Executive Summary and Recommendations

This TIP is based on a fundamental rethinking of the concept of motivation. Motivation is not seen as static but as dynamic. It is redefined here as purposeful, intentional, and positive--directed toward the best interests of the self.

Specifically, motivation is considered to be related to the probability that a person will enter into, continue, and adhere to a specific change strategy. This TIP shows how substance abuse treatment staff can influence change by developing a therapeutic relationship that respects and builds on the client's autonomy and, at the same time, makes the treatment clinician a partner in the change process.

The TIP also describes different motivational interventions that can be used at all stages of the change process, from precontemplation and preparation to action and maintenance, and informs readers of the research, results, tools, and assessment instruments related to enhancing motivation.

The primary purpose of this TIP is to link research to practice by providing clear applications of motivational approaches in clinical practice and treatment programs. This TIP also seeks to shift the conception of client motivation for change toward a view that empowers the treatment provider to elicit motivation. These approaches may be especially beneficial to particular populations (e.g., court-mandated offenders) with a low motivation for change.

Despite the preponderance of evidence supporting the efficacy of motivation-focused interventions, their use in the United States has occurred primarily in research settings. One obstacle to their implementation may be ideological: low motivation, denial, and resistance are often considered characteristic attributes of those diagnosed with substance abuse disorders.

The cognitive-behavioral emphasis of motivational approaches, however, requires a different perspective on the nature of the problem and the prerequisites for change. This approach places greater responsibility on the clinician, whose job is now expanded to include engendering motivation. Rather than dismissing the more challenging clients as unmotivated, clinicians are equipped with skills to enhance motivation and to establish partnerships with their clients.

The Consensus Panel recommends that substance abuse treatment staff view motivation in this new light. Motivation for change is a key component in addressing substance abuse. The results of longitudinal research suggest that an individual's level of motivation is a very strong predictor of whether the individual's substance use will change or remain the same.

Motivation-enhancing techniques are associated with increased participation in treatment and such positive treatment outcomes as reductions in consumption, higher abstinence rates, better social adjustment, and successful referrals to treatment. In addition, having a positive attitude toward change and being committed to change are associated with positive treatment outcomes.

This is not a new insight. However, until relatively recently motivation was more commonly viewed as a static trait that the client either did or did not have. According to this view, the clinician has little chance of influencing a client's motivation. If the client is not motivated to change, it is the client's--not the clinician's--problem.

Recent models of change, however, recognize that change itself is influenced by biological, psychological, sociological, and spiritual variables. The capacity that each individual brings to the change process is affected by these variables. At the same time, these models recognize that although the client is ultimately responsible for change, this responsibility is shared with the clinician through the development of a "therapeutic partnership."

Chapter 1 of this TIP presents an overview of how the concepts of motivation and change have evolved in recent years and describes the "stages-of-change" model, developed by Prochaska and DiClemente and upon which this TIP is based. Chapter 2 presents interventions that can enhance clients' motivation, highlights their effective elements, and links them to the stages-of-change model.

Developed by Miller and Rollnick, motivational interviewing is a therapeutic style used to interact with substance-using clients that can help them resolve issues related to their ambivalence; this is discussed in Chapter 3.

Chapters 4 through 7 address the five stages of change and provide guidelines for clinicians to tailor their treatment to clients' stages of readiness for change. Various tools and instruments used to measure components of change are summarized in Chapter 8. Chapter 9 provides examples of integrating motivational approaches into existing treatment programs. As motivational interventions are still a relatively new field, there are many unanswered questions; Chapter 10 offers directions for future research.

In order to avoid awkward construction and sexism, this TIP alternates between "he" and "she" for generic examples.

Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, commencing with this TIP, it will be used to denote both substance dependence and substance abuse disorders.

The term does relate to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders as described by the DSM-IV.

Summary of Recommendations

The Consensus Panel's recommendations, summarized below, are based on both research and clinical experience. Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2). References for the former are cited in the body of this document, where the guidelines are presented in detail.

Conceptualizing Motivation

In the past 15 years, considerable research has focused on ways to better motivate substance-using clients to initiate and continue substance abuse treatment. A series of motivational approaches has been developed to elicit and enhance a substance-using client's motivation to change. These approaches are based on the following assumptions about the nature of motivation:

Motivation is a key to change. (2)
Motivation is multidimensional. (2)
Motivation is a dynamic and fluctuating state. (2)
Motivation is interactive. (2)
Motivation can be modified. (2)
The clinician's style influences client motivation. (2)

To incorporate these assumptions about motivation while encouraging a client to change substance-using behavior, the clinician can use the following strategies:

Focus on the client's strengths rather than his weaknesses. (2)

Respect the client's autonomy and decisions. (2)

Make treatment individualized and client centered. (1)

Do not depersonalize the client by using labels like "addict" or "alcoholic." (2)

Develop a therapeutic partnership. (2)

Use empathy, not authority or power. (1)

Focus on early interventions. Extend motivational approaches into nontraditional settings. (2)

Focus on less intensive treatments. (1)

Recognize that substance abuse disorders exist along a continuum. (2)

Recognize that many clients have more than one substance use disorder. (1)

Recognize that some clients may have other coexisting disorders that affect all stages of the change process. (1)

Accept new treatment goals, which involve interim, incremental, and even temporary steps toward ultimate goals. (2)

Integrate substance abuse treatment with other disciplines. (2)

Motivational approaches build on these ideas. They seek to shift control away from the clinician and back to the client. They emphasize treating the client as an individual. They also recognize that treating substance abuse is a cyclical rather than a linear process and that recurrence of use does not necessarily signal failure.

Transtheoretical Model of Change

Substantial research has focused on the determinants and mechanisms of personal change. Theorists have developed various models for how behavior change happens. One perspective sees external consequences as being largely responsible for influencing individuals to change. Another model views intrinsic motivations as causing substance abuse disorders. Others believe that motivation is better described as a continuum of readiness than as one consisting of separate stages of change.

The transtheoretical stages-of-change model, described in Chapter 1, emerged from an examination of 18 psychological and behavioral theories about how change occurs, including components that make up the biopsychosocial framework for understanding addiction. This model of change provides the foundation for this TIP. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. These stages can be conceptualized as a cycle through which clients move back and forth. The stages are not viewed as linear, such that clients enter into one stage and then directly progress to the next. Framing clients' treatment within the stages of change can help the clinician better understand clients' treatment progress.

This model also takes into account that for most people with substance abuse problems, recurrence of substance use is the rule, not the exception. After a return to substance use, clients usually revert to an earlier change stage--not always to maintenance or action, but many times to some level of contemplation. In this model, recurrence is not equivalent to failure and does not mean that a client has abandoned a commitment to change.

Thus, recurrence is not considered a stage but an event that can occur at any point along the cycle of recovery. Based on research and clinical experience, the Consensus Panel endorses the transtheoretical model as a useful model of change (1, 2); however, it is important to note that the model's use has been primarily conceptual and that no current technology is available to definitively determine an individual's stage of readiness for change.

Motivational Interventions

A motivational intervention is any clinical strategy designed to enhance client motivation for change. It can include counseling, client assessment, multiple sessions, or a 30-minute brief intervention. To understand what prompts a person to reduce or eliminate substance use, investigators have searched for the critical components--the most important and common elements that inspire positive change--of effective interventions. The Consensus Panel considers the following elements of current motivational approaches to be important:

The FRAMES approach (1)
Decisional balance exercises (1)
Developing discrepancy (1)
Flexible pacing (2)
Personal contact with clients who are not actively in treatment (1)

The FRAMES approach consists of the following components:

Feedback regarding personal risk or impairment is given to the individual following an assessment of substance use patterns and associated problems. This feedback usually compares the client's scores or ratings on standard tests with normative data from the general population or specified treatment groups.

Responsibility for change is placed squarely and explicitly with the individual. Clients have the choice to either continue their substance use behavior or change it.

Advice about changing--reducing or stopping--substance use is clearly given to the individual by the clinician in a nonjudgmental manner. It is better to suggest than to tell. Asking clients' permission to offer advice can make clients more receptive to that advice.

Menu of self-directed change options and treatment alternatives is offered to the client.

Empathic counseling, showing warmth, respect, and understanding, is emphasized. Empathy entails reflective listening.

Self-efficacy or optimistic empowerment is engendered in the person to encourage change.

Research has shown that simple motivation-enhancing interventions are effective for encouraging clients to return for another clinical consultation, return to treatment following a missed appointment, stay involved in treatment, and be more compliant.

The simplicity and universality of the concepts underlying motivational interventions permit broad-scale application in many different settings and offer great potential to reach individuals with many types of problems and in many different cultures. This is important because treatment professionals work with a wide range of clients who differ with regard to ethnic and racial background, socioeconomic status, education level, gender, age, sexual orientation, type and severity of substance abuse problems, physical health, and psychological health.

Although the principles and mechanisms of enhancing motivation to change seem to be broadly applicable, there may be important differences among populations and cultural contexts regarding the expression of motivation for change and the importance of critical life events. Therefore, clinicians should be thoroughly familiar with the populations with whom they expect to establish therapeutic relationships. (2)

Because motivational strategies emphasize clients' responsibilities to voice personal goals and values as well as to make choices among options for change, clinicians should understand and respond in a nonjudgmental way to expressions of cultural differences. They should identify elements in a population's values that present potential barriers to change.

Clinicians should learn what personal and material resources are available to clients and be sensitive to issues of poverty, social isolation, or recent losses in offering options for change or probing personal values. In particular, it should be recognized that access to financial and social resources is an important part of the motivation for and process of change. (2)

Motivational Interviewing

Motivational interviewing is a therapeutic style intended to help clinicians work with clients to address their ambivalence. While conducting a motivational interview, the clinician is directive yet client centered, with a clear goal of eliciting self-motivational statements and behavioral change from the client, and seeking to create client discrepancy to enhance motivation for positive change. The Consensus Panel recommends that motivational interviewing be seen not as a set of techniques or tools, but rather as a way of interacting with clients. (2) The Panel believes that motivational interviewing is supported by the following principles:

Ambivalence about substance use and change is normal and constitutes an important motivational obstacle in recovery. (2)

Ambivalence can be resolved by working with the client's intrinsic motivations and values. (2)

The alliance between client and clinician is a collaborative partnership to which each brings important expertise. (2)

An empathic, supportive, yet directive counseling style provides conditions within which change can occur. (Direct argument and aggressive confrontation tend to increase client defensiveness, reducing the likelihood of change.) (2)

The motivational interviewing style facilitates an exploration of stage-specific motivational conflicts that can potentially hinder further progress. (1) However, each dilemma also offers an opportunity to use the motivational style as a way of helping clients explore and resolve opposing attitudes.

