Chapter 7 From Action to Maintenance: Stabilizing Change

The real test of change for...addictive behavior...is long-term sustained change over several years... In this [maintenance] stage, the new behavior is becoming firmly established, and the threat of...a return to the old patterns becomes less frequent and less intense... Helping clients increase their sense of self-efficacy is an important task at [these] stages... Individuals in the action and maintenance stages may need skills training in addition to motivational strategies. DiClemente, 1991

Maintenance is not an absence of change, but the continuance of change. Prochaska and DiClemente, 1984

A motivational counseling style has been used mostly with clients in the precontemplation through preparation stages as they move toward initiating behavioral change. Many clients and clinicians believe that formal treatment is a different domain--conducted according to various philosophies and procedures that guide separate modalities--where motivational strategies are no longer required. This is not true for two reasons.

First, clients 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 need support and encouragement to maintain the gains they have achieved and to handle crises that may return them to problem behaviors.

Second, many clients arrive at treatment in a stage of change that actually precedes action or they vacillate between some level of contemplation--with associated ambivalence--and continuing action.

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 early stages of recovery require only thinking about change, which is not as threatening as actually implementing it.

This chapter addresses ways in which motivational strategies can be used effectively at different points in the formal treatment process. The first section discusses the importance of understanding and offsetting clients' natural doubts and reservations about treatment immediately after admission so that they stay long enough to benefit from the process rather than dropping out prematurely.

The next part outlines ways to help your clients plan for stabilizing change, develop coping strategies to avoid or defuse high-risk situations, and enlist family and social support. The third section describes types of alternative reinforcers that can be used, including a broad-spectrum approach that attempts to make a nonusing lifestyle more attractive and rewarding than previous self-destructive behavior.

Engaging and Retaining Clients in Treatment

Premature termination of treatment--early dropout--is a major concern of clinicians and researchers (Kolden et al., 1997; Zweben et al., 1988). The literature on treatment for users of illicit substances finds that the amount of time spent in treatment is a consistent indicator of more favorable outcomes (e.g., Simpson et al., 1997). Poorer outcomes in terms of continuing substance use and criminal behavior as well as a rapid return to daily substance use are associated with shorter treatment episodes (Pickens and Fletcher, 1991).

This robust finding from outcome literature contrasts with other research findings that brief interventions can be as effective as more intensive care (Bien et al., 1993b) and that outcomes seldom differ when clients are randomly assigned to more versus less intensive treatment.

Causes of premature termination of treatment are varied. For some clients, dropping out, missing appointments, or failing to comply with other aspects of the treatment program are clear messages of discouragement, disillusionment, or change of heart.

For others, dropping out of treatment without discussing this option with you may not indicate dissatisfaction or resistance, but rather a decision that things are going well and desired change can be achieved and maintained without your continuing help or monitoring (DiClemente, 1991).

Perhaps the strongest predictor of success versus failure or dropout in outpatient treatment is severity of substance dependence at treatment entry (McLellan et al., 1994) and, more specifically, submission of a drug-negative versus drug-positive urine specimen at treatment entry (Alterman et al., 1996, 1997).

For example, one study found that cocaine-using patients with a positive urine screen at intake were less than half as likely to complete treatment or achieve initial abstinence as those submitting negative urine samples (Alterman et al., 1997). With alcohol problems, the relationship between severity and outcome is less obvious (Project MATCH Research Group, 1997a).

Although much research focuses on predictors of treatment retention, including client and therapist characteristics, treatment environment, therapeutic elements, and interactions among these variables, Kolden and colleagues conclude that there are too many factors for practical analysis and thus predictors of treatment compliance remain elusive (Kolden et al., 1997).

Nevertheless, these investigators and others report on variables that show some correlation with treatment retention or that seem, intuitively, to affect early termination. For example, the degree of congruence between clients' and clinicians' expectations about treatment elements and duration plays some role in retention, as does clinician interest expressed through such small actions as telephone calls between sessions or interactive exploration and agreement on the goals of treatment.

"Failure" may be tied to a poor therapeutic alliance, which may reflect on clinical skillfulness. Social stability, previous treatment, expectations for reducing future substance use, higher methadone doses, and higher motivation--defined here as a desire or perceived need for help--seemed to predict that opiate-using clients would stay in methadone treatment for more than 60 days (Simpson and Joe, 1993). Furthermore, studies of therapeutic communities demonstrate that less severe psychopathology and higher motivation and readiness--defined as the wish to change and the use of treatment to change--are positive predictors of retention (e.g., DeLeon et al., 1994).

