Motivational Intervention And the Stages of Change

Clients need and use different kinds of motivational support according to which stage of change they are in and into what stage they are moving. If you try to use strategies appropriate to a stage other than the one the client is in, the result could be treatment resistance or noncompliance.

For example, if your client is at the contemplation stage, weighing the pros and cons of change versus continued substance use, and you pursue change strategies appropriate to the action stage, your client will predictably resist. The simple reason for this reaction is that you have taken the positive (change) side of the argument, leaving the client to argue the other (no change) side; this results in a standoff.

To consider change, individuals at the precontemplation stage must have their awareness raised. To resolve their ambivalence, clients in the contemplation stage require help choosing positive change over their current situation.

Clients in the preparation stage need help identifying potential change strategies and choosing the most appropriate one for their circumstances. Clients in the action stage (the stage at which most formal treatment occurs) need help to carry out and comply with the change strategies.

During the maintenance stage, clients may have to develop new skills for maintaining recovery and a lifestyle without substance use. Moreover, if clients resume their substance use, they can be assisted to recover as quickly as possible to resume the change process.

Figure 2-2 provides examples of appropriate motivational strategies you can use at each stage of change. Of course, these are not the only ways to enhance motivation for beneficial change. Chapter 3 describes some of the fundamental principles of motivational interviewing that apply to all stages.

Chapters 4 through 7 describe in more detail the motivational strategies that are most appropriate for encouraging progression to each new change stage. Chapters 4 and 8 present some tools to help you recognize clients' readiness to change in terms of their current stage.

Catalysts for Change

In the search for common processes--integrative models--of personal growth and change across psychotherapies and behavioral approaches, Prochaska (Prochaska, 1979) initially isolated the core approaches of many therapeutic systems and further developed these in a factor analytic study (Davidson, 1994; Prochaska and DiClemente, 1983).

These fundamental processes represent cognitive, affective, behavioral, and environmental factors influencing change as they appear in major systems of therapy (DiClemente and Scott, 1997).

These change catalysts are derived from studies examining smoking cessation, alcohol abstinence, general psychotherapeutic problems, weight loss, and exercise adoption (Prochaska et al., 1992b).

For each of the 10 catalysts, several different interventions can be used to encourage change. Figure 2-3 describes these catalysts for change and illustrates a few interventions often used for each.

Typically, cognitive-experiential processes are used early in the cycle (i.e., contemplation, preparation), and behavioral processes are critical for the later stages (i.e., action, maintenance) (Prochaska and Goldstein, 1991).

Figure 2-4 suggests which catalysts are most appropriate for each change stage. To avoid confusion for both the client and clinician, only those catalysts that are best supported or most logical are recommended for a particular stage; this does not imply, however, that the other catalysts are irrelevant.

Special Applications of Motivational Interventions

The principles underlying motivational enhancement have been applied across cultures, to different types of problems, in various treatment settings, and with many different populations. The research literature suggests that motivational interventions are associated with a variety of successful outcomes, including facilitation of referrals for treatment, reduction or termination of substance use, and increased participation in and compliance with specialized treatment (Bien et al., 1993b; Noonan and Moyers, 1997).

Motivational interventions have been tested in at least 15 countries, including Canada, England, Scotland, Wales, the Netherlands, Australia, Sweden, Bulgaria, Costa Rica, Kenya, Zimbabwe, Mexico, Norway, the former Soviet Union, and the United States (Bien et al., 1993; Miller and Rollnick, 1991).

Motivational strategies have been used primarily with problem alcohol drinkers and cigarette smokers, but also have yielded encouraging results in marijuana and opiate users with serious substance-related problems (Bernstein et al., 1997a; Miller and Rollnick, 1991; Noonan and Moyers, 1997; Sobell et al., 1995).

Special applications of motivational approaches have been or are currently being explored with diabetic patients, for pain management, in coronary heart disease rehabilitation, for HIV risk reduction, with sex offenders, with pregnant alcohol drinkers, with severely alcohol-impaired veterans, with persons who have eating disorders, and with individuals with coexisting substance use and psychiatric disorders (Carey, 1996; Noonan and Moyers, 1997; Ziedonis and Fisher, 1996).

