Letter writing as a tool to increase client motivation to change: application to an inpatient crisis unit.

This paper describes the application of a letter writing exercise as a motivational technique for group counseling in contemporary crisis unit settings. The rationale for the use of this exercise is offered; then the implementation of the letter writing exercise is described and illustrated with a case example. Letter writing can be effective tool in "window of opportunity" settings (such as crisis units) for increasing client motivation to adopt positive behavioral changes and to seek appropriate aftercare services. Guidelines and implications for clinical practice with clients with multiple, chronic problems are discussed.

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The use of personal letters to facilitate individual or interpersonal change in counseling has a long and varied history (e.g., Kramish, 1956; Sacks, 1974). Letter writing has been used with individuals, couples, families, and groups to address a range of issues including conflicted communication between family members, stressful life transitions such as loss, the modification of personal narratives or identities, coping with trauma, and the redefinition of problems or goals. While the technique of letter writing has been used in many settings and populations for a variety of purposes (see Riordan, 1996, for a review), there has been little discussion of the utility of letter writing in crisis intervention settings. While care received in these settings is likely to be brief and intensive, crisis intervention presents opportunities for brief interventions to enhance clients' motivation to consider making significant changes in their behavior or interpersonal relationships. This article describes the potential utility of a letter writing exercise for promoting behavioral changes in the context of a brief motivational intervention for clients presenting with chronic problems in crisis intervention settings.

A review of available literature reveals many uses for the technique of letter writing in conjunction with traditional counseling interventions. For example, issues of grief, mourning, and forgiveness have been addressed via letter writing in which clients use this exercise to express feelings of grief, perform leave-taking rituals, communicate with a lost person or object, or develop empathy with a transgressor (Conley, 1984; Nau, 1997; Van der Hart & Goossens, 1987; Worthington et al., 2000). In addition, letter writing has played a central role in counseling interventions as a strategy to externalize problem behaviors, overcome defense mechanisms, promote desensitization to past trauma, or engage individuals and families in the counseling process (Lindahl, 1988; Lown & Britton, 1991; Rasmussen & Tomm, 1992; Zimmerman & Shepherd, 1993). Letter writing has also been used as a component of couples or family counseling to open lines of communication blocked by challenging transitions, to transcend relationship conflict or to eliminate interference or distortion in communication patterns (e.g., Riordan & Soet, 2000; Sloman & Pipitone, 1991). Finally, letter writing has been used in narrative forms of counseling to foster a proactive stance in clients with respect to the "authorship" of their life stories and their exploration of possible future selves (France, Cadieax, & Allen, 1995; Goldberg, 2000; Madigan & Grieves, 1997; White & Epston, 1990).

LETTER WRITING AS A BRIEF MOTIVATIONAL INTERVENTION

In addition to these purposes, letter writing may be implemented in a way that is compatible with the principles of motivational interviewing such that the exercise itself becomes a brief motivational intervention. Motivational interviewing and motivational enhancement counseling strategies are gaining popularity as alternative or adjunctive approaches to more traditional counseling approaches designed to produce behavior change among clients (Ryder, 1999; Walitzer, Dermen, & Connors, 1999; Yahne & Miller, 1999). While initially used with addictive behavior problems, such interventions have been implemented with success for a variety of behaviors ranging from diabetes self-management (Doherty, Hall, James, Roberts, & Simpson, 2000) to routine health practices (Thevos, Quick, & Yanduli, 2000) to treatment adherence among psychiatric patients (Swanson, Pantalon, & Cohen, 1999).

Miller and Rollnick (1991) describe the five principles of motivational interviewing as expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy. These five guidelines distinguish motivational interviewing from more traditional skills-training, confrontational, and nondirective counseling approaches. In contrast to these approaches, motivational interventions are intended, through support and persuasion, to increase the likelihood that people will make changes in their behavior by helping them to recognize that problems exist in their lives and to overcome ambivalence about change. This directive, client-centered counseling style has as an overarching goal to create and magnify discrepancies between client goals and current behavior. This counseling approach may be particularly appropriate in crisis intervention settings where clients are more likely to be in the earlier stages of change, i.e., the precontemplation or contemplation stages (Prochaska & DiClemente, 1984), and are experiencing direct and immediate negative consequences related to their behavior. For such clients, appropriate intervention goals include increasing awareness and decreasing defensiveness (precontemplation stage); or evaluating decisional balance, increasing self-efficacy, and resolving ambivalence (contemplation stage).