By contrast, a combination of distrust of treatment programs and a sense of self-efficacy that says "something will work for me" are predictors of success in achieving sobriety through AA (Longshore et al., 1998). Studies also show large differences among clinical staff in the percentage of clients who drop out of treatment (Miller, 1985b).

At least three studies suggest that motivational interviewing can be a useful adjunct for increasing client retention and participation in treatment. In the first study, one group of residents admitted to a 13-day alcoholism treatment program received two sessions of assessment and prompt feedback provided in a motivational style stressing empathy and support (see Chapter 4) as part of the intake process (Brown and Miller, 1993).

Although the motivational intervention added only 2 hours to the routine protocol, the therapists reported that residents who participated were more fully involved in later treatment than were counterparts not assigned to the motivational intervention. Moreover, the extra attention and support offered by the motivational intervention resulted in 64 percent of the group having favorable outcomes (i.e., abstinent or asymptomatic) at 3-month followup, compared with only 29 percent of the control group.

Similarly, Aubrey found significantly better treatment retention, lower alcohol use, and lower illicit drug use among adolescents given one session of motivational interviewing and personal feedback on entry to substance abuse treatment (Aubrey, 1998). Adolescents who received the motivational interviewing session completed nearly three times as many sessions (average of 17) compared with those receiving the same outpatient program without motivational interviewing (average of six sessions). Abstinence at followup was also twice as high when the single initial session was added.

In the third study, of opiate users in an outpatient methadone maintenance treatment program in Australia, an hour-long intervention that used motivational interviewing techniques at treatment initiation resulted in increased and more immediate commitment to treatment and abstention among participants (Saunders et al., 1995).

Rather surprisingly for such a brief adjunct to treatment, these outpatients appeared to have fewer problems, more treatment compliance, better retention, and less rapid return to opiate use following treatment than a control group that received an educational intervention. Although 40 percent of the clients studied dropped out of treatment by the end of 6 months, only 30 percent of the clients who participated in the adjunct motivational intervention left treatment by this time, compared with nearly half (49 percent) of the control group.

Another interesting finding was that clients entering methadone treatment were not necessarily in an action stage of change as expected. Rather, they seemed to represent all stages and to cycle rapidly back and forth from precontemplation through maintenance. A large percentage (38 percent) of the group participating in the motivational intervention were contemplating change at admission, and 37 percent of this group were in an action stage 3 months later.

By contrast, 35 percent of the control group were not yet considering change (precontemplation) at admission and an increased percentage (47 percent) were still in this stage of the change process at 3 months. This accentuates the need for assessing how ready clients are for change, no matter what the external circumstances. The boundaries between stages of change seem to be fluid, even for clients whose motivation for change is enhanced by the clinician's counseling style and therapeutic strategies.

Specific Strategies To Increase Engagement and Retention in Treatment

The strategies discussed in this section have been found by some clinicians to be useful in increasing clients' involvement or participation in treatment and decreasing early dropout. All entail some application of motivational approaches already outlined in earlier chapters.

Develop rapport

As noted in Chapters 3 and 4, clinician style is an important element for establishing rapport and building a trusting relationship with clients. The principles of motivational interviewing exemplify proven methods to get in touch with and understand your clients' unique perspectives and personal values, as opposed to yours or your program's. Accurate empathy and reflective listening (client-centered skills for eliciting clients' concerns through an interactive process that facilitates rapport) have been well described and tested in clinical research.

Clients will confide in you if they feel comfortable and safe within the treatment setting. Their natural reactions may depend on such factors as their gender, age, ethnicity, and previous experience. For example, ethnic minorities may bring a reticence to the clinic situation that is based on negative life experiences or problems encountered with earlier episodes of treatment. Initially, for these clients and others who have been oppressed or abused, safety in the treatment setting is a particularly important issue.

Programs can devise innovative ways to make their clients feel welcomed into a familiar milieu or a shared effort. For example, African-Americans call each other brother and sister, and Native Americans consider each other relatives. Some treatment programs refer to clients as members, a term that denotes participation and inclusion.

Programs sometimes provide a meal to help clients feel part of a family. In one program that serves Native Americans, a client's trauma and pain are addressed with "honoring." For example, if a person is experiencing a problem, a sweat lodge can be requested as an appropriate and safe setting in which to disclose feelings and obtain feedback. It is important to honor the request, and it is an honor to be invited.

Participating in a sweat lodge allows Native Americans to embrace their ethnic identity, gain ethnic pride, and honor Native American spirituality, thus encouraging a sense of belonging. In another Native American program, a young woman who was struggling to stop using substances had returned to using them. Rather than punish and isolate her, the group selected her to be fire keeper at the sweat lodge, a position of honor. The group's respect for the individual transcended her current behavior.

