of problem drinkers attempting to moderate their drinking, people with severity scores resembling theirs were much more likely to succeed with abstinence. Those falling in range 4 can further be advised that in this same study, no one with scores like theirs managed to maintain problem-free drinking. Clients who are unwilling to discuss immediate and long-term abstinence as a goal might be more responsive to intermediate options, such as a short-term (e.g., 3month) trial abstinence period, or tapering off of drinking toward an ultimate goal of abstention (Miller and Page 1991).

Table 2. Relationship of severity measures to types of treatment outcome

Severity Treatment Outcome

Total Asymptomatic Improved but Ratio

Range Scores abstainers drinkers impaired Not improved AB:AS

Michigan Alcoholism Screening Test (MAST)

1 0-10 3 14 % 5 23 % 8 36 % 6 27 % 3:5
2 11-18 7 21 7 21 6 18 14 41 1:1
3 19-28 10 40 2 8 4 16 9 36 5:1
4 29+ 4 29 0 0 4 29 6 43 4:0

Median 19.5 12.0 15.0 18.0
Mean 19.0 13.2 18.0 18.6
SD 7.6 6.2 12.5 9.1

Alcohol Dependence Scale (ADS)

Lifetime Accumulation of Symptoms

1 0-14 2 8% 6 24% 9 36% 8 32% 1:3

2 15-20 4 14 4 14 4 14 16 57 1:1
3 21-27 11 35 6 19 5 16 9 29 11:6
4 28+ 6 75 0 0 2 25 0 0 6:0

Median 22.5 19.0 15.0 16.5
Mean 27.2 16.6 17.1 18.0
SD 14.5 7.8 7.7 5.4

Source: Data from Miller et al. 1992.

NOTE: Asymptomatic = Drinking moderately with no evidence of problems

Improved = Drinking less, but still showing alcohol-related problems
AB/AS Ratio = Ratio of successful abstainers to asymptomatic drinkers

Dealing With The same principles used for defusing resistance in the first phase of
Resistance MET also apply here. Reluctance and ambivalence are not challenged
directly but rather can be met with reflection or reframing. Gently
paradoxical statements may also be useful during the commitment
phase of MET. One form of such statements is permission to continue
unchanged:

Maybe you'll decide that it's worth it to you to keep on drinking
the way you have been, even though it's costing you.
Another form is designed to pose a kind of crisis for the person by
juxtaposing two important and inconsistent values:
I wonder if it's really possible for you to keep drinking and still
have your marriage, too.

The Change The Change Plan Worksheet (CPW) is to be used during Phase 2 to
Plan Worksheet help in specifying the client's action plan. You can use it as a format
for taking notes as the client's plan emerges. Do not start Phase 2 by
filling out the CPW. Rather, the information needed for the CPW
should emerge through the motivational dialog described above. This
information can then be used as a basis for your recapitulation (see
below). Use the CPW as a guide to ensure that you have covered these
aspects of the client's plan:

The changes I want to make are. . . In what ways or areas does the client want to make a change? Be specific. It is also wise to include goals that are positive (wanting to begin, increase, improve, do more of something) and not only goals that could be accomplished through general anesthesia (to stop, avoid, or decrease behaviors).

The most important reasons why I want to make these changes are . . . What are the likely consequences of action and inaction? Which motivations for change seem most impelling to the client?

The steps 1 plan to take in changing are . . . How does the client plan to achieve the goals? How could the desired change be accomplished? Within the general plan and strategies described, what are some specific, concrete first steps that the client can take? When, where, and how will these steps be taken?

The ways other people can help me are . . . In what ways could other people (including the significant other, if present) help the client in taking these steps toward change? How will the client arrange for such support?

I will know that my plan is working if... What does the client hope will happen as a result of this change plan? What benefits could be expected from this change?

Some things that could interfere with my plan are . . . Help the client to anticipate situations or changes that could undermine the plan. What could go wrong? How could the client stick with the plan despite these problems or setbacks?

Preprinted Change Plan Worksheet forms are convenient for MET therapists. Carbonless copy forms are recommended so you can write or print on the original and automatically have a copy to keep in the client's file. Give the original to the client and retain the copy for the file.

Change Plan Worksheet

The changes I want to make are:

The most important reasons why I want to make these changes are:

The steps I plan to take in changing are:

The ways other people can help me are:
Person Possible ways to help

I will know that my plan is working if:

Some things that could interfere with my plan are:

Recapitulating Toward the end of the commitment process, as you sense that the client
is moving toward a firm decision for change, it is useful to offer a broad
summary of what has transpired (Miller and Rollnick 1991). This may
include a repetition of the reasons for concern uncovered in Phase 1
(see "Summarizing") as well as new information developed during
Phase 2. Emphasis should be given to the client's self-motivational
statements, the SO's role, the client's plans for change, and the
perceived consequences of changing and not changing. Use your notes
on the Change Plan Worksheet as a guide. Here is an example of how
a recapitulation might be worded:

Let me see if I understand where you are. Last time, we
reviewed the reasons why you and your husband have been
concerned about your drinking. There were a number of these.
You were both concerned that your drinking has contributed to
problems in the family, both between you and with the children.
You were worried, too, about the test results you received
indicating that alcohol has been damaging your health. Your
drinking seems to have been increasing slowly over the years,
and with it, your dependence on alcohol. The accident that you
had helped you realize that it was time to do something about
your drinking, but I think you were still surprised when I gave
you your feedback, just how much in danger you were.
We've talked about what you might do about this, and you and
your husband had different ideas at first. He thought you
should go to AA, and you thought you'd just cut down on your
drinking and try to avoid drinking when you are alone. We
talked about what the results might be if you tried different
approaches. Your husband was concerned that if you didn't
make a sharp break with this drinking pattern you've had for
so many years, you'd probably slip back into drinking too much
and forget what we've discussed here. You agreed that that
would be a risk and could imagine talking yourself into drink
ing alone or drinking to feel high. You didn't like the idea of
AA, because you were concerned that people would see you
there, even though, as we discussed, there is a strong principle
of anonymity.

Where you seem to be headed now is toward trying out a period
of not drinking at all, for 3 months at least, to see how it goes
and how you feel. Your husband likes this idea, too, and has
agreed to spend more time with you so you can do things
together in the evening or on weekends. You also thought you
would get involved again in some of the community activities
you used to enjoy during the day or maybe look for a job to keep
you busy. Do I have it right? What have I missed?

If the client offers additions or changes, reflect these and integrate them into your recapitulation. Also note them on the Change Plan Worksheet.

Asking for After you have recapitulated the client's situation and responded to
Commitment additional points and concerns raised by the client (and SO), move
toward getting a formal commitment to change. In essence, the client
is to commit verbally to take concrete, planned steps to bring about
the needed change. The key question (not necessarily in these words)
is: Are you ready to commit yourself to doing this?

* As you discuss this commitment, also cover the following points:

* Clarify what, exactly, the client plans to do. Give the client the completed Change Plan Worksheet and discuss it.

* Reinforce what the client (and SO) perceive to be likely benefits of making a change, as well as the consequences of inaction.

* Ask what concerns, fears, or doubts the client (and SO) may have that might interfere with carrying out the plan.

* Ask what other obstacles might be encountered that could divert the client from the plan. Ask the client (and SO) to suggest how they could deal with these.

* Clarify the SO's role in helping the client to make the desired change.

* Remind the client (and SO) that you will be seeing the client for followthrough visits (scheduled at weeks 6 and 12) to see how he/she is doing.

If the client is willing to make a commitment, ask him/her to sign the Change Plan Worksheet and give the client the signed original, retaining a copy for your file.

Some clients are unwilling to commit themselves to a change goal or program. When clients remain ambivalent or hesitant about making a written or verbal commitment to deal with the alcohol problem, you may ask them to defer the decision until later. A specific time should be agreed upon to reevaluate and resolve the decision. The hope in allowing clients the opportunity to postpone such decisionmaking is that the motivational processes will act more favorably on them over time (Goldstein et al. 1966). Such flexibility provides clients with the opportunity to explore more fully the potential consequences of change and prepare themselves to deal with the consequences. Otherwise, clients may feel coerced into making a commitment before they are ready to take action.

In this case, clients may withdraw prematurely from treatment, rather than "lose face" over the failure to follow through on a commitment. It can be better, then, to say something like this:

* It sounds like you're really not quite ready to make this decision yet. That's perfectly understandable. This is a very tough choice for you. It might be better not to rush things here, not to try to make a decision right now. Why don't you think about it between now and our next visit, consider the benefits of making a change and of staying the same. We can explore this further next time, and sooner or later I'm sure it will become clear to you what you want to do. OK?

It can be helpful in this way to express explicit understanding and acceptance of clients' ambivalence as well as confidence in their ability to resolve the dilemma.

Involving a When skillfully handled by the therapist, the involvement of a signif
Significant icant other (spouse, family member, friend) can enhance motivational
Other discrepancy and commitment to change. Whenever possible, clients in
MET will be strongly urged to bring an SO to the first two MET
sessions. At these meetings, the SO is actively engaged in the treat
ment process. Emphasis is placed on the need for the client and SO to
work collaboratively on the drinking problem.
The MET approach recognizes the importance of the significant other
in affecting the client's decision to change drinking behavior. This
emphasis is based upon recent findings from a variety of alcohol
treatment studies. For example, alcoholics seen in an outpatient
setting were found more likely to remain in a spouse-involved treat
ment than in an individual approach (Zweben et al. 1983). Similarly,
clients maintaining positive ties with family members fared better in
a relationship enhancement therapy than in an intervention focused
primarily on the psychological functioning of the client (Longabaugh
et al. in press).

Involvement of an SO in the treatment process offers several
advantages. It provides the SO an opportunity for firsthand under
standing of the problem. It permits the SO to provide input and
feedback in the development and implementation of treatment goals.
The client and SO can also work collaboratively on issues and problems
that might interfere with the attainment of treatment goals.