The Consensus Panel recognizes that successful motivational interviewing will entail being able to

Express empathy through reflective listening. (1)

Communicate respect for and acceptance of clients and their feelings. (2)

Establish a nonjudgmental, collaborative relationship. (2)

Be a supportive and knowledgeable consultant. (2)

Compliment rather than denigrate. (2)

Listen rather than tell. (2)

Gently persuade, with the understanding that change is up to the client. (2)

Provide support throughout the process of recovery. (2)
Develop discrepancy between clients' goals or values and current behavior, helping clients recognize the discrepancies between where they are and where they hope to be. (2)

Avoid argument and direct confrontation, which can degenerate into a power struggle. (2)

Adjust to, rather than oppose, client resistance. (2)

Support self-efficacy and optimism: that is, focus on clients' strengths to support the hope and optimism needed to make change. (2)

Clinicians who adopt motivational interviewing as a preferred style have found that the following five strategies are particularly useful in the early stages of treatment:

Ask open-ended questions. Open-ended questions cannot be answered with a single word or phrase. For example, rather than asking, "Do you like to drink?" ask, "What are some of the things that you like about drinking?" (2)

Listen reflectively. Demonstrate that you have heard and understood the client by reflecting what the client said. (2)

Summarize. It is useful to summarize periodically what has transpired up to that point in a counseling session. (2)

Affirm. Support and comment on the client's strengths, motivation, intentions, and progress. (2)

Elicit self-motivational statements. Have the client voice personal concerns and intentions, rather than try to persuade the client that change is necessary. (2)

Tailoring Motivational Interventions to the Stages of Change

Individuals appear to need and use different kinds of help, depending on which stage of readiness for change they are currently in and to which stage they are moving. (2) Clients who are in the early stages of readiness need and use different kinds of motivational support than do clients at later stages of the change cycle.

To encourage change, individuals in the precontemplation stage must increase their awareness. (2) To resolve their ambivalence, clients in the contemplation stage should choose positive change over the status quo. (2) Clients in the preparation stage must identify potential change strategies and choose the most appropriate one for their circumstances.

Clients in the action stage must carry out change strategies. This is the stage toward which most formal substance abuse treatment is directed. During the maintenance stage, clients may have to develop new skills that help maintain recovery and a healthy lifestyle. Moreover, if clients resume their problem substance use, they need help to recover as quickly as possible and reenter the change process.

From precontemplation to contemplation

According to the stages-of-change model, individuals in the precontemplation stage are not concerned about their substance use or are not considering changing their behavior. These substance users may remain in precontemplation or early contemplation for years, rarely or never thinking about change. Often, a significant other finds the substance user's behavior problematic.

Chapter 4 discusses a variety of proven techniques and gentle tactics that clinicians can use to address the topic of substance abuse with people who are not thinking of change. Use of these techniques will serve to (1) create client doubt about the commonly held belief that substance abuse is "harmless" and (2) lead to client conviction that substance abuse is having, or will in the future have, significant negative results. The chapter suggests that clinicians practice the following:

Commend the client for coming to substance abuse treatment. (2)

Establish rapport, ask permission to address the topic of change, and build trust. (2)

Elicit, listen to, and acknowledge the aspects of substance use the client enjoys. (2)

Evoke doubts or concerns in the client about substance use. (2)

Explore the meaning of the events that brought the client to treatment or the results of previous treatments. (2)

Obtain the client's perceptions of the problem. (2)
Offer factual information about the risks of substance use. (2)

Provide personalized feedback about assessment findings. (2)

Help a significant other intervene. (2)

Examine discrepancies between the client's and others' perceptions of the problem behavior. (2)

Express concern and keep the door open. (2)

The assessment and feedback process can be an important part of the motivational strategy because it informs clients of how their own substance use patterns compare with norms, what specific risks are entailed, and what damage already exists or is likely to occur if changes are not made.

Giving clients personal results from a broad-based and objective assessment, especially if the findings are carefully interpreted and compared with norms or expected values, can be not only informative but also motivating. (1) Providing clients with personalized feedback on the risks associated with their own use of a particular substance--especially for their own cultural and gender groups--is a powerful way to develop a sense of discrepancy that can motivate change.

Intervening through significant others

Considerable research shows that involvement of family members or significant others (SOs) can help move substance-using persons toward contemplation of change, entry into treatment, involvement and retention in the therapeutic process, and successful recovery. (1) Involving SOs in the early stages of change can greatly enhance a client's commitment to change by addressing the client's substance use in the following ways:

Providing constructive feedback to the client about the costs and benefits associated with her substance abuse (2)

Encouraging the resolve of the client to change the negative behavior pattern (2)

Identifying the client's concrete and emotional obstacles to change (2)

Alerting the client to social and individual coping resources that lead to a substance-free lifestyle (2)

Reinforcing the client for employing these social and coping resources to change the substance use behavior (2)

The clinician can engage an SO by asking the client to invite the SO to a treatment session. Explain that the SO will not be asked to monitor the client's substance use but that the SO can perform a valuable role by providing emotional support, identifying problems that might interfere with treatment goals, and participating in activities with the client that do not involve substance use. To strengthen the SO's belief in his capacity to help the client, the clinician can use the following strategies:

Positively describe the steps used by the SO that have been successful (define "successful" generously). (2)
Reinforce positive comments made by the SO about the client's current change efforts. (2)
Discuss future ways in which the client might benefit from the SO's efforts to facilitate change. (2)

Clinicians should use caution when involving an SO in motivational counseling. Although a strong relationship between the SO and the client is necessary, it is not wholly sufficient. The SO must also support a client's substance-free life, and the client must value that support. (1)

An SO who is experiencing hardships or emotional problems stemming from the client's substance use may not be a suitable candidate. (1) Such problems can preclude the SO from constructively participating in the counseling sessions, and it may be better to wait until the problems have subsided before including an SO in the client's treatment. (1)

In general, the SO can play a vital role in influencing the client's willingness to change; however, the client must be reminded that the responsibility to change substance use behavior is hers. (2)

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Continued on Page 2

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Contents on this site:
1,2 Executive Summary
3,4 Chapter 1-- Conceptualizing Motivation And Change
5,6 Chapter 2 Motivation and Intervention
7,8 Chapter 3 Motivational Interviewing as a Counseling Style

For additional Chapters, diagrams, references see
SAMHSA/CSAT Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Index Page
     

Motivational interventions and coerced clients

An increasing number of clients are mandated to obtain treatment by an employer or employee assistance program, the court system, or probation and parole officers. Others are influenced to enter treatment because of legal pressures. The challenge for clinicians is to engage coerced clients in the treatment process.

A stable recovery cannot be maintained by external (legal) pressure only; motivation and commitment must come from internal pressure. If you provide interventions appropriate to their stage, coerced clients may become invested in the change process and benefit from the opportunity to consider the consequences of use and the possibility of change--even though that opportunity was not voluntarily chosen. (2)

From contemplation to preparation

Extrinsic and intrinsic motivators should be considered when trying to increase a client's commitment to change and move the client closer to action because these motivators can be examined to enhance decisionmaking, thereby enhancing the client's commitment. Many clients move through the contemplation stage acknowledging only the extrinsic motivators pushing them to change or that brought them to treatment.

Help the client discover intrinsic motivators, which typically move the client from contemplating change to acting. (2) In addition to the standard practices for motivational interviewing (e.g., reflective listening, asking open-ended questions), clinicians can help spur this process of changing extrinsic motivators to intrinsic motivators by doing the following:

Show curiosity about clients. Because a client's desire to change is seldom limited to substance use, he may find it easier to discuss changing other behaviors. This will help strengthen the therapeutic alliance. (2)
Reframe a client's negative statement about perceived coercion by re-expressing the statement with a positive spin. (2)

Clinicians can use decisional balancing strategies to help clients thoughtfully consider the positive and negative aspects of their substance use. (1) The ultimate purpose, of course, is to help clients recognize and weigh the negative aspects of substance use so that the scale tips toward beneficial behavior. Techniques to use in decisional balancing exercises include the following:

Summarize the client's concerns. (2)

Explore specific pros and cons of substance use behavior. (1)

Normalize the client's ambivalence. (2)

Reintroduce feedback from previous assessments. (1)

Examine the client's understanding of change and expectations of treatment. (1)

Reexplore the client's values in relation to change. (2)

Throughout this process, emphasize the clients' personal choices and responsibilities for change. The clinician's task is to help clients make choices that are in their best interests. This can be done by exploring and setting goals. Goal-setting is part of the exploring and envisioning activities characteristic of the early and middle preparation stage. The process of talking about and setting goals strengthens commitment to change. (1)

During the preparation stage, the clinician's tasks broaden from using motivational strategies to increase readiness--the goals of precontemplation and contemplation stages--to using these strategies to strengthen a client's commitment and help her make a firm decision to change. At this stage, helping the client develop self-efficacy is important. (2) Self-efficacy is not a global measure, like self-esteem; rather, it is behavior specific. In this case, it is the client's optimism that she can take action to change substance-use behaviors.

From preparation to action

As clients move through the preparation stage, clinicians should be alert for signs of clients' readiness to move into action. There appears to be a limited period of time during which change should be initiated. (2) Clients' recognition of important discrepancies in their lives is too uncomfortable a state to remain in for long, and unless change is begun they can retreat to using defenses such as minimizing or denying to decrease the discomfort. (2) The following can signal a client's readiness to act:

The client's resistance (i.e., arguing, denying) decreases. (2)

The client asks fewer questions about the problem. (2)
The client shows a certain amount of resolve and may be more peaceful, calm, relaxed, unburdened, or settled. (2)

The client makes direct self-motivational statements reflecting openness to change and optimism. (2)

The client asks more questions about the change process. (2)

The client begins to talk about how life might be after a change. (2)

The client may have begun experimenting with possible change approaches such as going to an Alcoholics Anonymous meeting or stopping substance use for a few days. (2)

Mere vocal fervor about change, however, is not necessarily a sign of dogged determination. Clients who are most vehement in declaring their readiness may be desperately trying to convince themselves, as well as the clinician, of their commitment.

When working with clients in the preparation stage, clinicians should try to

Clarify the client's own goals and strategies for change. (2)

Discuss the range of different treatment options and community resources available to meet the client's multiple needs. (2)

With permission, offer expertise and advice. (2)

Negotiate a change--or treatment--plan and a behavior contract (2); take into consideration
Intensity and amount of help needed
Timeframe
Available social support, identifying who, where, and when
The sequence of smaller goals or steps needed for a successful plan
Multiple problems, such as legal, financial, or health concerns

Consider and lower barriers to change by anticipating possible family, health, system, and other problems. (2)

Help the client enlist social support (e.g., mentoring groups, churches, recreational centers). (2)

Explore treatment expectancies and client role. (2)
Have clients publicly announce their change plans to significant others in their lives. (2)

From action to maintenance

A motivational counseling style has most frequently been used with clients in the precontemplation through preparation stages as they move toward initiating behavioral change. Some clients and clinicians believe that formal, action-oriented substance abuse treatment is a different domain and that motivational strategies are no longer required. This is not true for two reasons. First, clients may still need a surprising amount of support and encouragement to stay with a chosen program or course of treatment.

Even after a successful discharge, they may need support and encouragement to maintain the gains they have achieved and to know how to handle recurring crises that may mean a return to problem behaviors. (2) Second, many clients remain ambivalent in the action stage of change or vacillate between some level of contemplation--with associated ambivalence--and continuing action. (2)

Moreover, clients who do take action are suddenly faced with the reality of stopping or reducing substance use. This is more difficult than just contemplating action. The first stages of recovery require only thinking about change, which is not as threatening as actually implementing it.