The rationale is that without this continued bond, the woman would not have had an opportunity to choose to change her future behavior.

Indirect expression is another way of helping clients from some cultures feel comfortable. Metaphors, stories, legends, or proverbs can explain, through example, a situation that clients can then interpret. For instance, for those clients who appear to have trouble asking others for help, you might tell a story or use an expression to illustrate that point.

Most clients will "get it" and have a clear understanding of what is being communicated without feeling any disrespect. You simply bring a concept to the table; clients then interpret it and draw their own conclusions.

Induct clients into their role

As discussed in Chapter 6, your clients must become acquainted with you and the agency. Tell your clients explicitly what treatment involves, what is expected, and what rules there are. If the client has not been prepared by a referring source, review exactly what will happen in treatment so that any confusion is eliminated.

Use language the client understands. Also be sure to encourage questions and provide clarification of anything that seems perplexing or not justified. Some will want to know why the clinic does not have more desirable hours, why loitering is discouraged, why they must come to group sessions on a particular schedule, or what it means to participate in treatment.

This is the time to explain what information must be reported to a referring agency that has mandated the treatment, including what it means to consent to release information. Role induction by itself is not likely to prevent premature termination, but it does clarify to the client what is expected from the program's perspective (Zweben et al., 1988).

Explore client expectancies and determine discrepancies

One of the first things to discuss with new clients is their expectations about the treatment process, including past experiences, and whether there are serious discrepancies with the reality of the upcoming treatment. To decrease intrusiveness, ask permission before delving into these private and sometimes painful areas.

Then ask clients to elaborate on what they expect and what their initial impressions, hopes, and fears about treatment are. Showing clients a list of concerns other people in treatment have had can help them feel more comfortable expressing their own, which will likely be similar.

Some of these fears include the following:

The clinician will be confrontational and impose treatment goals.

Treatment will take too long and require the client to give up too much.

The rules are too strict, and the client will be discharged for the slightest infringement.

Medication will not be prescribed for painful withdrawal symptoms.

The program does not understand women, members of different ethnic groups, or persons who take a particular substance or combination of substances.

A spouse or other family member will be required to participate.

Many clients will have negative expectations based on previous and usually unsuccessful treatment episodes. A motivational approach can elicit a client's concerns without being judgmental. Each client needs an opportunity to vent anxieties or negative reactions to the treatment process and have these validated as normal--not punishable, but therapeutic.

This is particularly important for clients who feel coerced into treatment to appease someone else (e.g., employer, court, wife) and fear revealing any worries or negative reactions lest these be used against them.

Unrealistic hopes about what treatment can accomplish--particularly without much work by the client--are equally dangerous and seductive but have to be brought out. The client may believe, for instance, that treatment will restore a marriage or erase guilt about the fatal auto accident that preceded admission.

Perhaps the client hopes the program will include acupuncture as part of the treatment, and this is not an option. Be honest about what the program can do and what it cannot do (e.g., pay rent, remove effects of childhood sexual abuse, counteract a poor education).

It is important that you reach understanding with the client about positive and negative expectancies before you enter into the real work of change. Perceptions, hopes, and concerns will change: As old ones are resolved, new ones will likely emerge.

"Immunize" the client against common difficulties

During treatment, clients may have negative reactions or embarrassing moments when they reveal more than they planned, react too emotionally, realize discrepancies in the information they have supplied, or pull back from painful insights about how they have hurt others or jeopardized their own futures. One way to forestall impulsive early termination in response to these situations is to "immunize" or "inoculate" your client: Anticipate and discuss such problems before they occur, indicate they are a normal part of the recovery process, and develop a plan to handle them.

Warn the client, for example, that he may not want to return to treatment immediately after such a situation and that this is a common reaction. Clients may want to keep a diary of any strong or adverse reactions so that these can be discussed or revealed to you in subsequent sessions or even by telephone between sessions (Zweben et al., 1988).

Be culturally aware as you attempt to immunize clients against expected difficulties. The Native American culture, for example, is more comfortable with visual and oral exchange of information than with the written word. The use of art (e.g., drawing, collage) or the talking feather (in group) may be helpful in identifying common and expected difficulties to these clients.

Investigate and resolve barriers to treatment

As treatment progresses, clients may experience or reveal other barriers that impede progress and could result in early termination unless resolved. These barriers can include not understanding written materials easily, having difficulty making transportation or child care arrangements, or having insufficient funds or insurance coverage to continue treatment as initially planned.

