the client has made a rating, this ruler can be used to elicit change talk regarding the readiness rating.  By asking the client to discuss what makes the rating as high as it is, the therapist places the client in the role of making an argument for change.

“So right now, you are feeling somewhat ready, a 2 on this scale.  Can I ask, what makes you rate this 2 as compared to a 1 or 0?”

Responding to low ratings
If clients rate a ruler at any value greater than zero, exploration of the rating (e.g., “why is this a one and not a zero?”) is a good means enhancing motivation for change.  If a rating on the rulers is zero, the therapist should consider optional exercises for increasing motivation.

Consider ways to increase ratings (optional)
When ratings on the personal rulers worksheet are below five, the therapist may choose to use optional exercises to selectively bolster the area that has a low rating.  Simply asking clients to consider how they could increase a rating by a few points may move the client closer to change.

“You rated your readiness at a 2 on this scale.  I wonder, if you wanted to increase your readiness to a 4, or perhaps a 5, what could you do to bring this rating up?”

“Is there anything in your daily life or routine that you could do differently in order to bring you closer to being ready for this change you are considering?” 

Summarize the rulers

“So, you said that you are at a 5 on importance, and the primary reasons you think you need to make a change in your drinking are that your wife is angry at you and your doctor told you it would be a good idea.  In terms of confidence, you are fairly confident that if you made up your mind to stop drinking, you could, although you believe you would need some help.  In terms of readiness, you’re not certain that it is the right time for you to make this change, but, if certain things happened at work or you had more information about your health this might change.  Does that sound about right?”

Reviewing past successes (optional)
If the clients need help building confidence in their ability to change, reviewing past successes can be helpful.  The therapist might begin this discussion by asking the client to recall a time when he or she decided to make a change and did so successfully.  It is important to look at an example where the client initiated change and it was not imposed, and the client felt proud about his or her behavior.  In addition, the therapist should explore what the client did that worked, and how similar skills or strengths might be applied to changing alcohol or drug use.  Other things to examine include: the barriers encountered in making the change; what the client did to overcome these barriers; and what does the client believe this means about his or her strengths and skills.

Recognizing readiness
Attention to client language and behavior will give the therapist information about the client’s readiness for making changes in substance use.  A client’s use of language that reflects a commitment to change is a good indicator that the client is ready and willing to change.  Clients may also ask directive questions about how to begin changing, or use language which reflects that they are envisioning what it would be like to make a change.  Some examples of client language that reflects readiness to change includes:

“I am going to do this.”
“This is something I need to change.”
“I can’t go on like this, I need to make this change now.”
“Making this change won’t be easy but I’m sure I want this.”
“How do people just stop using?”
“Do you have any suggestions for how I can start?”
“Some of the problems with my wife will get better right away when I stop.”
“I’m looking forward to the day that I can tell my family about what I am doing.”
“I’m not sure how I will do this, but I need to make a change.”

Consolidate commitment to change
When it appears that the client is ready and willing to consider change, the therapist should transition to discussing the client’s desired goals.  Transitional summary can be 

used to begin the shift from talking about the possibility of change to talking about how to change.

“I would like to pull together what I have learned about you so far.  You came to this appointment not really knowing what to expect.  Your doctor said your drinking was on the edge of being harmful and recommended that you cut back at the very least.  You have noticed some problems related to your drinking, but you are not sure that they are so bad that you would need to make any immediate changes.  There are some things you like about drinking, but also some things that you worry about.  You notice how your drinking has progressed from drinking only when you wanted to, to feeling like you need to drink just to get through some days.  You are not sure how far this will go and realize that there is some chance that drinking will cause a lot more harm in your life in the future.  You seem particularly worried about how this might affect your marriage and your health in the long-term.  Does that sound about right?”

Allow the client to respond, and then ask the client to consider what they would like to do about their substance use.

“Given all of this, what do you think you want to do about your drinking?”
“Where do you go from here?”

Depending on how the client responds to this transition, the therapist may take more time to explore ambivalence about change before progressing to working on treatment planning.  Clinical judgment is necessary to make a determination about whether to shift from motivation enhancement to goal setting.  Some clients will be clearly in favor of change and will leave the therapist with no doubt that moving onto talking about how to change is appropriate.  For clients who express a reluctance to change, additional work on motivation using any of the MI strategies in this treatment manual is encouraged.  For 

Continue on to functional analysis

Continue exploring ambivalence

Client reluctance 
to change

Client ambivalence about change 

Client ready and willing to change

Clients who are ambivalent about change, the therapist should make a determination about whether to continue on to the functional analysis of substance use, or spend more time with motivation enhancing exercises.  Including the client in this decision-making may be helpful.