Clients' involvement or participation in treatment can be increased when clinicians

Develop a nurturing rapport with clients. (2)

Induct clients into their role in the treatment process. (2)

Explore what clients expect from treatment and determine discrepancies. (2)

Prepare clients so that they know there may be some embarrassing, emotionally awkward, and uncomfortable moments but that such moments are a normal part of the recovery process. (2)

Investigate and resolve barriers to treatment. (2)

Increase congruence between intrinsic and extrinsic motivation. (2)

Examine and interpret noncompliant behavior in the context of ambivalence. (2)

Reach out to demonstrate continuing personal concern and interest to encourage clients to remain in the program. (2)

Clients who are in the action stage can be most effectively helped when clinicians

Engage clients in treatment and reinforce the importance of remaining in recovery. (2)

Support a realistic view of change through small steps. (2)

Acknowledge difficulties for clients in early stages of change. (2)

Help the client identify high-risk situations through a functional analysis and develop appropriate coping strategies to overcome these. (2)

Assist the client in finding new reinforcers of positive change. (2)

Assess whether the client has strong family and social support. (2)

The next challenge that clients and clinicians face is maintaining change. With clients in the maintenance stage, clinicians will be most successful if they can

Help the client identify and sample substance-free sources of pleasure--i.e., new reinforcers. (1)

Support lifestyle changes. (2)

Affirm the client's resolve and self-efficacy. (2)

Help the client practice and use new coping strategies to avoid a return to substance use. (2)

Maintain supportive contact. (2)

After clients have planned for stabilization by identifying risky situations, practicing new coping strategies, and finding their sources of support, they still have to build a new lifestyle that will provide sufficient satisfaction and can compete successfully against the lure of substance use. A wide range of life changes ultimately needs to be made if clients are to maintain lasting abstinence. Clinicians can help this change process by using competing reinforcers. (1) A competing reinforcer is anything that clients enjoy that is or can become a healthy alternative to drugs or alcohol as a source of satisfaction.

The essential principle in establishing new sources of positive reinforcement is to get clients involved in generating their own ideas. Clinicians should explore all areas of clients' lives for new reinforcers. Reinforcers should not come from a single source or be of the same type. That way, a setback in one area can be counterbalanced by the availability of positive reinforcement from another area. Since clients have competing motivations, clinicians can help them select reinforcers that will win out over substances over time.

Following are a number of potential competing reinforcers that can help clients:

Doing volunteer work, thus filling time, connecting with socially acceptable friends, and improving their self-efficacy (2)

Becoming involved in 12-Step-based activities and other self-help groups (2)

Setting goals to improve their work, education, exercise, and nutrition (2)

Spending more time with their families and significant others (2)

Participating in spiritual or cultural activities (2)

Socializing with nonsubstance-using friends (2)

Learning new skills or improving in such areas as sports, art, music, and other hobbies (2)

Contingency reinforcement systems, such as voucher programs, have proven to be effective when community support and resources are available. (1) Research has shown that these kinds of reinforcement systems can help to sustain abstinence in drug abusers. The rationale for this type of incentive program is that an appealing external motivator can be used as an immediate and powerful reinforcer to compete with substance use reinforcers. Not all contingent incentives have to have a monetary value. In many cultures, money is not the most powerful reinforcer.

Measuring Client Motivation

Because motivation is multidimensional, it cannot be easily measured with one instrument or scale. Instead, the Consensus Panel recommends that substance abuse treatment staff use a variety of tools to measure several dimensions of motivation, including (2):

Self-efficacy
Importance of change
Readiness to change
Decisional balancing
Motivations for using substances

Integrating Motivational Approaches Into Treatment Programs

One of the principles of current health care management is that the most intensive and expensive treatments should be used only with those with the most serious problems or with those who have not responded to lesser interventions. Motivational interventions can serve many purposes in treatment settings:

As a means of rapid engagement in the general medical setting to facilitate referral to treatment (2)

As a first session to increase the likelihood that a client will return and to deliver a useful service if the client does not return (1)

As an empowering brief consultation when a client is placed on a waiting list, rather than telling a client to wait for treatment (1)

As a preparation for treatment to increase retention and participation (1)

To help clients coerced into treatment to move beyond initial feelings of anger and resentment (2)

To overcome client defensiveness and resistance (2)

As a stand-alone intervention in settings where there is only brief contact (1)

As a counseling style used throughout the process of change (1)

Need for Future Research

Motivational interventions are a relatively new, but favorably received, approach to encouraging positive behavioral change. As indicated earlier, motivational interventions have been successfully used with a variety of problems, client populations, and settings, and the methodology appears to be generally applicable, although it was developed primarily with heavy alcohol drinkers and cigarette smokers.

Researchers should consider some of the following questions when planning and developing future research studies (2):

What are the active ingredients of motivational interventions?

Can motivational interventions be standardized and taught?

What types of clients are most amenable to motivational interventions?

What types of outcomes can be defined and measured?

What clinician characteristics affect the outcomes of motivational interventions?

Are stage-matched interventions appropriate?

How do motivational interventions compare with other substance abuse treatments in terms of cost-effectiveness?

How do culture and context influence the effectiveness of motivational interventions?

What kinds of training and support are needed to teach motivational interventions?

How can motivational interventions be applied successfully to an even broader variety of problems, populations, and settings?

To Which Clients Does This TIP Apply?

Motivational interviewing was originally developed for problem alcohol drinkers in the early stages (precontemplation and contemplation) of readiness for change and was conceived as a way of initiating treatment. However, it soon became apparent that this approach constitutes an intervention in itself. Benefits have been reported with severely substance-dependent populations, polydrug-abusing adolescents, and users of heroin and marijuana.

In Project MATCH, the largest clinical trial ever conducted to compare different alcohol treatment methods, a four-session motivational enhancement therapy yielded long-term overall outcomes virtually identical to those of longer outpatient methods. Clients varied widely in problem severity; the vast majority met criteria for alcohol dependence, and they represented a range of cultural backgrounds, particularly Hispanic.

It is noteworthy that neither Hispanic nor African-American samples responded differentially to the motivational enhancement therapy approach. In addition, analyses of clinical trials of motivational interviewing that had substantial representation of Hispanic clients found no indication of self-identified ethnicity and socioeconomic status as predictors of outcome. Evidence strongly suggests that motivational interviewing can be applied across cultural and economic differences.

The motivational style of counseling can be useful, not only to instill motivation initially, but throughout the process of treatment in the preparation, action, and maintenance stages as well, with a range of client populations. This is reflected in the following chapters of this TIP.
 
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From SAMHSA/CSAT  Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
  

Motivation can be understood not as something that one has but rather as something one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy. There are, it turns out, many ways to help people move toward such recognition and action. Miller, 1995

Why do people change? What is motivation? Can individuals' motivation to change their substance-using behavior be modified? Do clinicians have a role in enhancing substance-using clients' motivation for recovery?

Over the past 15 years, considerable research and clinical attention have focused on ways to better motivate substance users to consider, initiate, and continue substance abuse treatment, as well as to stop or reduce their excessive use of alcohol, cigarettes, and drugs, either on their own or with the help of a formal program.

A related focus has been on sustaining change and avoiding a recurrence of problem behavior following treatment discharge. This research represents a paradigmatic shift in the addiction field's understanding of the nature of client motivation and the clinician's role in shaping it to promote and maintain positive behavioral change.

This shift parallels other recent developments in the addiction field, and the new motivational strategies incorporate or reflect many of these developments. Coupling a new therapeutic style--motivational interviewing--with a transtheoretical stages-of-change model offers a fresh perspective on what clinical strategies may be effective at various points in the recovery process.

Motivational interventions resulting from this theoretical construct are promising clinical tools that can be incorporated into all phases of substance abuse treatment as well as many other social and health services settings.

A New Look at Motivation

In substance abuse treatment, clients' motivation to change has often been the focus of clinical interest and frustration. Motivation has been described as a prerequisite for treatment, without which the clinician can do little (Beckman, 1980).

Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment (Appelbaum, 1972; Miller, 1985b). Until recently, motivation was viewed as a static trait or disposition that a client either did or did not have.

If a client was not motivated for change, this was viewed as the client's fault. In fact, motivation for treatment connoted an agreement or willingness to go along with a clinician's or program's particular prescription for recovery.

A client who seemed amenable to clinical advice or accepted the label of "alcoholic" or "drug addict" was considered to be motivated, whereas one who resisted a diagnosis or refused to adhere to the proffered treatment was deemed unmotivated.

Furthermore, motivation was often viewed as the client's responsibility, not the clinician's (Miller and Rollnick, 1991). Although there are reasons why this view developed that will be discussed later, this guideline views motivation from a substantially different perspective.

A New Definition

The motivational approaches described in this TIP are based on the following assumptions about the nature of motivation:

Motivation is a key to change.
Motivation is multidimensional.
Motivation is dynamic and fluctuating.
Motivation is influenced by social interactions.
Motivation can be modified.
Motivation is influenced by the clinician's style.

The clinician's task is to elicit and enhance motivation.

Motivation is a key to change

The study of motivation is inexorably linked to an understanding of personal change--a concept that has also been scrutinized by modern psychologists and theorists and is the focus of substance abuse treatment.

The nature of change and its causes, like motivation, is a complex construct with evolving definitions. Few of us, for example, take a completely deterministic view of change as an inevitable result of biological forces, yet most of us accept the reality that physical growth and maturation do produce change--the baby begins to walk and the adolescent seems to be driven by hormonal changes.

We recognize, too, that social norms and roles can change responses, influencing behaviors as diverse as selecting clothes or joining a gang, although few of us want to think of ourselves as simply conforming to what others expect. Certainly, we believe that reasoning and problem-solving as well as emotional commitment can promote change.

The framework for linking individual change to a new view of motivation stems from what has been termed a phenomenological theory of psychology, most familiarly expressed in the writings of Carl Rogers.

In this humanistic view, an individual's experience of the core inner self is the most important element for personal change and growth--a process of self-actualization that prompts goal-directed behavior for enhancing this self (Davidson, 1994).

In this context, motivation is redefined as purposeful, intentional, and positive--directed toward the best interests of the self. More specifically, motivation is the probability that a person will enter into, continue, and adhere to a specific change strategy (Miller and Rollnick, 1991).

Motivation is multidimensional

Motivation, in this new meaning, has a number of complex components that will be discussed in subsequent chapters of this TIP. It encompasses the internal urges and desires felt by the client, external pressures and goals that influence the client, perceptions about risks and benefits of behaviors to the self, and cognitive appraisals of the situation.

Motivation is dynamic and fluctuating

Research and experience suggest that motivation is a dynamic state that can fluctuate over time and in relation to different situations, rather than a static personal attribute. Motivation can vacillate between conflicting objectives.

Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved and goals are more clearly envisioned. In this sense, motivation can be an ambivalent, equivocating state or a resolute readiness to act--or not to act.

Motivation is influenced by social interactions

Motivation belongs to one person, yet it can be understood to result from the interactions between the individual and other people or environmental factors (Miller, 1995b). Although internal factors are the basis for change, external factors are the conditions of change.