CRISIS INTERVENTION AS A CONTEXT FOR INTERVENTIONS

In contemporary health and mental health delivery systems, serious suicidal and homicidal thoughts, intentions, and actions by clients are commonly addressed within the framework of crisis intervention. Crisis intervention has multiple goals that include the psychological and medical stabilization of the client, the comprehensive assessment of the client, formulation of a treatment plan, implementation of the treatment plan and initial evaluation, and linking the client to family and community supports (Mitchell, 1999). While different typologies of individual crises exist based on the sources and developmental history of presenting problems (e.g., Burgess & Baldwin, 1981), contemporary mental health care systems frequently encounter clients experiencing crisis due to either inadequate coping skills stemming from chronic psychiatric disorders or to severe distress and the exacerbation of mental health problems associated with acute substance abuse (Hendricks & Byers, 1996). Therefore, crisis intervention services, particularly inpatient crisis units, function as "front line" community-based organizations coordinating medical, psychological, and social services within a structured and safe environment to individuals with persistent psychiatric disorders and inadequate environmental supports (Torrey, 1997; U.S. Public Health Service, 1999).

While crisis-oriented interventions are intended to address the acute disruption clients have experienced as a result of negative events, inadequate coping styles, and insufficient social resources, crisis intervention services also provide a context that may promote changes in clients' maladaptive patterns of behavior (Romano, 1990). Clients who have experienced crisis and who are currently in contact with crisis intervention services often have high levels of readiness to change (Rollnick, 1998). In addition, the structured environment of the inpatient crisis unit represents a setting in which clients often experience various forms of motivational interviewing (Miller & Rollnick, 1991) and, for a brief period of time, they may be more amenable to motivational interventions. In fact, a substantial research literature suggests that "opportunistic brief interventions" conducted in hospitals and other medical settings for health risk behaviors (e.g., tobacco use, problematic alcohol use) demonstrate significant efficacy (Heather, 1998). Some studies have indicated that as little as one half hour of brief motivational interviewing (i.e., an assessment followed by advice and counseling) results in changes such as significant reductions in alcohol consumption (Babor & Grant, 1992). Similar efficacy may be achieved with other types of behaviors seen among clients involved in crisis intervention.

LETTER WRITING EXERCISE IN CRISIS SETTINGS

In working with clients, both those in acute crises and those with more moderate levels of distress, we favor approaches that assume that clients are the primary architects and sustainers of their own change, and that clients are motivated to make changes in their behavior when they (a) recognize that problems exist in their lives and (b) overcome their ambivalence about making the changes necessary for solving these problems. We see other counseling techniques such as skills training, nondirective exploration, or directive confrontation as being most valuable when employed as techniques that support an individual's movement in the direction that they have chosen--in other words, in a context where individuals already see themselves as responsible for creating their own "life stories" and feel motivated to make changes in their stories (White & Epston, 1990). Therefore, we were drawn to the possibilities of using letter writing as a motivational intervention that could increase the likelihood of clients in crisis recognizing their problems and overcoming their ambivalence about making substantial changes in their lives in order to confront their problems. In addition, letter writing held promise as a technique that could give clients practice with taking a position of "authorship" in relation to their post-care lives. Thus, we began to systematize the application of letter writing as a motivational technique to brief intervention settings such as crisis units.

The letter-prompting questions (See Table) that form the basis for clients' goodbye letters to their drug of choice (or another problem) are consistent with the goals of a motivational interviewing style. The questions were designed to address issues pertinent to individuals in the initial stages of change, i.e., the precontemplation or contemplation stages as described by Prochaska and DiClemente (1984). For example, questions regarding their relationship with the drug and their reasons for saying good-bye were intended to increase clients' awareness of the scope of their alcohol and other drug problems while decreasing their defensiveness by normalizing the nature of these problems. Questions regarding feelings about saying good-bye, positive and negative aspects of drug use, potential outcomes, and confidence to make changes assist in resolving ambivalence about change, appraising decisional balance, and bolstering client self-efficacy. While these issues may be addressed directly or indirectly, the crisis setting and the brevity of the intervention make the presentation format for these questions critical for the potential efficacy of the intervention.