Sometimes clients do not feel ready to participate, or suddenly reconsider. This is usually because a planned change is too threatening in reality or in anticipation.

If barriers cannot be overcome by some mutually satisfactory arrangement, it may be necessary to interrupt treatment or make another referral. Discuss early disengagement from therapy at the onset and consider what options might be acceptable to you and your client.

Stress that it is all right to take a break from treatment, if necessary, to allow time to consider alternatives and prepare to act on them, but set up the expectation for or schedule a return to treatment. This type of "therapeutic break" is an option when other motivational techniques have failed (Zweben et al., 1988).

Increase congruence between intrinsic and extrinsic motivation

Ryan and colleagues found that internal motivation is associated with increased client involvement and retention in treatment, but a combination of internal and external motivation seems to promote an even more positive treatment response. They concluded that coercion or external motivation can actually fit into the clients' perceptions of problems and the need for treatment and change (Ryan et al., 1995).

Thus, explore the significance of external motivators to your clients. Perceiving coercive forces as positive--and compatible with the clients' concerns--may be more helpful than trying to convert all external motivation to intrinsic motivation.

These investigators also hypothesized that some amount of emotional distress about problems, rather than a rational catalog of the negative impact of substance use, may be helpful to enhance client motivation for change. Anxiety or depression about life problems may be more significant indicators of readiness to change than the intensity of substance use itself.

Examine and interpret noncompliant behavior

Noncompliant behavior often is a thinly veiled expression of dissatisfaction with treatment or the therapeutic process. For example, clients miss appointments, arrive late, fail to complete required forms, or remain mute when asked to participate. Any occurrence of such behavior provides an opportunity to discuss the reasons for the behavior and learn from it. Often, the client is expressing continuing ambivalence and is not ready to make a change.

You can explore the incident in a nonjudgmental, problem-solving manner that probes whether it was intentional and whether a reasonable explanation can be found for the reaction. For example, a client might be late as a gesture of defiance, to shorten what is anticipated as a distressing session, or because her car broke down. The significance of the event must be established and then understood in terms of precipitating emotions or anxieties and ensuing consequences.

As with all motivational strategies, drawing out your client's perceptions and interpretation of the event is important. Generally, if you can get clients to voice their frustrations, they will come up with the answers themselves. Asking a question such as, "What do you think is getting in the way of being here on time?" is likely to elicit an interpretation from clients and open a dialog. You can respond with reflective listening and add your own interpretation or affirmation.

For example, you can observe that clients who come late to appointments often do not complete treatment and describe how other clients solved the problem in the past. However, do not forget to commend the client for simply getting there.

Finally, alternative responses to similar situations have to be explored so that the client finds a more acceptable coping mechanism that is consistent with the expectations of treatment. Often, this exploration of noncompliant behavior reveals ways in which the goals or activities of treatment should be slowed or changed. Use noncompliance as a signal that you have to get more information or shift your strategy.

This is much more useful than the client's simply retreating and dropping out (Zweben et al., 1988). Means of responding to missed appointments are listed in Figure 7-1.

Research-based clues or indicators of continuing ambivalence or lack of readiness that could result in premature and unanticipated dropout unless explored and resolved include the following (Zweben et al., 1988):

The client has a history of appointment cancellations or early dropout from treatment.

The client feels coerced into treatment and fears offending that coercive source.

The client has little social stability.

The client is hesitant about scheduling appointments or does not think that he can follow a routine schedule.

The client does not appear to feel confident about capabilities for positive change and seems to resent the loss of status involved in getting help.

The client resents completing intake forms or assessments.

The treatment offered is significantly different from any the client has been exposed to previously.

The client has difficulty expressing feelings and revealing personal information.

Reach out

Certain life events, such as a client's wedding, the birth of a child, a client's traumatic injury or illness, or several missed appointments, might require you to reach out to the client to demonstrate personal concern and continuing interest in the interest of preserving the therapeutic relationship and enhancing the recovery process.

However, you must be careful not to cross professional boundaries or put the therapeutic relationship at risk by violating a client's privacy or confidentiality rights. An example of a violation might be attending the funeral for a member of a client's family, without the client's consent, when the family and friends do not know the client is receiving substance abuse treatment.

Any contemplated change in the boundaries of the clinician-client therapeutic relationship must be supported theoretically, well thought out, discussed with your clinical supervisor, consistent with program policies, and reviewed for any legal or ethical issues that could arise.

For example, it may be your program's policy that clients are treated only in the program's offices. If a client is hospitalized, however, it may be necessary for you to go to the hospital to continue the client's treatment. Such a move should be discussed with your supervisor.