An individual's motivation to change can be strongly influenced by family, friends, emotions, and community support. Lack of community support, such as barriers to health care, employment, and public perception of substance abuse, can also affect an individual's motivation.

Motivation can be modified

Motivation pervades all activities, operating in multiple contexts and at all times. Consequently, motivation is accessible and can be modified or enhanced at many points in the change process.

Clients may not have to "hit bottom" or experience terrible, irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image (Miller, 1985; Miller et al., 1993).

Although there are substantial differences in what factors influence people's motivation, several types of experiences may have dramatic effects, either increasing or decreasing motivation. Experiences such as the following often prompt people to begin thinking about making changes and to consider what steps are needed:

Distress levels may have a role in increasing the motivation to change or search for a change strategy (Leventhal, 1971; Rogers et al., 1978). For example, many individuals are prompted to change and seek help during or following episodes of severe anxiety or depression.

Critical life events often stimulate the motivation to change. Milestones that prompt change range from spiritual inspiration or religious conversion through traumatic accidents or severe illnesses to deaths of loved ones, being fired, becoming pregnant, or getting married (Sobell et al., 1993b; Tucker et al., 1994).

Cognitive evaluation or appraisal, in which an individual evaluates the impact of substances in his life, can lead to change. This weighing of the pros and cons of substance use accounts for 30 to 60 percent of the changes reported in natural recovery studies (Sobell et al., 1993b).

Recognizing negative consequences and the harm or hurt one has inflicted on others or oneself helps motivate some people to change (Varney et al., 1995). Helping clients see the connection between substance use and adverse consequences to themselves or others is an important motivational strategy.

Positive and negative external incentives also can influence motivation. Supportive and empathic friends, rewards, or coercion of various types may stimulate motivation for change.

Motivation is influenced by the clinician's style

The way you, the clinician, interact with clients has a crucial impact on how they respond and whether treatment is successful. Researchers have found dramatic differences in rates of client dropout or completion among counselors in the same program who are ostensibly using the same techniques (Luborsky et al., 1985).

Counselor style may be one of the most important, and most often ignored, variables for predicting client response to an intervention, accounting for more of the variance than client characteristics (Miller and Baca, 1983; Miller et al., 1993).

In a review of the literature on counselor characteristics associated with treatment effectiveness for substance users, researchers found that establishing a helping alliance and good interpersonal skills were more important than professional training or experience (Najavits and Weiss, 1994).

The most desirable attributes for the counselor mirror those recommended in the general psychological literature and include nonpossessive warmth, friendliness, genuineness, respect, affirmation, and empathy.

A direct comparison of counselor styles suggested that a confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centered, supportive, and empathic style that uses reflective listening and gentle persuasion (Miller et al., 1993).

In this study, the more a client was confronted, the more alcohol the client drank. Confrontational counseling in this study included challenging the client, disputing, refuting, and using sarcasm.

The clinician's task is to elicit and enhance motivation

Although change is the responsibility of the client and many people change their excessive substance-using behavior on their own without therapeutic intervention (Sobell et al., 1993b), you can enhance your client's motivation for beneficial change at each stage of the change process.

Your task is not, however, one of simply teaching, instructing, or dispensing advice. Rather, the clinician assists and encourages clients to recognize a problem behavior (e.g., by encouraging cognitive dissonance), to regard positive change to be in their best interest, to feel competent to change, to develop a plan for change, to begin taking action, and to continue using strategies that discourage a return to the problem behavior (Miller and Rollnick, 1991).

Be sensitive to influences such as your client's cultural background; knowledge or lack thereof can influence your client's motivation.

Why Enhance Motivation?

Research has shown that motivation-enhancing approaches are associated with greater participation in treatment and positive treatment outcomes. Such outcomes include reductions in consumption, increased abstinence rates, social adjustment, and successful referrals to treatment (Landry, 1996; Miller et al., 1995a).

A positive attitude toward change and a commitment to change are also associated with positive treatment outcomes (Miller and Tonigan, 1996; Prochaska and DiClemente, 1992).

The benefits of employing motivational enhancement techniques include

Inspiring motivation to change
Preparing clients to enter treatment
Engaging and retaining clients in treatment
Increasing participation and involvement
Improving treatment outcomes
Encouraging a rapid return to treatment if symptoms recur

Changing Perspectives on Addiction and Treatment

Americans have often shown ambivalence toward excessive drug and alcohol use. They have vacillated between viewing offenders as morally corrupt sinners who are the concern of the clergy and the law and seeing them as victims of compulsive craving who should receive medical treatment.

After the passage of the Harrison Narcotics Act in 1914, physicians were imprisoned for treating addicts. In the 1920s, compassionate treatment of opiate dependence and withdrawal was available in medical clinics, yet at the same time, equally passionate support of the temperance movement and Prohibition was gaining momentum.

These conflicting views were further manifested in public notions of who deserved treatment (e.g., Midwestern farm wives addicted to laudanum) and who did not (e.g., urban African-Americans).

Different views about the nature and etiology of addiction have more recently influenced the development and practice of current treatments for substance abuse. Differing theoretical perspectives have guided the structure and organization of treatment and the services delivered (Institute of Medicine, 1990b).

Comparing substance abuse treatment to a swinging pendulum, one writer noted, Notions of moral turpitude and incurability have been linked with problems of drug dependence for at least a century.

Even now, public and professional attitudes toward alcoholism are an amalgam of contrasting, sometimes seemingly irreconcilable views: The alcoholic is both sick and morally weak. The attitudes toward those who are dependent on opiates are a similar amalgam, with the element of moral defect in somewhat greater proportion (Jaffee, 1979, p. 9).

Evolving Models of Treatment

The development of a modern treatment system for substance abuse dates only from the late 1960s, with the decriminalization of public drunkenness and the escalation of fears about crime associated with increasing heroin addiction.

Nonetheless, the system has rapidly evolved in response to new technologies, research, and changing theories of addiction with associated therapeutic interventions. The six models of addiction described below have competed for attention and guided the application of treatment strategies over the last 30 years.

Moral model

Addiction is viewed by some as a set of behaviors that violate religious, moral, or legal codes of conduct. From this perspective, addiction results from a freely chosen behavior that is immoral, perhaps sinful, and sometimes illegal.

It assumes that individuals who choose to misuse substances create suffering for themselves and others and lack self-discipline and self-restraint. Substance misuse and abuse are irresponsible and intentional actions that deserve punishment (Wilbanks, 1989), including arrest and incarceration (Thombs, 1994).

Because excessive substance use is seen as the result of a moral choice, change can only come about by an exercise of will power (IOM, 1990b), external punishment, or incarceration.

Medical model

A contrasting view of addiction as a chronic and progressive disease inspired what has come to be called the medical model of treatment, which evolved from earlier forms of disease models that stressed the need for humane treatment and hypothesized a dichotomy between "normals" and "addicts" or "alcoholics."

The latter were asserted to differ qualitatively, physiologically, and irreversibly from normal individuals. More recent medical models take a broader "biopsychosocial" view, consonant with a modern understanding of chronic diseases as multiply determined.

Nevertheless, emphasis continues to be placed on physical causes. In this view, genetic factors increase the likelihood for an individual to misuse psychoactive substances or to lose control when using them.

Neurochemical changes in the brain resulting from substance use then induce continuing consumption, as does the development of physiological dependence.

Treatment in this model is typically delivered in a hospital or medical setting and includes various pharmacological therapies to assist detoxification, symptom reduction, aversion, or maintenance on suitable alternatives.

Responsibility for resolving the problem does not rest with the client, and change can come about only through acknowledging loss of control, adhering to medical prescriptions, and participating in a self-help group (IOM, 1990b).

Spiritual model

The spiritual model of addiction is one of the most influential in America, largely because of such 12-Step fellowships as Alcoholics Anonymous (AA), Cocaine Anonymous, Narcotics Anonymous, and Al-Anon.

This model is often confused with the moral and medical models, but its emphasis is quite distinct from these (Miller and Kurtz, 1994). In the original writings of AA, there is discussion of "defects of character" as central to understanding alcoholism, with particular emphasis on issues such as pride versus humility and resentment versus acceptance.

In this view, substances are used in an attempt to fill a spiritual emptiness and meaninglessness.

Spiritual models give much less weight to etiology than to the importance of a spiritual path to recovery.

Twelve-Step programs emphasize recognizing a Higher Power (often called God in AA) beyond one's self, asking for healing of character, maintaining communication with the Higher Power through prayer and meditation, and seeking to conform one's life to its will. Twelve-Step programs are not wholly "self-help" programs but rather "Higher Power-help" programs.

The first of the 12 steps is to recognize that one literally cannot help oneself or find recovery through the power of one's own will. Instead, the path back to health is spiritual, involving surrender of the will to a Higher Power. Clinicians follow various guidelines in supporting their clients' involvement in 12-Step programs (Tonigan et al., 1999).

Twelve-Step programs are rooted in American Protestantism, but other distinctly spiritual models do not rely on Christian or even theistic thought. Transcendental meditation, based on Eastern spiritual practice, has been widely practiced as a method for preventing and recovering from substance abuse problems (Marlatt and Kristeller, 1999).

Native American spirituality has been integrated into treatment programs serving Native American populations through the use of sweat lodges and other traditional rituals, such as singing and healing ceremonies.

Spiritual models all share a recognition of the limitations of the self and a desire to achieve health through a connection with that which transcends the individual.

Psychological model

In the psychological model of addiction, problematic substance use results from deficits in learning, emotional dysfunction, or psychopathology that can be treated by behaviorally or psychoanalytically oriented dynamic therapies.

Sigmund Freud's pioneering work has had a deep and lasting effect on substance abuse treatment. He originated the notion of defense mechanisms (e.g., denial, projection, rationalization), focused on the importance of early childhood experiences, and developed the idea of the unconscious mind.

Early psychoanalysis viewed substance abuse disorders as originating from unconscious death wishes and self-destructive tendencies of the id (Thombs, 1994). Substance dependence was believed to be a slow form of suicide (Khantzian, 1980). Other early psychoanalytic writers emphasized the role of oral fixation in substance dependence.

A more contemporary psychoanalytic view is that substance use is a symptom of impaired ego functioning--a part of the personality that mediates the demands of the id and the realities of the external world. Another view considers substance abuse disorders as "both developmental and adaptive" (Khantzian et al., 1990).

From this perspective, the use of substances is an attempt to compensate for vulnerabilities in the ego structure. Substance use, then, is motivated by an inability to regulate one's inner life and external behavior.

Thus, psychoanalytic treatment assumes that insight obtained through the treatment process results in the strengthening of internal mechanisms, which becomes evident by the establishment of external controls; in other words, the change process shifts from internal (intrapsychic) to external (behavioral, interpersonal).

An interesting psychoanalytic parallel to modern motivational theory is found in the writings of Anton Kris, who described the "conflicts of ambivalence" seen in clients that May cast a paralyzing inertia not only upon the patient but upon the treatment method. In such instances, patient and analyst, like the driver of an automobile stuck in a snowdrift, must aim at a rocking motion that eventually gathers enough momentum to permit movement in one direction or another (Kris, 1984, p. 224).