In a group meeting led by a facilitator, clients are asked to respond to these questions by writing a brief letter and then to read their letters aloud to the group. The facilitator's responses during the reading of letters are of key importance for highlighting clients' reasons and desire to change while also drawing out and fostering the resolution of ambivalent feelings about changing. Miller and Rollnick (1991) describe strategies that are effective in an initial session for helping clients to explore both ambivalence about making changes and reasons for change.

* Open-ended questions invite clients to describe the origins and course of problem development and their broader life circumstances.

* Reflective listening clarifies and amplifies meanings in client statements without increasing client resistance.

* Affirmation communicates support for clients as they generate statements about their experiences.

* Summarizing links client statements, provides reinforcement, underscores client ambivalence, and focuses the discussion.

These counseling techniques are all used to elicit self-motivational statements. All of these strategies are used as the group members take turns reading their "goodbye" letters. The facilitator affirms, reinforces, and reflects back to clients self-statements that function as arguments for change such as problem recognition, expressions of concern, intentions to change, and expressions of optimism. Simple questions may be directed to clients to assist them. The answers to eliciting questions may be explored further, if time permits, or used by the facilitator to highlight decisional balance, encourage client elaboration, or set short- and long-term goals (Miller & Rollnick, 1991) as strategies to immediately increase client motivation to change.

Example of the Implementing the Technique

The letter writing exercise was implemented during the first author's second field placement as part of a master's-level, clinical-training program. This clinical field placement was conducted and supervised in the Department of Psychiatry in a large private hospital in South Florida. As part of their field placements, all interns facilitate psycho-educational groups in the 25-bed adult Mood Disorder Unit. Psycho-educational groups met in the large activity room on the unit. For 14 weeks the first author facilitated a group that addressed topics related to dual diagnosis. Clients ranged in age from their early 20s to their early 60s and were diverse in terms of their race/ethnicity, cultural background, socio-economic status, gender, and sexual orientation. While every client in the unit was assigned a DSM-IV mood disorder (i.e., depressive disorder, bipolar disorder), the majority of the clients also were assigned a substance use disorder (SUD) or a substance induced disorder. Most clients with a diagnosis of SUD used multiple substances although presenting problems typically involved the use of alcohol or a form of cocaine. In addition, a significant proportion of clients were assigned diagnoses on Axis II and Axis III. Consonant with a client population in crisis, each client had severe psychosocial or environmental issues noted on Axis IV. Typical stay in the unit prior to discharge ranged from 3 to 7 days, based on client progress in reaching goals in initial treatment plans (e.g., for safety, symptom remission, improved coping skills, medication regimens).

The letter writing exercise was implemented in groups ranging in size from 8 to 12 clients, divided in half and sitting at two adjacent tables. After the facilitator introduced himself and stated the general topic of the group, clients were given sheets of paper and pencils. Clients were asked to write a brief letter in which they would "Say good-bye to your drug of choice." If the client was assigned a mood disorder without a coexisting substance-related disorder, the client was encouraged to address his or her letter to "some problem in your life that you want to change." In the body of the letter, clients responded to the series of questions (see Table).

Once clients had written their letters, they were asked to share them with the group if they felt comfortable doing so. On average, clients took 15 minutes to write the brief letters, leaving 45 minutes for group discussion. If clients had difficulty with literacy skills, they were encouraged to share their narratives in a spoken format.

Client Responses and Group Process

Client responses in session varied widely but were generally positive. Clients' responses often corresponded to key clinical issues, e.g., clients with Axis II features tended to respond with labile affect, anger, or dramatic accounts of precipitating events while clients with major depression tended to have difficulty orienting to task and often cried while reading their letters. The vast majority of clients participated actively after the facilitator and the other clients expressed interest in their stories. Some were guarded with the material they included, and a few refused to read their letters (e.g., clients with a hostile or suspicious demeanor). Generally, however, clients responded positively to the active, participatory format of the letter writing exercise that contrasted sharply with the didactic or skills-based approaches used in other groups conducted on the unit (e.g., medication management, coping skills, discharge planning). Many clients stated that this was the first time since arriving on the unit that a staff member solicited their story, listened without judgment, and asked them about their plans for change.

