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