Other practitioners view addiction as a symptom of an underlying mental disorder. From this perspective, successful treatment of the primary psychiatric disorder should result in resolution of the substance use problem.

However, over the past decade, substantial research and clinical attention have revealed a more complex relationship between psychiatric and substance abuse disorders and symptoms.

Specifically, substance use can cause psychiatric symptoms and mimic psychiatric disorders; substance use can prompt or worsen the severity of psychiatric disorders; substance use can mask psychiatric disorders and symptoms; withdrawal from severe substance dependence can precipitate psychiatric symptoms and mimic psychiatric disorders; psychiatric and substance abuse disorders can coexist; and psychiatric disorders can produce behaviors that mimic ones associated with substance use problems (CSAT, 1994b; Landry et al., 1991).

From the perspective of behavioral psychology, substance use is a learned behavior that is repeated in direct relation to the quality, number, and intensity of reinforcers that follow each episode of use (McAuliffe and Gordon, 1980).

Addiction is based on the principle that people tend to repeat certain behaviors if they are reinforced for engaging in them. Positive reinforcers of substance use depend on the substance used but include powerful effects on the central nervous system.

Other social variables, such as peer group acceptance, can also act as positive reinforcers. Negative reinforcers include lessened anxiety and elimination of withdrawal symptoms. A person's experiences and expectations in relation to the effects of selected substances on certain emotions or situations will determine substance-using patterns.

Change comes about if the reinforcers are outweighed or replaced by negative consequences, also known as punishers, and the client learns to apply strategies for coping with situations that lead to substance use.

Other psychologists have emphasized the role of cognitive processes in addictive behavior. Bandura's concept of self-efficacy--the perceived ability to change or control one's own behavior--has been influential in modern conceptions of addiction (Bandura, 1997).

Cognitive therapists have described treatment approaches for modifying pathogenic beliefs that may underlie substance abuse (Beck et al., 1993; Ellis and Velten, 1992).

Sociocultural model

A related, sociocultural perspective on addiction emphasizes the importance of socialization processes and the cultural milieu in developing--and ameliorating--substance abuse disorders.

Factors that affect drinking behavior include socioeconomic status, cultural and ethnic beliefs, availability of substances, laws and penalties regulating substance use, the norms and rules of families and other social groups as well as parental and peer expectations, modeling of acceptable behaviors, and the presence or absence of reinforcers.

Because substance-related problems are seen as occurring in interactive relations with families, groups, and communities, alterations in policies, laws, and norms are part of the change process.

Building new social and family relations, developing social competency and skills, and working within one's cultural infrastructure are important avenues for change in the sociocultural model (IOM, 1990b).

From the sociocultural perspective, an often neglected aspect of positive behavioral change is sorting out ethical principles or renewing opportunities for spiritual growth that can ameliorate the guilt, shame, regret, and sadness about the substance-related harm clients may have inflicted on themselves and others.

Composite biopsychosocial-spiritual model

As the conflicts among these competing models of addiction have become evident and as research has confirmed some truth in each model, the addiction field has searched for a single construct to integrate these diverse perspectives (Wallace, 1990).

This has led to an emerging biopsychosocial--spiritual framework that recognizes the importance of many interacting influences. Indeed, the current view is that all chronic diseases, whether substance use, cancer, diabetes, or coronary artery disease, are best treated by collaborative and comprehensive approaches that address both biopsychosocial and spiritual components (Borysenko and Borysenko, 1995; Williams and Williams, 1994).

This overarching model of addiction retains the proven elements and techniques of each of the preceding models while eliminating some previous--and erroneous--assumptions, which are discussed below.

Myths About Client Traits and Effective Counseling

Although the field is evolving toward a more comprehensive understanding of substance misuse and abuse, earlier views of addiction still persist in parts of our treatment system. Some of these are merely anachronisms; others may actually harm clients. Recent research has shown that some types of interventions that have been historically embedded within treatment approaches in the United States may paradoxically reduce motivation for beneficial change.

Other persisting stereotypes also interfere with the establishment of a helping alliance or partnership between the clinician and the client. Among the suppositions about clients and techniques that are being questioned and discarded are those discussed below.

Addiction stems from an addictive personality

Although it is commonly believed that substance abusers possess similar personality traits that make treatment difficult, no distinctive personality traits have been found to predict that an individual will develop a substance abuse disorder.

The tendencies of an addictive personality most often cited are denial, projection, poor insight, and poor self-esteem. Research efforts, many of which have focused on clients with alcohol dependence, suggest there is no characteristic personality among substance-dependent individuals (Loberg and Miller, 1986; Miller, 1976; Vaillant, 1995).

Rather, research suggests that people with substance abuse problems reflect a broad range of personalities. Nonetheless, the existence of an addictive personality continues to be a popular belief.

One reason for this may be that certain similarities of behavior, emotion, cognition, and family dynamics do tend to emerge along the course of a substance abuse disorder. In the course of recovery, these similarities diminish, and people again become more diverse.

Resistance and denial are attributes of addiction

Engaging in denial, rationalization, evasion, defensiveness, manipulation, and resistance are characteristics that are often attributed to substance users. Furthermore, because these responses can be barriers to successful treatment, clinicians and interventions often focus on these issues.

Research, however, has not supported the conclusion that substance-dependent persons, as a group, have abnormally robust defense mechanisms.

There are several possible explanations for this belief. The first is selective perception--that is, in retrospect, exceptionally difficult clients are elevated to become models of usual responses.

Moreover, the terms "denial" and "resistance" are often used to describe lack of compliance or motivation among substance users, whereas the term "motivation" is reserved for such concepts as acceptance and surrender (Kilpatrick et al., 1978; Nir and Cutler, 1978; Taleff, 1997).

Thus, clients who disagree with clinicians, who refuse to accept clinicians' diagnoses, and who reject treatment advice are often labeled as unmotivated, in denial, and resistant (Miller, 1985b; Miller and Rollnick, 1991). In other words, the term "denial" can be misused to describe disagreements, misunderstandings, or clinician expectations that differ from clients' personal goals and may reflect countertransference issues (Taleff, 1997).

Another explanation is that behaviors judged as normal in ordinary individuals are labeled as pathological when observed in substance-addicted populations (Orford, 1985). Clinicians and others expect substance users to exhibit pathological--or abnormally strong--defense mechanisms.

A third explanation is that treatment procedures actually set up many clients to react defensively. Denial, rationalization, resistance, and arguing, as assertions of personal freedom, are common defense mechanisms that many people use instinctively to protect themselves emotionally (Brehm and Brehm, 1981).

When clients are labeled pejoratively as alcoholic or manipulative or resistant, given no voice in selecting treatment goals, or directed authoritatively to do or not to do something, the result is a predictable--and quite normal--response of defiance. Moreover, when clinicians assume that these defenses must be confronted and "broken" by adversarial tactics, treatment can become counterproductive (Taleff, 1997).

A strategy of aggressive confrontation is likely to evoke strong resistance and outright denial. Hence, one reason that high levels of denial and resistance are often seen as attributes of substance-dependent individuals as a group is that their normal defense mechanisms are so frequently challenged and aroused by clinical strategies of confrontation. Essentially, this becomes a self-fulfilling prophecy (Jones, 1977).

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SAMHSA/CSAT Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Index Page
  

Confrontation is an effective counseling style

In contemporary treatment, the term "confrontation" has several meanings, referring usually to a type of intervention (a planned confrontation) or to a counseling style (a confrontational session). The term can reflect the assumption that denial and other defense mechanisms must be aggressively "broken through" or "torn down," using therapeutic approaches that can be characterized as authoritarian and adversarial (Taleff, 1997).

As just noted, this type of confrontation may promote resistance rather than motivation to change or cooperate. Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance-using clients, the less likely clients will change (Miller et al., 1993), and controlled clinical trials place confrontational approaches among the least effective treatment methods (Miller et al., 1998).

What About Confrontation?

For a number of reasons, the treatment field in the United States fell into some rather aggressive, argumentative, "denial-busting" methods for confronting people with alcohol and drug problems.

This was guided in part by the belief that substance abuse is accompanied by a particular personality pattern characterized by such rigid defense mechanisms as denial and rationalization. Within this perspective, the clinician must take responsibility for impressing reality on clients, who are thought to be unable to see it on their own.

Such confrontation found its way into the popular Minnesota model of treatment and, more particularly, into Synanon (a drug treatment community well known for its group encounter sessions in which participants verbally attacked each other) and other similar therapeutic community programs.

There is, however, a constructive type of therapeutic confrontation. If helping clients confront and assess the reality of their behaviors is a prerequisite for intentional change, clinicians using motivational strategies focus on constructive confrontation as a treatment goal.

From this perspective, constructive or therapeutic confrontation is useful in assisting clients to identify and reconnect with their personal goals, to recognize discrepancies between current behavior and desired ideals (Ivey et al., 1997), and to resolve ambivalence about making positive changes.

Changes in the Addictions Field

As the addictions field has matured, it has tried to integrate conflicting theories and approaches to treatment, as well as to incorporate relevant research findings into a single, comprehensive model. Many positive changes have emerged, and the new view of motivation and the associated strategies to enhance client motivation fit into and reflect many of these changes.

Some of the new features of treatment that have important implications for applying motivational methods are discussed below.

Focus on Client Competencies And Strengths

Whereas the treatment field has historically focused on the deficits and limitations of clients, there is a greater emphasis today on identifying, enhancing, and using clients' strengths and competencies.

This trend parallels the principles of motivational counseling, which affirm the client, emphasize free choice, support and strengthen self-efficacy, and encourage optimism that change can be achieved (see Chapter 4).

As with some aspects of the moral model of addiction, the responsibility for recovery again rests squarely on the client; however, the judgmental tone is eliminated.

Individualized and Client-Centered Treatment

In the past, clients frequently received standardized treatment, no matter what their problems or severity of substance dependence.

Today, treatment is usually based on a client's individual needs, which are carefully and comprehensively assessed at intake.

Research studies have shown that positive treatment outcomes are associated with flexible program policies and a focus on individual client needs (Inciardi et al., 1993). Furthermore, clients are given choices about desirable and suitable treatment options, rather than having treatment prescribed.

As noted, motivational approaches emphasize client choice and personal responsibility for change--even outside the treatment system.

Motivational strategies elicit personal goals from clients and involve clients in selecting the type of treatment needed or desired from a menu of options.

A Shift Away From Labeling

Historically, a diagnosis or disease defined the client and became a dehumanizing attribute of the individual. In modern medicine, individuals with asthma or a psychosis are seldom referred to--at least face to face--as "the asthmatic" or "the psychotic."

Similarly, in the substance use arena, there is a trend to avoid labeling persons with substance abuse disorders as "addicts" or "alcoholics."

Clinicians who use a motivational style avoid branding clients with names, especially those who may not agree with the diagnosis or do not see a particular behavior as problematic.

Therapeutic Partnerships For Change

In the past, especially in the medical model, clients passively received treatment. Today, treatment usually entails a partnership in which the client and the clinician agree on treatment goals and work together to develop strategies to meet those goals.