In the discussion that followed after reading each letter, clients varied widely in their ability to generate statements in response to the facilitator's questions, due to factors including a lack of reflection on these issues, psychiatric symptoms, or side effects of new medications. Yet, most clients could respond concretely to open-ended questions about their narratives, provide increasingly elaborated answers, and acknowledge discrepancies between their current state and a more preferable state. When addressing the issue of personal change, most clients freely generated numerous self-motivational statements, suggesting the utility of this exercise in crisis intervention settings.

The group context in which letters were shared varied in both composition and cohesion, depending how much time key members had co-resided on the unit. For example, if many group members had dual diagnoses, an individual member's narrative could rapidly shift to other members' sharing of "war stories" in which the pleasures of substance abuse were overvalued while related consequences were minimized. In these instances, gentle redirection was effective in refocusing attention in the group and exploring the ambivalence inherent in this theme. While the facilitator maintained a supportive and motivational stance with individual clients and the group in general, clients would often confront each other if they considered a target client to be giving insincere answers or if the information they provided in the group differed from information the letter-writer shared previously on the unit. Cohesive groups were marked by clients sharing deeply personal and powerful narratives in which they disclosed their feelings and fears about making changes related to substance abuse, the cumulative costs they had incurred, their hopes for a better future, and their uncertainty about maintaining more positive behavior patterns. Most group members listened with respect and compassion during such moments. Following individual narratives, and in the context of eliciting questions from the facilitator, group members often provided supportive feedback that reflected back individual client's self-motivating statements and provided potent reinforcement for such statements. Group members also provided advice and information (e.g., regarding available community resources, problem-solving strategies) critical to resolving ambivalence and constructing concrete solutions to barriers to change. Therefore, group processes often provided additional motivational elements that supplemented the strategies used by the facilitator. Many clients made positive remarks in response to the exercise.

Follow-Up After the Initial Group Session

The letter writing exercise lasted an hour, but additional significant work with individual clients occurred in the hours or days following. Clients on the unit often contacted the facilitator the next day to discuss their narrative in greater detail or to reflect upon group interactions that occurred during the exercise. This provided the opportunity to focus in depth on the issues of the individual client in an unstructured manner, again using many of the skills emphasized by motivational interviewing. The facilitator's overarching goal in these conversations, given the setting and brief course of treatment provided therein, was to elicit additional motivational statements, to reinforce them, and to concretely link short-term goals to discharge planning. Eliciting questions focused on what resources and supports clients considered to be essential to initiating and maintaining positive behavioral changes. Available community resources were identified and discussed with clients with appropriate referrals to access these services.

Case Illustration

A sample case illustrates how the letter writing exercise may function as a significant catalyst for promoting client motivation for change. The heightened motivation the client experienced as a result of the letter writing exercise provided a productive starting point for follow-up counseling in which the client's motivation for change was supported and focused with specific post-treatment plans. In this case, as in others that occurred over the 14-week period, the session was informal, unplanned, and held at the client's request. A follow-up discussion, however, could be combined routinely with the letter writing exercise or another single session motivational intervention prior to discharge from a crisis setting.

M., an African-American, substance-dependent client with significant shame about his gay sexual orientation, was admitted to the unit subsequent to a relapse and serious suicidal ideation. In the letter writing exercise, M. read a brief letter to the group that allowed him to access strong emotions that he was not prepared to address in the group setting. Reading from his letter, M. made statements like "I know that I can't go on using cocaine," "I have lost everything that I had," and "when I use, I don't have to feel the pain that I have from the past." These are powerful statements that reflect both his strong motivation to change maladaptive patterns of behavior and his ambivalence about implementing change due to the functions substance abuse served for him. This was a moment of clarity for M. regarding his motivation to change, one to be amplified and reinforced by dialogue with a counselor. Open-ended questions were used to prompt him to explore his letter's content (e.g. "How does using cocaine help you to cope with pain in your life"), but M. responded with anger and stated that he didn't want to talk about his letter any more. Consistent with his wishes and the philosophy of motivational interviewing, the facilitator moved to the letter of the next client.