Privacy and confidentiality issues that should be addressed include obtaining the client's written authorization for release of information to the hospital, the client's physician, and ancillary personnel; and what to do if the client has a roommate, receives a phone call during the treatment session, and if a session is interrupted by hospital staff.

Early in treatment, you should identify the client's social support network. Tactfully discuss with the client her preferred avenues for keeping in touch with her, such as written consent to contact certain relatives or friends. She will perhaps want to provide letters to referral sources authorizing them to respond if you contact them. In addition, you should be aware of and abide by your clients' cultural mores regarding contact outside the substance abuse treatment setting.

Brief adjunctive motivational intervention

The brief adjunctive motivational intervention in one study (Saunders et al., 1991) used the following strategies:

Elicit the client's perceptions of the so-called "good" things about substance use.

Help the client inventory less good things about substance use.

Invite the client to reflect on the lifestyle once envisaged, current life satisfactions, and what lifestyle is anticipated for the future.

Have the client determine which, if any, of the elicited problems are of real concern.

Assist the client in comparing and contrasting the costs and benefits of continuing current behavior.

Highlight areas of greatest concern, emphasizing discrepancies that generate discomfort and genuine emotional reactions to the current behavior and consequences.

Elicit and agree on future intentions regarding the target behavior.

Planning for Stabilization

In addition to handling problems that can interrupt treatment prematurely, work to stabilize actual change in the problem behavior. This requires considerable interactive planning, including conducting a functional analysis, developing a coping plan, and ensuring family and social support.

Conducting a Functional Analysis

Although a functional analysis can be used at various points in treatment, it can be particularly informative in preparing for maintenance. A functional analysis is an assessment of the common antecedents and consequences of substance use.

Through functional analysis, you help clients understand what has "triggered" them to drink or use drugs in the past and the effects they experienced from using alcohol or drugs. With this information, you and your clients can then work on developing coping strategies to maintain abstinence. The following approach is adapted from Miller and Pechacek, 1987.

To begin a functional analysis, first label two columns on a sheet of paper or blackboard as "Triggers" and "Effects." Then begin with a statement such as, "I'd like to understand how substance use has fit into the rest of your life."

Next, find out about your client's antecedents: "Tell me about situations in which you have been most likely to drink or use drugs in the past, or times when you have tended to drink or use more. These might be when you were with specific people, in specific places, or at certain times of day, or perhaps when you were feeling a particular way." Make sure to use the past tense because the present or future tense may unsettle currently abstinent clients.

As your client responds, listen reflectively to make sure that you understand. Under the Triggers column, write down each antecedent. Then ask, "When else in the past have you felt like drinking or using drugs?" and record each response.

If your client completed a pretreatment questionnaire about substance use, you may be able to use this information to elicit any triggers the client did not mention. For example, "I notice on this questionnaire you marked that you might be 'very tempted' to drink when you... Tell me about this." Then write down any additional antecedents in the Triggers column.

After the client seems to have exhausted the antecedents of substance use, ask about what the client liked about drinking or using drugs. Here you are trying to elicit the client's own perceptions or expectations from substance use, not necessarily the actual effects.

As the client volunteers this information, respond with reflective listening to ensure that you understand, and make sure not to communicate disapproval or disagreement. Write down each desired consequence in the Effects column. Then ask, "What else have you liked about drinking or using drugs in the past?" and record each response.

Again, if the client completed a pretreatment questionnaire about the desired consequences of substance use, you can use this information to elicit more consequences the client may not have brought up. For example, "I notice on this questionnaire you marked that you often used drugs to... Tell me about this." Write down any new consequences in the Effects column.

Once the client has finished giving antecedents and consequences, you can point out how a certain trigger can lead to a certain effect. First, pick out one item from the Triggers column and one from the Effects column that clearly seem to go together. Then ask the client to identify pairs, letting the client draw connecting lines on the paper or blackboard.

For trigger items that have not been paired, ask the client to tell you what alcohol or drug use might have done for her in that situation, and draw a line to the appropriate item in the Effects column. Sometimes there is no corresponding item in the Effects column, which suggests that something has to be added. Then do the same thing for the Effects column. It is not necessary, however, to pair all entries.

With this information, you can develop maintenance strategies. Point out that some of the pairs your client identified are common among most users. Next, you can say that if the only way a client can go from the Triggers column to the Effects column is through substance use, then the client is psychologically dependent on it.

Then make clear that freedom of choice is about having options--different ways--of moving from the Triggers to the Effects column. You can then review the pairs, beginning with those the client finds most important, and develop a coping plan that will enable the client to achieve the desired effects without using substances (Miller and Pechacek, 1987).