The client is seen as an active partner in treatment planning. The clinician who uses motivational strategies establishes a therapeutic alliance with the client and elicits goals and change strategies from the client.

The client has ultimate responsibility for making changes, with or without the clinician's assistance. Although motivational strategies elicit statements from the client about intentions and plans for change, they also recognize biological reality: the heightened risk associated with a genetic predisposition to substance abuse or dependence and the powerful effect of substances on the brain, both of which can make change exceedingly difficult.

In fact, motivational strategies ask the client to consider what they like about substances of choice--the motivations to use--before focusing on the less good or negative consequences, and weighing the value of each.

Use of Empathy, Not Authority and Power

Whereas the traditional treatment provider was seen as a disciplinarian and imbued with the power to recommend client termination for rule infractions, penalties for "dirty" urine, or promotion to a higher phase of treatment for successfully following direction, research now demonstrates that positive treatment outcomes are associated with high levels of clinician empathy reflected in warm and supportive listening (Landry, 1996).

Clinician characteristics found to increase a client's motivation include good interpersonal skills, confidence in the therapeutic process, the capacity to meet the client where the client happens to be, and optimism that change is possible (Najavits and Weiss, 1994).

Focus on Earlier Interventions

The formal treatment system, especially in the early days of public funding, primarily served a chronic, hard-core group of clients with severe substance dependence (Pattison et al., 1977). This may be one reason why certain characteristics such as denial became associated with addiction.

If these clients did not succeed in treatment, or did not cooperate, they were viewed as unmotivated and were discharged back to the community to "hit bottom"--i.e., suffer severe negative consequences that might motivate them for change.

More recently, a variety of treatment programs have been established to intervene earlier with persons whose drinking or drug use is problematic or potentially risky, but not yet serious. These early intervention efforts range from educational programs (including sentencing review or reduction for people apprehended for driving while intoxicated who participate in such programs) to brief interventions in opportunistic settings, such as hospital emergency departments, clinics, and doctors' offices, that point out the risks of excessive drinking, suggest change, and make referrals to formal treatment programs as necessary.

Some of the most successful of these early intervention programs use motivational strategies to intercede with persons who are not yet aware they have a substance-related problem (see Chapter 2 and the companion forthcoming Treatment Improvement Protocol (TIP), Brief Interventions and Brief Therapies for Substance Abuse [CSAT, in press (a)]).

This shift in thinking means not only that treatment services are provided when clients first develop a substance use problem but also that clients have not depleted personal resources and can more easily muster sufficient energy and optimism to initiate change.

Brief motivationally focused interventions are increasingly being offered in acute and primary health care settings (D'Onofrio et al., 1998; Ockene et al., 1997; Samet et al., 1996).

Focus on Less Intensive Treatments

A corollary of the new emphasis on earlier intervention and individualized care is the provision of less intensive, but equally effective, treatments. When care was standardized, most programs had not only a routine protocol of services but also a fixed length of stay.

Twenty-eight days was considered the proper length of time for successful inpatient (usually hospital-based) care in the popular Minnesota model of alcohol treatment. Residential facilities and outpatient clinics also had standard courses of treatment.

Research has now demonstrated that shorter, less intensive forms of intervention can be as effective as more intensive therapies (Bien et al., 1993b; IOM, 1990b; Project MATCH Research Group, 1997a).

The issue of treatment "intensity" is far too vague, in that it refers to the length, amount, and cost of services provided without reference to the content of those services.

The challenge for future research is to identify what kinds of intervention demonstrably improve outcomes in an additive fashion. For purposes of this TIP, emphasis has been placed on the fact that even when therapeutic contact is constrained to a relatively brief period, it is still possible to affect client motivation and trigger change.

Impact of Managed Care on Treatment

Changes in health care financing (managed care) have markedly affected the amount of treatment provided, shifting the emphasis from inpatient to outpatient settings and capping the duration of some treatments.

Still unknown is the overall impact of these changes on treatment access, quality, outcomes, and cost. In this context, it is important to remember that even within relatively brief treatment contacts, one can be helpful to clients in evoking change through motivational approaches.

Brief motivational interventions can also be an effective way for intervening earlier in the development of substance abuse while severity and complexity of problems are lower (Obert et al., 1997).

Recognition of a Continuum of Substance Abuse Problems

Formerly, substance misuse, particularly the disease of alcoholism, was viewed as a progressive condition that, if left untreated, would inevitably lead to full-blown dependence and, likely, an early death. Currently, clinicians recognize that substance abuse disorders exist along a continuum from risky or problematic use through varying types of abuse to dependence that meets diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association [APA], 1994).

Moreover, progression toward increasing severity is not automatic. Many individuals never progress beyond risky consumption, and others cycle back and forth through periods of abstinence, excessive use, and dependence. Recovery from substance dependence is seen as a multidimensional process that differs among people and changes over time within the same person (IOM, 1990a, 1990b).

Motivational strategies can be effectively applied to persons in any stage of substance use through dependence. The crucial variable, as will be seen, is not the severity of the substance use pattern, but the client's readiness for change.

Recognition of Multiple Substance Abuse

Practitioners have come to recognize not only that substance-related disorders vary in intensity but also that most involve more than one substance. For example, a recent study reported that in the United States, just over 25 percent of the general adult population smoke cigarettes, whereas 80 to 90 percent of adults with alcohol use disorders are smokers (Wetter et al., 1998).

Formerly, alcohol and drug treatment programs were completely separated by ideology and policy, even though most individuals with substance abuse disorders also drink heavily and many persons who drink excessively also experiment with substances, including prescribed medications that can be substituted for alcohol or that alleviate withdrawal symptoms.

Although many treatment programs properly specialize in serving a particular type of client for whom their therapies are appropriate (e.g., methadone maintenance programs for opioid-using clients), most now also treat secondary substance use and psychological problems or at least identify these and make referrals as necessary (Brown et al., 1995, 1999). Here, too, motivational approaches involve clients in choosing goals and negotiating priorities.

Acceptance of New Treatment Goals

In the past, addiction treatment, at least for clients having trouble with alcohol, was considered successful only if the client became abstinent and never returned to substance use following discharge--a goal that proved difficult to achieve (Brownell et al., 1986; Polich et al., 1981).

The focus of treatment was almost entirely to have the client stop using and to start understanding the nature of her addiction.

Today, treatment goals include a broad range of biopsychosocial measures, such as reduction in substance use, improvement in health and psychosocial functioning, improvement in employment stability, and reduction in criminal justice activity.

Recovery itself is multifaceted, and gains made toward recovery can appear in one aspect of a client's life, but not another; achieving the goal of abstinence does not necessarily translate into improved life functioning for the client. Treatment outcomes include interim, incremental, and even temporary steps toward ultimate goals. Motivational strategies incorporate these ideas and help clients select and work toward the goals of most importance to them, including reducing substance use to less harmful levels, even though abstinence may become an ultimate goal if cutting back does not work.

Harm reduction (e.g., reducing the intensity of use and high-risk behavior, substituting a less risky substance) can be an important goal in early treatment (APA, 1995). The client is encouraged to focus on personal values and goals, including spiritual aspirations and repair of marital and other important interpersonal relationships.

Goals are set within a more holistic context, and significant others are often included in the motivational sessions.

Integration of Substance Abuse Treatment With Other Disciplines

Historically, the substance abuse treatment system was often isolated from mainstream health care, partly because medical professionals had little training in this area and did not recognize or know what to do with substance users whom they saw in practice settings.

Welfare offices, courts, jails, emergency departments, and mental health clinics also were not prepared to respond appropriately to substance misuse. Today there is a strong movement to perceive addiction treatment in the context of public health and to recognize its impact on numerous other service systems.

Thanks to the cross-training of professionals and an increase in jointly administered programs, other systems are identifying substance users and either making referrals for them or providing appropriate treatment services (e.g., substance abuse treatment within the criminal justice system, special services for clients who have both substance abuse disorders and mental health disorders).

Motivational interventions have been tested and found to be effective in most of these opportunistic settings. Although substance users originally come in for other services, they can be identified and often motivated to reduce use or become abstinent through carefully designed brief interventions (see Chapter 2 and the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Abuse [CSAT, in press (a)]).

If broadly applied, these brief interventions will tie the addiction treatment system more closely to other service networks through referrals of persons who, after a brief intervention, cannot control their harmful use of substances either on their own or with the limited help of a nonspecialist.

A Transtheoretical Model Of the Stages of Change

As noted at the beginning of this chapter, motivation and personal change are inescapably linked. In addition to developing a new understanding of motivation, substantial addiction research has focused on the determinants and mechanisms of personal change.

By understanding better how people change without professional assistance, researchers and clinicians have become better able to develop and apply interventions to facilitate changes in clients' maladaptive and unhealthy behaviors.

Natural Change

The shift in thinking about motivation includes the notion that change is more a process than an outcome (Sobell et al., 1993b; Tucker et al., 1994).

Change occurs in the natural environment, among all people, in relation to many behaviors, and without professional intervention. This is also true of positive behavioral changes related to substance use, which often occur without therapeutic intervention or self-help groups.

There is well-documented evidence of self-directed or natural recovery from excessive, problematic abuse of alcohol, cigarettes, and drugs (Blomqvist, 1996; Chen and Kandel, 1995; Orleans et al., 1991; Sobell and Sobell, 1998).

One of the best-documented studies of this natural recovery process is the longitudinal followup of returning veterans from the Vietnam War (Robins et al., 1974).

Although a substantial number of these soldiers became addicted to heroin during their tours of duty in Vietnam, only 5 percent continued to be addicted a year after returning home, and only 12 percent began to use heroin again within the first 3 years--most for only a short time.

Although a few of these veterans benefited from short-term detoxification programs, most did not enter formal treatment programs and apparently recovered on their own.

Recovery from substance dependence also can occur with very limited treatment and, in the longer run, through a maturation process (Brecht et al., 1990; Strang et al., 1997).

Recognizing the processes involved in natural recovery and self-directed change helps illuminate how changes related to substance use can be precipitated and stimulated by enhancing motivation.

Figure 1-1 illustrates two kinds of natural changes: common and substance-related. Everyone must make decisions about important life changes such as marriage or divorce or buying a house. Sometimes, individuals consult a counselor or other specialist to help with these ordinary decisions, but usually people decide on such changes without professional assistance.

Natural change related to substance use also entails decisions to increase, decrease, or stop substance use. Some of the decisions are responses to critical life events, others reflect different kinds of external pressures, and still others seem to be motivated by an appraisal of personal values.

It is important to note that natural changes related to substance use can go in either direction. In response to an impending divorce, for example, one individual may begin to drink heavily whereas another may reduce or stop using alcohol.

People who use psychoactive substances thus can and do make many choices regarding consumption patterns without professional intervention.

Stages of Change

Theorists have developed various models to illustrate how behavioral change happens. In one perspective, external consequences and restrictions are largely responsible for moving individuals to change their substance use behaviors.

In another model, intrinsic motivations are responsible for initiating or ending substance use behaviors. Some researchers believe that motivation is better described as a continuum of readiness than as separate stages of change (Bandura, 1997; Sutton, 1996).