For the rest of the group counseling session, M. attended to the stories of others and gave feedback, but it was clear that he was troubled by thoughts or feelings triggered by writing his letter. The next day, however, he approached the facilitator to initiate a more private one-on-one discussion of the themes in his letter. This longer session allowed the extensive use of open-ended questions (e.g., who, what, where, when, and why) to prompt M. to create a fuller version of the story leading to his admission to the unit. As he told his story, several key issues emerged, facilitated by the counselor's use of fundamental reflective listening skills, affirmation, and summarizing, which contributed to the construction of an elaborated yet coherent report of the problem as M. saw it, and the factors maintaining his behavior. He described an extensive history of childhood sexual abuse, including rape by same-age male peers and cousins as well as older neighbors and family members. He described these traumatic events as experiences that he endured, in the past and currently as memories, without benefit of treatment, stating "I just don't want to go back and deal with all that." He readily acknowledged that substance abuse was his method of managing recurring psychological distress related to sexual feelings and sexual behavior, noting "then I don't feel anything." While M. managed sexual feelings via denial, celibacy, and membership in a fundamentalist church, relapse to substance abuse was typically triggered when other men expressed interest in him and attempted to initiate sexual relations. His major sources of social support for maintaining sobriety were other church members, who not only supported abstinence from drugs and alcohol, but who also openly condemned any expression of homosexual behavior as sinful. In contrast, the supportive and nonjudgmental environment created by the counselor allowed M. to recognize and articulate the relationships between his substance abuse and the family and community systems that played different roles in his life.

With rapport established and a more complete assessment of the issues that brought M. to the crisis unit, the facilitator was able to use motivational interviewing techniques to examine the content of M.'s letter and to build his readiness to change by (a) exploring with him the importance he assigned to changing his patterns of substance abuse, and (b) enhancing his self-efficacy to implement a plan to change his behavior. There are a number of questioning strategies for exploring and developing both of these facets of readiness to change and for moving smoothly between them (for an excellent guide for counseling professionals see Rollnick, Mason, & Butler, 1999). In further discussion with M., the facilitator was able to apply these strategies to his current situation in an effort to prepare him for discharge planning.

In exploring the importance of change with M., the facilitator pursued several lines of questions. For example, he asked M. to describe what he perceived as positive and negative things about using cocaine and positive and negative things about a potential reduction or cessation of use. Once the costs and benefits of use versus cessation were listed, M. was asked to compare them. In addition, M. was asked what would need to happen before he could seriously consider changing his substance use patterns as well as what would make this behavior change more important to him. He was also asked to think about what it would be like to stop using cocaine and to describe any concerns that he had about not using this drug. Since M. had significant suicidal ideation and had in the past lost all his possessions, he was able to describe the potential costs of cocaine abuse and to confirm the personal importance of gaining control over his use of cocaine.

The facilitator used a second line of questions to enhance M.'s confidence in being able to change his patterns of cocaine abuse. Specifically, he asked M. to describe what would make him more confident that he would be able to change his patterns of use and how unit staff could help him with this goal. He also explored M.'s previous attempts to abstain and his subsequent relapses in order to highlight triggers for relapse and the need for sources of support for sobriety. M. was asked to generate a list of options that could function as alternative plans to implement goals for change, and to weigh the costs and benefits of the different options. He was also asked to evaluate how easily he could implement each of the different options that he had generated and to speculate about what kinds of resources would be necessary to ensure their full implementation.

In concluding the session, the facilitator sought to bolster M.'s self-efficacy by emphasizing that his other short- and long-term goals for himself (e.g., related to work, housing, and relationships) were reasonable ones and that sufficient community resources were available to assist him in the implementation process. However, M. expressed ambivalence about seeking counseling for sexual abuse or supports for maintaining sobriety outside the African-American community, so the counselor and M. generated a list of specific community resources that M. felt comfortable relying on for implementing his goals and referral options to help him implement his goals for behavior change. These referrals included resources for counseling specific to childhood sexual abuse and to substance abuse interventions in settings that served a predominantly GLBT clientele.

Approximately 6 weeks following discharge, M. returned during visiting hours and reported that his halfway house placement was satisfactory, that he was employed, and that he was participating in several organizations that provided social support and counseling services. It appears that M. had been motivated by his experience in the crisis unit, including the letter-writing exercise in which he said goodbye to his substance of choice, to take responsibility for making significant life changes that enhanced his health and well-being. Therefore, the letter writing exercise and the subsequent discussion was a significant opportunity to expand and clarify M.'s understanding of the forces that brought him to the crisis unit: (a) the individual and social factors that maintained his distress and substance abuse; (b) the powerful antecedent role of sexual abuse in the development of his mood and substance use disorders; and, (c) causal links among his life stressors, coping styles, triggers for substance use, and of the process leading to relapse.