Populations that have been responsive to motivational interventions include persons arrested for driving under the influence and other nonviolent offenders, adolescents (Colby et al., 1998), older adults, employees, married couples, opioid-dependent clients receiving methadone maintenance, and victims and perpetrators of domestic violence (Bernstein et al., 1997a; Miller and Rollnick, 1991; Noonan and Moyers, 1997).

The literature also describes successful use of these motivational techniques in primary care facilities (Daley et al., 1998), hospital emergency departments (Bernstein et al., 1997a; D'Onofrio et al., 1998), traditional inpatient and outpatient substance abuse treatment environments, drug courts, and community prevention efforts.

These interventions have been used with individuals, couples, groups, and in face-to-face sessions or through mailed materials (Miller and Rollnick, 1991; Sobell and Sobell, 1998). The simplicity and universality of the concepts underlying motivational interventions permit broad application and offer great potential to reach clients with many types of problems and in many different cultures or settings.

Figure 2-4 Cultural Appropriateness

In my practice with persons who have different world views, I've made a number of observations on the ways in which culture influences the change process. I try to pay attention to cultural effects on a person's style of receiving and processing information, making decisions, pacing, and being ready to act.

The more clients are assimilated into the surrounding culture, the more likely they are to process information, respond, and make choices that are congruent with mainstream beliefs and styles. The responsibility for being aware of different cultural value systems lies with the practitioner, not the client being treated.

Responding to Differing Needs

Clients in treatment for substance abuse differ in ethnic and racial backgrounds, socioeconomic status, education, gender, age, sexual orientation, type and severity of substance use problems, and psychological health.

As noted above, research and experience suggest that the change process is the same or similar across different populations. Thus, the principles and mechanisms of enhancing motivation to change seem to be broadly applicable. Nonetheless, there may be important differences among populations and cultural contexts regarding the expression of motivation for change and the importance of critical life events.

Hence, be familiar with the populations with whom you expect to establish therapeutic relationships and use your clients as teachers regarding their own culture.

Because motivational strategies emphasize the client's responsibility to voice personal goals and values as well as to select among options for change, a sensitive clinician will understand and, ideally, respond in a nonjudgmental way to cultural differences.

Cultural differences might be reflected in the value of health, the meaning of time, the stigma of heavy drinking, or responsibilities to community and family. Try to understand the client's perspective rather than impose mainstream values or make quick judgments.
This requires knowledge of the influences that promote or sustain substance use among different populations. Motivation-enhancing strategies should be congruent with clients' cultural and social principles, standards, and expectations.

For example, older adults often struggle with loss of status and personal identity when they retire, and they may not know how to occupy their leisure time. Help such retired clients understand their need for new activities and how their use of substances is a coping mechanism.

Similarly, when you try to enhance motivation for change in adolescents, consider how peers influence their behaviors and values and how families may limit their emerging autonomy.

In addition to understanding and using a special population's values to encourage change, identify how those values may present potential barriers to change.

Some clients will identify strongly with cultural or religious traditions and work diligently to gain the respect of elders or other group leaders; others find membership or participation in groups of this type an anathema. Some populations are willing to involve family members in counseling; others find this disrespectful, if not disgraceful.

The label "alcoholic" is proudly and voluntarily adopted by members of AA but viewed as dehumanizing by others. The message is simple: Know and be sensitive to the concerns and values of your clients.

Another sensitive area is matching the client with the clinician. Although the literature suggests that warmth, empathy, and genuine respect are more important in building a therapeutic partnership than professional training or experience (Najavits and Weiss, 1994), nevertheless, programs can identify those clinicians who may be optimally suited because of cultural identification, language, or other similarities of background, to work with clients from specific populations.

Programs will find it useful to develop a network of bilingual clinicians or interpreters who can communicate with non--English-speaking clients.