This hypothesis is also supported by motivational research involving serious substance abuse of illicit drugs (Simpson and Joe, 1993).

The change process has been conceptualized as a sequence of stages through which people typically progress as they think about, initiate, and maintain new behaviors (Prochaska and DiClemente, 1984).

This model emerged from an examination of 18 psychological and behavioral theories about how change occurs, including components that compose a biopsychosocial framework for understanding addiction. In this sense, the model is "transtheoretical" (IOM, 1990b).

This model also reflects how change occurs outside of therapeutic environments. The authors applied this template to individuals who modified behaviors related to smoking, drinking, eating, exercising, parenting, and marital communications on their own, without professional intervention. When natural self-change was compared with therapeutic interventions, many similarities were noticed, leading these investigators to describe the occurrence of change in steps or stages.

They observed that people who make behavioral changes on their own or under professional guidance first "move from being unaware or unwilling to do anything about the problem to considering the possibility of change, then to becoming determined and prepared to make the change, and finally to taking action and sustaining or maintaining that change over time" (DiClemente, 1991, p. 191).

As a clinician, you can be helpful at any point in the process of change by using appropriate motivational strategies that are specific to the change stage of the individual. Chapters 4 through 7 of this TIP use the stages-of-change model to organize and conceptualize ways in which you can enhance clients' motivation to progress to the next change stage.

In this context, the stages of change represent a series of tasks for both you and your clients (Miller and Heather, 1998).

The stages of change can be visualized as a wheel with four to six parts, depending on how specifically the process is broken down (Prochaska and DiClemente, 1984). For this TIP, the wheel (Figure 1-2) has five parts, with a final exit to enduring recovery. It is important to note that the change process is cyclical, and individuals typically move back and forth between the stages and cycle through the stages at different rates. In one individual, this movement through the stages can vary in relation to different behaviors or objectives.

Individuals can move through stages quickly. Sometimes, they move so rapidly that it is difficult to pinpoint where they are because change is a dynamic process. It is not uncommon, however, for individuals to linger in the early stages.

For most substance-using individuals, progress through the stages of change is circular or spiral in nature, not linear. In this model, recurrence is a normal event because many clients cycle through the different stages several times before achieving stable change.

The five stages and the issue of recurrence are described below.

Precontemplation

During the precontemplation stage, substance-using persons are not considering change and do not intend to change behaviors in the foreseeable future. They may be partly or completely unaware that a problem exists, that they have to make changes, and that they may need help in this endeavor.

Alternatively, they may be unwilling or too discouraged to change their behavior. Individuals in this stage usually have not experienced adverse consequences or crises because of their substance use and often are not convinced that their pattern of use is problematic or even risky.

Contemplation

As these individuals become aware that a problem exists, they begin to perceive that there may be cause for concern and reasons to change. Typically, they are ambivalent, simultaneously seeing reasons to change and reasons not to change.

Individuals in this stage are still using substances, but they are considering the possibility of stopping or cutting back in the near future. At this point, they may seek relevant information, reevaluate their substance use behavior, or seek help to support the possibility of changing behavior.

They typically weigh the positive and negative aspects of making a change. It is not uncommon for individuals to remain in this stage for extended periods, often for years, vacillating between wanting and not wanting to change.

Preparation

When an individual perceives that the envisioned advantages of change and adverse consequences of substance use outweigh any positive features of continuing use at the same level and maintaining the status quo, the decisional balance tips in favor of change.

Once instigation to change occurs, an individual enters the preparation stage, during which commitment is strengthened. Preparation entails more specific planning for change, such as making choices about whether treatment is needed and, if so, what kind.

Preparation also entails an examination of one's perceived capabilities--or self-efficacy--for change. Individuals in the preparation stage are still using substances, but typically they intend to stop using very soon. They may have already attempted to reduce or stop use on their own or may be experimenting now with ways to quit or cut back (DiClemente and Prochaska, 1998).

They begin to set goals for themselves and make commitments to stop using, even telling close associates or significant others about their plans.

Action

Individuals in the action stage choose a strategy for change and begin to pursue it. At this stage, clients are actively modifying their habits and environment. They are making drastic lifestyle changes and may be faced with particularly challenging situations and the physiological effects of withdrawal.

Clients may begin to reevaluate their own self-image as they move from excessive or hazardous use to nonuse or safe use. For many, the action stage can last from 3 to 6 months following termination or reduction of substance use.

For some, it is a honeymoon period before they face more daunting and longstanding challenges.

Maintenance

During the maintenance stage, efforts are made to sustain the gains achieved during the action stage. Maintenance is the stage at which people work to sustain sobriety and prevent recurrence (Marlatt and Gordon, 1985).

Extra precautions may be necessary to keep from reverting to problematic behaviors. Individuals learn how to detect and guard against dangerous situations and other triggers that may cause them to use substances again. In most cases, individuals attempting long-term behavior change do return to use at least once and revert to an earlier stage (Prochaska et al., 1992).

Recurrence of symptoms can be viewed as part of the learning process. Knowledge about the personal cues or dangerous situations that contribute to recurrence is useful information for future change attempts.

Maintenance requires prolonged behavioral change--by remaining abstinent or moderating consumption to acceptable, targeted levels--and continued vigilance for a minimum of 6 months to several years, depending on the target behavior (Prochaska and DiClemente, 1992).

Decisionmaking

Decisionmaking has been conceptualized as a balance sheet of potential gains and losses

Recurrence

Most people do not immediately sustain the new changes they are attempting to make, and a return to substance use after a period of abstinence is the rule rather than the exception (Brownell et al., 1986; Prochaska and DiClemente, 1992). These experiences contribute information that can facilitate or hinder subsequent progression through the stages of change.

Recurrence, often referred to as relapse, is the event that triggers the individual's return to earlier stages of change and recycling through the process.

Individuals may learn that certain goals are unrealistic, certain strategies are ineffective, or certain environments are not conducive to successful change. Most substance users will require several revolutions through the stages of change to achieve successful recovery (DiClemente and Scott, 1997).

After a return to substance use, clients usually revert to an earlier change stage--not always to maintenance or action, but more often to some level of contemplation. They may even become precontemplators again, temporarily unwilling or unable to try to change soon.

As will be described in the following chapters, resuming substance use and returning to a previous stage of change should not be considered a failure and need not become a disastrous or prolonged recurrence. A recurrence of symptoms does not necessarily mean that a client has abandoned a commitment to change.

Triggers to Change

The multidimensional nature of motivation is captured, in part, in the popular phrase that a person is ready, willing, and able to change.

This expression highlights three critical elements of motivation--but in reverse order from that in which motivation typically evolves.

Ability refers to the extent to which the person has the necessary skills, resources, and confidence (self-efficacy) to carry out a change. One can be able to change, but not willing. The willing component involves the importance a person places on changing--how much a change is wanted or desired. (Note that it is possible to feel willing yet unable to change.)

However, even willingness and ability are not always enough. You probably can think of examples of people who are willing and able to change, but not yet ready to change. The ready component represents a final step in which the person finally decides to change a particular behavior.

Being willing and able but not ready can often be explained by the relative importance of this change compared with other priorities in the person's life. To instill motivation for change is to help the client become ready, willing, and able. As discussed in later chapters, your clinical approach can be guided by deciding which of these three needs bolstering.

To Whom DoesThis TIP Apply?

To which client populations is material covered in this TIP applicable? Motivational interviewing was originally developed to work with problem alcohol drinkers at early stages (precontemplation and contemplation) of readiness for change and was conceived as a way of initiating treatment (Miller, 1983; Miller et al., 1988).

It soon became apparent, however, that this brief counseling approach constitutes an intervention in itself. Problem alcohol drinkers in the community who were given motivational interventions seldom initiated treatment but did show large decreases in their drinking (Heather et al., 1996b; Marlatt et al., 1998; Miller et al., 1993; Senft et al., 1997).

In the largest clinical trial ever conducted to compare different alcohol treatment methods, a four-session motivational enhancement therapy yielded long-term overall outcomes virtually identical to those of longer outpatient methods (Project MATCH Research Group, 1998a), and the motivational approach was differentially beneficial with angry clients (Project MATCH Research Group, 1997a).

The MATCH population consisted of treatment-seeking clients who varied widely in problem severity, the vast majority of whom met criteria for alcohol dependence. Clients represented a range of cultural backgrounds, particularly Hispanic. It is noteworthy that neither Hispanic nor African-American samples responded differentially to the motivational enhancement therapy approach.

Moreover, analyses of clinical trials of motivational interviewing that have included substantial representation of Hispanic clients (Brown and Miller, 1993; Miller et al., 1988, 1993) have found no indication of self-identified ethnicity and socioeconomic status as predictors of outcome.

A motivational interviewing trial addressing weight and diabetes management among women, 41 percent of whom were African-American, demonstrated positive results (Smith et al., 1997). Evidence strongly suggests that motivational interviewing can be applied across cultural and economic differences.

While motivational counseling appears to be sufficient for some clients, for others it can be combined with additional therapeutic methods. With more severely dependent drinkers, a motivational interviewing session at the outset of treatment has been found to double the rate of abstinence following private inpatient treatment (Brown and Miller, 1993) and Veterans Affairs outpatient programs for substance abuse treatment (Bien et al., 1993a).

Benefits have been reported with other severely dependent populations (e.g., Allsop et al., 1997). Polydrug-abusing adolescents stayed in outpatient treatment nearly three times longer and showed substantially lower substance use and consequences after treatment when they had received a motivational interview at intake (Aubrey, 1998).

Similar additive benefits have been reported in treating problems with heroin (Saunders et al., 1995), marijuana (Stephens et al., 1994), weight control and diabetes management (Smith et al., 1997; Trigwell et al., 1997), and cardiovascular rehabilitation (Scales, 1998).

It is clear, therefore, that the motivational approach described in this TIP can be combined beneficially with other forms of treatment and can be applied with problems beyond substance abuse alone.

The motivational style of counseling, therefore, can be useful, not only to instill motivation initially, but throughout the process of treatment in the preparation, action, and maintenance stages as well. This is reflected in subsequent chapters of this TIP.

Whether motivational interviewing will be sufficient to trigger change in a given case is difficult to predict. Sometimes motivational counseling may be all that is needed. Sometimes it is only a beginning. A stepped care approach, described in Chapter 9, is one in which the amount of care provided is adjusted to the needs of the individual.

If lasting change follows after motivational interviewing alone, who can be dissatisfied? Often more is needed. However brief or extensive the service provided, the evidence indicates that you are most likely to help your clients change their substance use by maintaining an empathic motivational style.

It is a matter of staying with and supporting each client until together you find what works.

Summary

Linking the new view of motivation, the strategies found to enhance it, and the stages-of-change model, along with an understanding of what causes change, can create an innovative approach to helping substance-using clients.

This approach provokes less resistance and encourages clients to progress at their own pace toward deciding about, planning, making, and sustaining positive behavioral change.

In this treatment model, described in the next chapter, motivation is seen as a dynamic state that can be modified or enhanced by the clinician.