Goals for The following are general goals for the two SO-involved sessions:
Significant Other Establish rapport between the SO and the counselor.
Involvement Raise the awareness of the SO about the extent and severity of
the alcohol problem.

Strengthen the SO's commitment to help the client overcome the drinking problem.
Strengthen the SO's belief in the importance of his or her own contribution in changing the client's drinking patterns.
Elicit feedback from the SO that might help motivate the problem drinker to change the drinking behavior. For example, a
spouse might be asked to share concerns about the client's past, present, and future drinking. Having the spouse "deliver the
message" can be valuable in negotiating suitable treatment goals.

Promote higher levels of marital/family cohesiveness and satisfaction.

MET does not include intensive marital/family therapy. The main principle here is to elicit from client and SO those aspects of their relationship which are seen as most positive and to explore how they can work together in overcoming the drinking problem. Both client and SO can be asked to describe the other's strengths and positive attributes. Issues raised during SO-involved sessions can be moved toward the adoption of specific change goals. The counselor should not allow the client and SO to spend significant portions of a session complaining, denigrating, or criticizing. Such communications tend to be destructive and do not favor an atmosphere that motivates change.

Explaining the Ideally, a client will be accompanied by an SO at the first session. The
Significant invitation to the SO should be made for the first session only, allowing
Other's Role you the flexibility to include or not include the SO in a second session.
In the beginning of the session, the counselor should comment favor
ably on the SO's willingness to attend sessions with the problem
drinker. The rationale is then presented for having the SO attend:

* The SO cares about the client, and changes will have direct impact on both their lives.

* The SO's input will be valuable in setting treatment goals and developing strategies.

* SO may be directly helpful by working with the client to resolve the drinking problem.

* Emphasize that ultimate responsibility for change remains with the client but that the SO can be very helpful. It is useful here to explore tentatively, with both the SO and the client, how the SO might be supportive in resolving the drinking problem. You might ask the following:

To SO: In what ways do you think you could be helpful to ?

To SO: What has been helpful to in the past?

To client: How do you think might be supportive to you now,

as you're taking a look at your drinking?

Be careful not to "jump the gun" at this point. Asking such questions may elicit defensiveness and resistance if the client is not ready to consider change.

It is also important to remember that your role does not include prescribing specific tasks, offering spouse training, or conducting marital therapy. The MET approach provides the SO an opportunity to demonstrate support, verbally and behaviorally, and encourages the SO and client to generate their own solutions.

The Significant In the first conjoint session, an important goal is to establish rapport
Other in Phase 1 to create an environment in which the SO can feel comfortable about
openly sharing concerns and disclosing information that may help
promote change. The SO could also be expected to identify potential
problems or issues that might arise which could interfere with attain
ing these objectives. To begin with, the counselor should attempt to
"join" with the SO by asking about her or his own (past and present)
experiences with the alcohol problem.

What has it been like for you?
What have you noticed about [client's] drinking?
What has discouraged you from trying to help in the past?
What do you see that is encouraging?

Emphasis should be placed on positive attempts to deal with the
problem. At the same time, negative experiences-stress, family dis
organization, job and employment difficulties-should be discussed
and refrained as normative, that is, events that are common in families
with an alcohol problem. Such a perspective should be communicated
to the family member in the interview. The counselor might compare the SO's experiences to the personal stress experienced by families confronted with other chronic mental health or physical disorders such as heart disease, diabetes, and depression (without going into depth about such experiences).

Any concerns that the SO may have about the amount or type of treatment should be explored. Again, concerns expressed by family members or SOs should be responded to in an accepting, reflective, reassuring manner. SOs who express concern about the brevity of MET can be told about the findings of previous research (see table 1), namely, that people can and do overcome their drinking problems given even briefer treatment than this, and that making a firm commitment is the key.

The SO can often play an important role in helping the client resolve uncertainties or ambivalence about drinking and change during Phase 1. The SO can be asked to elaborate on the risks and costs of continued heavy drinking. For example, one spouse revealed during counseling that she was becoming increasingly alienated from her partner as a result of the negative impact that the drinking was having on their children. These questions, asked of the SO in the presence of the client, can be helpful in eliciting such concerns:

How has the drinking affected you?

What is different now that makes you more concerned about the drinking?

What do you think will happen if the drinking continues as it has been?

Feedback provided by the SO can often be more meaningful to a client than information presented by the counselor. It can help the client mobilize commitment to change (Pearlman et al. 1989). In sharing information about the potential consequences of the drinking problem for family members, an SO may cause the client to experience emotional conflict (discrepancy) about drinking. Thus, the client may be confronted with a dilemma in which it is not possible both to continue drinking and to have a happy family. In this way, the decisional balance can be further tipped in favor of changing the drinking. One client became more conflicted about his drinking after his wife described the negative impact it was having on their children. He subsequently decided to give up drinking rather than to experience himself as a harmful parent.

At the same time, there is a danger of overwhelming the client if the feedback given by the SO is new, extremely negative, or presented in a hostile manner. Negative information presented by both the SO and