Finally, know what personal and material resources are available to your clients and be sensitive to issues of poverty, social isolation, and recent losses. In particular, recognize that access to financial and social resources is an important part of the motivation for and process of change. Prolonged poverty and lack of resources make change more difficult, both because many alternatives are not possible and because despair can be pervasive.

It is a challenge to affirm self-efficacy and stimulate hope and optimism in clients who lack material resources and have suffered the effects of discrimination. The facts of the situation should be firmly acknowledged.

Nevertheless, clients' capacity for endurance and personal growth in the face of dire circumstances can be respected and affirmed and then drawn on as a strength in attempting positive change.

Brief Interventions

Over the last two decades, there has been a growing trend worldwide to view substance-related problems in a much broader context than diagnosable abuse and dependence syndromes.

The recognition that persons with substance-related problems compose a much larger group--and pose a serious and costly public health threat--than the smaller number of persons needing traditional, specialized treatment is not always reflected in the organization and availability of treatment services.

As part of a movement toward early identification of hazardous drinking patterns and the development of effective and low-cost methods to ameliorate this widespread problem, brief interventions have been initiated and evaluated, primarily in the United Kingdom (Institute of Medicine, 1990a) and Canada but also in many other nations. (For a greater discussion of brief intervention and brief therapy, refer to the forthcoming TIP, Brief Interventions and Brief Therapies for Substance Abuse [CSAT, in press (a)].)

They have been tried in the United States and elsewhere with great success, although they have not been widely adopted outside research settings (Drummond, 1997; Kahan et al., 1995).

The impetus to expand the use of this shorter form of treatment is a response to the need for a broader base of treatment and prevention components to serve all segments of the population who have minimal to severe substance-related problems and consumption patterns.

The need for cost-effective interventions that will not further deplete public coffers and will also satisfy cost-containment policies in an era of managed health care (although research indicates that intensive treatment for nicotine dependence is more cost effective [Agency for Health Care Policy and Research, 1996])

A growing body of research findings that consistently demonstrate the efficacy of brief interventions relative to no intervention.

Brief Intervention in the Emergency Department

When I apply a motivational interviewing style in my practice of emergency medicine, I experience considerable professional satisfaction. Honestly, it's a struggle to let go of the need to be the expert in charge. It helps to recognize that the person I'm talking with in these medical encounters is also an expert--an expert in her own lifestyle, needs, and choices.

Uses of Brief Interventions

Brief interventions for substance-using individuals are applied most often outside traditional treatment settings (in what are often referred to as opportunistic settings), where clients are not seeking help for a substance abuse disorder but have come, for example, to seek medical attention, to pick up a welfare check, or to respond to a court summons.

These settings provide an opportunity to meet and engage with individuals with substance abuse disorders "where they are at." In these situations, persons seeking services may be routinely screened for substance-related problems or asked about their consumption patterns. (For more on how this can work in one such setting, see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians[CSAT, 1997].)

Those found to have risky or excessive patterns of substance use or related problems receive a brief intervention of one or more sessions, each lasting a few minutes to an hour.

Urgent care may involve just one brief encounter, with possible referral to other services. These brief interventions are usually conducted by professionals from the service area where the person seeks services, not by substance abuse treatment specialists.

The purpose of a brief intervention is usually to counsel individuals about hazardous substance use patterns and to advise them to limit or stop their consumption altogether, depending on the circumstances.

If the initial intervention does not result in substantial improvement, the professional can make a referral for additional specialized substance abuse treatment. A brief intervention also can explore the pros and cons of entering treatment and present a menu of options for treatment, as well as facilitate contact with the treatment system.

Brief interventions have been used effectively within substance abuse treatment settings with persons seeking assistance but placed on waiting lists, as a motivational prelude to engagement and participation in more intensive treatment, and as a first attempt to facilitate behavior change with little additional clinical attention.

A series of brief interventions can constitute brief therapy, a treatment strategy that applies therapeutic techniques specifically oriented toward a limited length of treatment, making it particularly useful for certain populations (e.g., older adults, adolescents)

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See Chapter 2 source page for links to diagrams and other references

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