Motivational enhancement has evolved, while various myths about clients and what constitutes effective counseling have been dispelled. The notion of the addictive personality has lost credence, and many clinicians have discarded the use of a confrontational style.

Other factors in contemporary counseling practices have encouraged the development and implementation of motivational interventions. Increasingly, counseling has become optimistic, focusing on clients' strengths, and client centered.

Counseling relationships are more likely to rely on empathy, rather than authority, to involve the client in treatment. Less intensive treatments have also become more common in the era of managed care.

Motivation is what propels substance users to make changes in their lives. It guides clients through several stages of change that are typical of people thinking about, initiating, and maintaining new behaviors.

When applied to substance abuse treatment, motivational interventions can help clients move from not even considering changing their behavior to being ready, willing, and able to do so.

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SAMHSA/CSAT Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Index Page
  

Using the transtheoretical perspective...seeks to assist clients in moving from the early stages of change...to determination or action. It uses stage-specific strategies to foster a commitment to take action for change...[and it] assists clients to convince themselves that change is necessary. Noonan and Moyers, 1997

Motivational intervention is broadly defined as any clinical strategy designed to enhance client motivation for change. It can include counseling, client assessment, multiple sessions, or a 30-minute brief intervention.

This chapter examines the elements of effective motivational approaches and supporting research. Motivational strategies are then correlated with the stages-of-change model (a framework that is discussed in Chapter 1 and elaborated on in later chapters) to highlight approaches that are appropriate to specific stages.

Recommendations are presented for providing motivational interventions that are responsive and sensitive to differing cultural and diagnostic needs, as well as to different settings and formats. This chapter concludes with a description of an increasingly accepted type of intervention known as a brief intervention, which is useful outside of traditional substance abuse treatment settings.

For a broader discussion of brief interventions and therapies, refer to the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Abuse (CSAT, in press [a]).

Elements of Effective Motivational Interventions

To understand what prompts a person to reduce or eliminate substance use, investigators have searched for the critical components--the most important and common elements that inspire positive change--of effective interventions.

The following are important elements of current motivational approaches:

The FRAMES approach
Decisional balance exercises
Discrepancies between personal goals and current behavior
Flexible pacing
Personal contact with clients not in treatment

These elements are described in the following subsections.

FRAMES Approach

Six elements have been identified that were present in brief clinical trials, and the acronym FRAMES was coined to summarize them (Miller and Sanchez, 1994). These elements are defined as the following:

Feedback regarding personal risk or impairment is given to the client following assessment of substance use patterns and associated problems.

Responsibility for change is placed squarely and explicitly on the client (and with respect for the client's right to make choices for himself).

Advice about changing--reducing or stopping--substance use is clearly given to the client by the clinician in a nonjudgmental manner.

Menus of self-directed change options and treatment alternatives are offered to the client.

Empathic counseling--showing warmth, respect, and understanding--is emphasized.

Self-efficacy or optimistic empowerment is engendered in the client to encourage change.

Figure 2-1 lists 32 trials and their FRAME components, as reviewed by Bien and colleagues (Bien et al., 1993b). Since the FRAMES construct was developed, further clinical research and experience have expanded on and refined elements of this motivational model.

These components have been combined in different ways and tested in diverse settings and cultural contexts. Consequently, additional building blocks or tools are now available that can be tailored to meet your clients' needs.

Feedback

The literature describing successful motivational interventions confirms the persuasiveness of personal, individualized feedback (Bien et al., 1993b; Edwards et al., 1977; Kristenson et al., 1983).

Providing constructive, nonconfrontational feedback about a client's degree and type of impairment based on information from structured and objective assessments is particularly valuable (Miller et al., 1988).

This type of feedback usually compares a client's scores or ratings on standard tests or instruments with normative data from a general population or from groups in treatment (for examples, see Figures 4-1 and 4-2).

Assessments may include measures related to substance consumption patterns, substance-related problems, physical health, risk factors including a family history of substance use or affective disorders, and various medical tests (Miller et al., 1995c). (Assessments and feedback are described in more detail in Chapter 4.)

A respectful manner when delivering feedback to your client is crucial. A confrontational or judgmental approach may leave the client unreceptive.

Do not present feedback as evidence that can be used against the client. Rather, offer the information in a straightforward, respectful way, using easy-to-understand and culturally appropriate language. The point is to present information in a manner that helps the client recognize the existence of a substance use problem and the need for change.

Reflective listening and an empathic style help the client understand the feedback, interpret the meaning, gain a new perspective about the personal impact of substance use, express concern, and begin to consider change.

Not all clients respond in the same way to feedback. One person may be alarmed to find that she drinks much more in a given week than comparable peers but be unconcerned about potential health risks. Another may be concerned about potential health risks at this level of drinking. Still another may not be impressed by such aspects of substance use as the amount of money spent on substances, possible impotence, or the level of impairment--especially with regard to driving ability--caused by even low blood alcohol concentrations (BACs).

Personalized feedback can be applied to other lifestyle issues as well, and can be used throughout treatment. Feedback about improvements is especially valuable as a method of reinforcing progress.

Responsibility

Individuals have the choice of continuing their behavior or changing. A motivational approach allows clients to be active rather than passive by insisting that they choose their treatment and take responsibility for changing.

Do not impose views or goals on clients; instead, ask clients for permission to talk about substance use and invite them to consider information. If clients are free to choose, they feel less need to resist or dismiss your ideas. Some clinicians begin an intervention by stating clearly that they will not ask the client to do anything he is unwilling to do but will try nevertheless to negotiate a common agenda in regard to treatment goals.

When clients realize they are responsible for the change process, they feel empowered and more invested in it. This results in better outcomes (Deci, 1975, 1980). When clients make their own choices, you will be less frustrated and more satisfied because the client is doing the work. Indeed, clients are the best experts about their own needs.

Advice

A Realistic Model of Change: Advice to Clients

Throughout the treatment process, it is important to give clients permission to talk about their problems with substance use. During these kinds of dialogs, I often point out some of the realities of the recovery process:

Most change does not occur overnight.
Change is best viewed as a gradual process with occasional setbacks, much like hiking up a bumpy hill.
Difficulties and setbacks can be reframed as learning experiences, not failures.

The simple act of giving gentle advice can promote positive behavioral change. As already discussed, research shows that short sessions in which you offer suggestions can be effective in changing behaviors such as smoking, drinking alcohol, and other substance use (Drummond et al., 1990; Edwards et al., 1977; Miller and Taylor, 1980; Sannibale, 1988; Wallace et al., 1988).

As with feedback, the manner in which you advise clients determines how the advice will be used. It is better not to tell people what to do--suggesting yields better results. A motivational approach to offering advice may be either directive (making a suggestion) or educational (explaining information). Educational advice is based on credible scientific evidence supported in the literature.

Facts that relate to the client's conditions, such as BAC levels at the time of an accident or safe drinking limits recommended by the National Institute on Alcohol Abuse and Alcoholism, can be presented in a nonthreatening way. Thoughtfully address the client's behavior by saying, "Can I tell you what I've seen in the past in these situations?" or, "Let me explain something to you about tolerance."

Such questions provide a nondirective opportunity to share your knowledge about substance use in a gentle and respectful manner. If the client requests direction, redirect her questions in order to clarify what is wanted rather than giving advice immediately.

Any advice you give should be simple, not overwhelming, and matched to the client's level of understanding and readiness, the urgency of the situation, and her culture. (In some cultures, a more directive approach is required to adequately convey the importance of the advice or situation; in other cultures, a directive style is considered rude and intrusive.)

This style of giving advice requires patience. The timing of any advice is also important, relying on your ability to "hear"--in the broad sense--what the client is requesting and willing to receive.

The PIES Approach

In World War I, military psychiatrists first realized that motivational interventions, done at the right time, could return a great number of dysfunctionally stressed soldiers to duty. The method could be put into an easily remembered acronym: PIES.

Proximity: Provide treatment near the place of duty; don't evacuate to a hospital.
Immediacy: Intervene and treat as soon as the problem is noticed.
Expectancy: Expect the intervention to be successful and return the person to duty.
Simplicity: Simply listening, showing empathy, and demonstrating understanding works best.

Options

Compliance with change strategies is enhanced when clients choose--or perceive that they can choose--from a menu of options. Thus, motivation for participating in treatment is heightened by giving clients choices regarding treatment goals and types of services needed.

Offering a menu of options helps decrease dropout rates and resistance to treatment and increases overall treatment effectiveness (Costello, 1975; Parker et al., 1979).

As you describe alternative approaches to treatment or change that are appropriate for your clients, provide accurate information about each option and a best guess about the implications of choosing one particular path.

Elicit from your clients what they think is effective or what has worked for them in the past. Providing a menu of options is consistent with the motivational principle that clients must choose and take responsibility for their choices.

Your role is to enhance your clients' ability to make informed choices. When clients make independent decisions, they are likely to be more committed to them. This concept is further discussed in Chapter 6.

Empathic counseling

Empathy is not specific to motivational interventions but rather applies to many types of therapies (Rogers, 1959; Truax and Carkhuff, 1967). Empathy during counseling has been interpreted in terms of such therapist characteristics as warmth, respect, caring, commitment, and active interest (Miller and Rollnick, 1991).

Empathy usually entails reflective listening--listening attentively to each client statement and reflecting it back in different words so that the client knows you understand the meaning.

The client does most of the talking when a clinician uses an empathic style. It is your responsibility to create a safe environment that encourages a free flow of information from the client. Your implied message to the client is "I see where you are, and I'm not judgmental. Where would you like to go from here?"

The assumption is that, with empathic support, a client will naturally move in a healthy direction. Let this process unfold, rather than direct or interrupt it. Although an empathic style appears easy to adopt, it actually requires careful training and significant effort on your part. This style can be particularly effective with clients who seem angry, resistant, or defensive.

Self-efficacy

To succeed in changing, clients must believe they are capable of undertaking specific tasks and must have the necessary skills and confidence (Bandura, 1989; Marlatt and Gordon, 1985). One of your most important roles is to foster hope and optimism by reinforcing your clients' beliefs in their own capacities and capabilities (Yahne and Miller, 1999).

This role is more likely to be successful if you believe in your client's ability to change (Leake and King, 1977). You can help clients identify how they have successfully coped with problems in the past by asking, "How did you get from where you were to where you are now?"

Once you identify strengths, you can help clients build on past successes. It is important to affirm the small steps that are taken and reinforce any positive changes. The importance of self-efficacy is discussed again in Chapters 3 and 5.

Decisional Balance Exercises

The concept of exploring the pros and cons--or benefits and disadvantages--of change is not new and is well documented in the literature (Colten and Janis, 1982; Janis and Mann, 1977). Individuals naturally explore the pros and cons of any major life choices such as changing jobs or getting married.

In the context of recovery from substance use, the client weighs the pros and cons of changing versus not changing substance-using behavior. You assist this process by asking your client to articulate the good and less good aspects of using substances and then list them on a sheet of paper.

This process is usually called decisional balancing and is further described in Chapters 5 and 8. The purpose of exploring the pros and cons of a substance use problem is to tip the scales toward a decision for positive change.

The actual number of reasons a client lists on each side of a decisional balance sh