“You have a clear sense that you need to do something about your drinking but you are not sure that right now it the best time, and you worry about whether you can do it.  We have a choice to make about how we proceed that I would like you to consider.  One option we have is to continue talking about whether making a change is the right thing for you now.  Thinking more about this, and talking more about this, may help you come to a decision.  We could also move along and talk about what we could work on that would help you make a change if that is what you ultimately decide to do.  Talking about how drinking fits into your life right now, and what we could work on together to help you make a change, may give you a greater sense that you can make a change if that is your choice.  What are your thoughts about how you would like to proceed?”

Complete agency specific tasks
Complete any agency specific paperwork with the client as needed.

Summarize session
The therapist should provide a closing summary of the session highlighting major accomplishments made during the session, reviewing any commitments the client has made to try out new strategies, and recognizing the client’s efforts.

“I would like to wrap-up for today and talk about what we can do in our next session.  We have been talking today about how you can make a decision about your drinking.  You have some reservations about missing alcohol in some circumstances.  You also have a clear sense that quitting is what you want right now, and you are eager to begin making some changes toward this goal.”

Review home assignment
The therapist may assign home exercises as needed to continue to work on the skills and concepts within the current module, or to prepare the client for material that will be covered in the next session.  For example, if the client was having difficulty identifying advantages to change and the Benefits of Change Worksheet was not completed during the session, the client may benefit from work on this optional exercise as a home assignment.

Preview next session
Provide a brief preview of what will be covered in the next session.

“So far, most of what I have learned are the reasons for why you want to make this change in your life.  In our next session we can begin to talk about how you can make it.  I hope to learn more about how drinking has fit into your life and begin to consider what we can work on together to help you change some of that.  How does this sound to you?”

End session
“I think we have made some good progress today; you seem to have a clear idea now about what you want to do.  Do you have any other questions, concerns or thoughts before we end today?”

APPENDIX A
DECISION MAKING
SESSION MATERIALS

DECISIONAL BALANCE WORKSHEET

Good things about changing

Not-so-good things about changing

PERSONAL RULERS WORKSHEET

1.	How Important is that you make a change in your drinking?

	0	   1	       2	            3	    4	         5	            6	     7	         8	             9	    10
Not at all		Somewhat		Fairly		     Important		      Very		Extremely
      Important		Important	         Important				   Important		Important

2.	If you decided that you wanted to quit drinking, how confident are you that you could actually do it?

           0	   1	       2	            3	    4	         5	            6	     7	         8	             9	    10
Not at all		Somewhat		Fairly		     Important		      Very		Extremely
      Confident		Confident	         Confident				   Confident		Confident

3.	How ready are you to make a change in your drinking?

0	   1	       2	            3	    4	         5	            6	     7	         8	             9	    10
Not at all		Somewhat		Fairly		     Important		      Very		Extremely
        Ready		  Ready	            Ready				   	     Ready		   Ready

BENEFITS OF CHANGE

Within a week	

Within a month	

Within a year	

In the long run	

Module 2 Session Checklist
Decision Making

PREPARATIONS	•		
  Session checklist		
  Agency-specific paperwork		
  Decisional Balance worksheet		
  Personal Rulers worksheet		
  Benefits of Change worksheet		
GETTING STARTED		
  Check-in		
  Review of previous session		
  Set the agenda		
REVIEW OF THE DECISIONAL BALANCE		
  Elicit disadvantages of change		
  Elicit advantages of change		
  Summarize Decisional Balance		
INTRODUCTION OF THE PERSONAL RULERS WORKSHEET		
  Discuss importance		
  Discuss confidence		
  Discuss readiness		
  Summarize rulers		
OPTIONAL EXERCISES		
  Review past successes		
  Discuss Benefits of Change		
CONSOLIDATION OF COMMITMENT TO CHANGE		
  Transitional summary statement		
  Discuss client’s goals		
COMPLETION OF AGENCY SPECIFIC TASKS		

WRAP UP		
  Summarize session		
  Preview coming sessions		
  Assign home exercise