Implications for Clinical Practice

The preceding text has described the use of letter writing by clients as a brief motivational intervention that may be used in a wide variety of settings to increase readiness to make positive behavioral change. This exercise may be particularly useful in "window of opportunity" settings or as a strategy for engaging clients who are in the earliest stages of considering changes in their behavior. While the bulk of this article has focused on practice with substance abusing clients in crisis intervention settings, the utility of the exercise should generalize to clients of varying ages, ability levels, cultural backgrounds, and presenting problems. Several suggestions may enhance the transferability of the exercise to different groups of clients.

First, client-generated letters may serve an ongoing motivational function. Therefore, clients should be allowed and encouraged to keep their letters as tangible reminders of the intervention. We know one client who kept his letter carefully folded in his wallet for months, looking at it frequently as a reminder of his decision to change, and showing it to other helping professionals whom he encountered in aftercare settings. In this manner, a letter can serve as an ongoing "quasi-booster" session, a device maintaining client commitment to goals.

Second, if this technique is administered in an outpatient crisis setting, clients should be evaluated carefully regarding whether they are stable enough to handle strong affect that might arise in the process of writing and sharing personal narratives. In some cases, depression or other negative emotions may arise after writing and may last for hours or even days (Spera, Buhrfeind, & Pennebaker, 1994). Some form of follow-up should be planned routinely, and in particular with clients who report a history of trauma, abuse, or life-threatening behavior. Single-session interventions have the potential for powerful effects as well as unintended consequences.

Third, when implementing the exercise, clients should be encouraged to write in any style that they find comfortable. Many clients, however, who present in crisis units may have dysgraphia or difficulty with written expression for a wide range of other reasons. Clients may be reluctant to write and may need reassurance that "it's the thought that counts" rather than the form used. The exercise may be facilitated significantly if alternative means of participating are provided for clients who are unwilling or unable to engage in the physical process of writing. Modifications might involve dictating to a group assistant or making a tape recording of a letter.

Fourth, successful implementation of the letter writing exercise requires sufficient time for meaningful feedback to the authors. Either in the same session or the next session, feedback from the group facilitator and other group members are of key importance for participants in consolidating the awareness, insight, or determination arising from letter writing into a behavioral reorientation to problems. The critical element in letter writing to increase client motivation for change is clients' reappraisal of their life position, rather than emotional catharsis. Additional opportunities for clients' processing of material generated in their letters can be planned in subsequent follow-up sessions or in the context of coordinated therapeutic modalities (e.g., art therapy).

Fifth, the letter-writing exercise can be expanded to involve an additional stage, where the "substance of choice" or "problem" to which the client addressed a letter is asked (through the client) to write a response. Deits (1988) used a similar technique with clients doing grief work. In the letter to grief, the client expresses feelings and thoughts; in the letter back from grief, the client writes down whatever it is that he or she thinks grief is trying to communicate in return. The advantage of this elaboration is in highlighting the functions that the problem serves in the client's life and drawing out ambivalent feelings about change. This additional step is appropriate for a range of settings where contact with the client is sustained, and motivation can be monitored and built gradually over time.

Finally, the eliciting questions described in the case illustration above are used to enhance clients' motivation to change by providing opportunities for clients to increase their perception of the importance of change or their confidence that they can implement planned changes. However, in interactions with clients, counselors can easily short-circuit consultations intended to enhance motivation to change (Rollnick et al., 1999). For example, giving simple direct advice to clients often has the unintended effect of reducing clients' motivation to change because overt recommendations, while they often provide necessary information, also disregard the autonomy of clients and in doing so, generate resistance. Similarly, the lack of a client-centered focus, found in some managed care settings, will reduce the ability of counselors to negotiate behavior change with clients, because the successful consultation process is fundamentally cooperative in nature, involving active listening to clients' concerns and informational needs and working with clients to develop a plan of action (Rollnick et al., 1999). To maintain a client-centered focus, we strongly encourage counselors to examine their assumptions regarding the nature of behavior change, i.e., the nature of motivation to change, how and why people change their behavior, how to encourage consideration of change, and who the "expert" is in the negotiation process.

DISCUSSION

In summary, the technique of letter writing is useful as a motivational adjunct for clients in crisis and other settings where brief interventions are standard practice. Similar to other motivational and brief interventions, the technique has broad applicability to clients from diverse cultural backgrounds and of different ages, sexual orientations, and abilities. Specifically, it is useful in increasing clients' awareness of their problems and in decreasing defensiveness. It may be used by counselors to evaluate clients' decisional balance and to provide clients an opportunity to explore ambivalence regarding behavioral change. Finally, letter writing enhances clients' sense of self-efficacy and authorship over their life stories by soliciting self-motivational statements about goals and future development as well as the methods to achieve these desired states.

There are, however, a number of factors that may reduce the effectiveness of brief interventions such as letter writing when employed in crisis intervention settings. First, crisis intervention organizations and the professionals who operate them may feel constrained by time, scarce resources, or the singular mission to stabilize the client and locate links to available services to maintain the client's level of functioning upon return to the community. Thus, motivating clients to consider making changes in their lives, even if this involves a very brief intervention, may be perceived as burdensome by both clients and providers. Second, professionals conducting crisis interventions often forgo immediate motivational interventions, choosing instead to refer their clients to more intensive forms of treatment as a key component of aftercare. In fact, in some settings, any form of intensive counseling may be seen as being beyond the scope of crisis intervention. Third, the risk factors that precipitated the current crisis (e.g., employment issues, substance abuse, psychiatric disorders, inadequate coping and supports, and social isolation) are likely to be present upon the client's return to his or her social environment, eroding the resolve that clients might have experienced as a result of the motivational interventions implemented during the preceding "time-out". Finally, the involuntary circumstances of treatment for a significant proportion of individuals receiving crisis care could reduce the gains that these individuals might otherwise derive from brief motivational interventions (Miller & Rollnick, 1991; Torrey, 1997).

Despite these potential limitations, we remain optimistic about the contribution that letter-writing exercises can make to client treatment in crisis settings. Letter writing is a significant means for promoting and amplifying discrepancies between clients' current circumstances and their stated goals. Moreover, most clients and counselors are likely to have written at least one letter at some point in their lives, and such familiarity facilitates the ease of implementing the technique in crisis and other clinical settings. The brief and flexible format of letter writing make it well suited to transitory "window of opportunity" settings serving multiproblem clients. Finally, client reports indicate that for some, writing a "goodbye" letter to their problem can serve to anchor decisions to make post-care changes in their lives.

Table 1 Guidelines for Letter Writing Exercise and Sample Eliciting Questions

Write a letter saying good-bye to your drug of choice (or another problem). In that letter:

1. Describe your relationship with the drug. What substances do you use? How often do you use each? On average, how much do you use? How long have you been using?

2. Describe how you feel about saying good-bye to this drug. What emotions are you feeling? Are they positive or negative? Do you feel like you are losing or gaining something? What does using alcohol and other drugs mean to you? What purpose does using them serve?

3. What are your reasons for saying good-bye? Have you experienced any negative consequences due to your substance use? How has your substance use affected your family and friends, your job, your health, your feelings about yourself and others, or your legal status? What role did substance use play in bringing you to this unit?

4. What positive and negative things could happen because of saying good-bye? What positive outcomes do you see for yourself? What negative outcomes do you see for yourself? On balance, are these changes more positive or more negative?

5. What short- and long-term changes could you make in your life after saying goodbye? What are some things that you would like to do in the next few days or weeks? What are some larger changes that you would like to make in your life? Is it more difficult to make these changes or reach these goals when you are using alcohol or other drugs? Why?

6. How confident are you that you can make these changes? What do you need to help you make these changes? What services or resources would be useful to help you make these changes? What do you need to keep you from returning to this unit?

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Jonathan G. Tubman, Ph.D., is an associate professor and Marilyn J. Montgomery, Ph.D., is an assistant professor. Both are with the Mental Health Research and Services Program, Department of Psychology, Florida International University, University Park Campus, Miami. Eric F. Wagner, Ph.D., is an associate professor, School of Social Work, College of Health and Urban Affairs, Florida International University, Biscayne Bay Campus, North Miami.

Correspondence may be sent to Dr. Tubman, Department of Psychology, Florida International University, University Park Campus, Miami FL 33199. Email [e-mail]. The preparation of this manuscript was supported in part by NIAAA Grant #AA121280 awarded to Eric E Wagner.