Chapter 9 Integrating Motivational Approaches Into Treatment Programs

How do the motivational approaches discussed in this TIP fit into the real world of health care delivery? Although the demand for treatment of substance abuse continues to far exceed its availability, changes in health care economics are placing greater pressure on providers and their clients. Payors increasingly demand evidence that the services being provided are not only effective, but cost-effective.

Clinicians and programs are increasingly challenged if they do not use research-supported, current methods. Public funding is scarce, and third-party payors exert great pressure to provide treatment that is shorter, less costly, and more effective. In sum, clinicians are asked to do more with less.

The incorporation of motivational approaches and interventions into treatment programs may be a practical and efficacious response to many of these challenges. Recent research (Brown and Miller, 1993; Kolden et al., 1997; McCaul and Svikis, 1991) supports the integration of motivational interviewing modules into programs to reduce attrition, to enhance client participation in treatment, and to increase the achievement and maintenance of positive behavioral outcomes.

Other studies have shown brief interventions using motivational strategies and motivational interviewing to be more effective than no treatment or being placed on a waiting list, and not inferior to some types of more extensive care (Bien et al., 1993a, 1993b; Noonan and Moyers, 1997). A review of the cost-effectiveness of treatments for alcohol use disorders concluded that brief motivational counseling ranked among the most effective treatment modalities, based on weighted evidence from rigorous clinical trials (Holder et al., 1991).

Brief motivational counseling was also the least costly--making it the most cost-effective treatment modality of the 33 evaluated. Although cautioning that it was an approximation that requires refinement, the same study found a negative correlation between effectiveness and costs for the most traditional forms of treatment for alcohol use disorders and highlighted a growing trend to favor effective outpatient care over less effective or less studied--but far more expensive--inpatient, hospital-based, or residential care (Holder et al., 1991).

This chapter begins with a discussion of the treatment continuum into which motivational interventions must be incorporated and ends with descriptions of motivational approaches that have been used in specific treatment settings. Also discussed is the importance of involving a significant other to enhance a client's motivation for change.

The Treatment Continuum and Stepped Care

In 1990, the Institute of Medicine (IOM), in a special report to Congress, called for broadening the base of treatment for alcohol use disorders (IOM, 1990a). Both before and after that summons, modalities and special interventions to treat problems related to substance use have proliferated. In the year following the IOM report, Holder and associates reviewed the effectiveness and costs of 33 separate types of treatment for alcohol problems that had been subjected to controlled clinical trials (Holder et al., 1991).

The costs are much larger if specialized treatment services for substance-related problems are added to the base. However, these multiple modalities are not always used appropriately. Moreover, services are not always available to all who need or want them because of costs, lack of physical accessibility, and too few staff members.

The IOM report called attention to several important suppositions that underlie its efforts:

Substance use problems are not homogeneous--they differ in intensity, duration, effects, and other important dimensions.

Individuals who have problems with substance use are also diverse and have preferences about the treatments they will accept.

The magnitude of substance-related problems is too large to be handled by specialized treatment programs that are isolated from mainstream health care and other social services.

In an era of managed care and decreasing public funds for services that are demonstrated as not cost-effective, the provision of health care must necessarily be limited. However, funds can still be allocated in a rational, fair, and effective way if the most expensive treatments are reserved for the most serious cases and the least intensive interventions that have a reasonable chance of success are applied as a first response. This stepped care approach to delivering treatment services operates according to the following principles (Sobell and Sobell, 1999):

Both assessment and treatment should be individualized, with different types and intensities tailored to the presenting problem (or problems) and client characteristics.

The treatment initially recommended should be the least intensive and least costly treatment that is most likely--based on research, assessment findings, and clinical judgment--to resolve the identified problem.
More intensive and expensive treatments should be reserved for more serious problems and for clients who do not respond to less intensive interventions.

Where two interventions are equally effective for clients with certain characteristics, the less costly treatment should be tried first. This principle applies to the use of group treatment instead of individual care and to counseling by telephone, Internet, or mail instead of a personal meeting when these approaches are demonstrated to be equally effective.
All recommended treatments should be based on solid research or, in the absence of adequate data, peer-established best practice guidelines.

When making recommendations, clinicians should consider the client's preferences regarding treatment. "It makes little sense to refer clients to treatments that they believe are inappropriate and where the referrals are likely to result in those individuals dropping out of treatment" (Sobell and Sobell, 1999).

Both assessments and treatments should be ongoing, increasingly comprehensive processes, not one-time activities. That is, simple screening and brief interventions may be sufficient for excessive drinkers identified in opportunistic settings, but more comprehensive assessments and more intensive treatments should follow if clients do not respond satisfactorily to initial care based on empirically established outcome measures.

The need for additional treatment is based on both performance in the initial setting and another, more thorough assessment. Additional treatment may consist of more sessions in the original setting or referral to an alternative intervention, depending on clinical judgment, assessment findings, and client preferences.

The implications for motivational interventions of a stepped care approach to planning and service delivery are many. First, this model reflects many of the same principles underlying motivational approaches, including the importance of offering treatment options to clients and respecting their informed choice in treatment decisions.

Second, the stepped care model supports an increase in brief outpatient interventions that could effectively address mildly impaired persons without providing unnecessary services for them, while meeting public health objectives for reducing the high social costs of hazardous drinking and drug use.

Motivational approaches entailing an assessment and only a few clinical sessions have proven effective and could be offered in a wide range of health care settings, provided staff members are properly trained and agree with the method. Finally, since a stepped care approach to planning and allocating treatment services is performance-based and does not specify a hierarchy of interventions, motivational approaches can be applied in different formats.

For example, clinicians can experiment with the number, duration, or frequency of sessions to find the format that best meets individual needs.

Applications of Motivational Approaches In Specific Treatment Settings

No single method to incorporate motivational approaches into service delivery systems is superior to others. A few obvious opportunities present themselves, but applications have been and continue to be a matter of clinical creativity.

Some of the ways in which motivational interventions have been used are as

A means of rapid engagement in the general medical setting to facilitate referral to treatment

A first session to increase the likelihood that a client will return and to deliver a useful service if the client does not return

An empowering brief consultation when a client is placed on a waiting list, rather than telling a client just to wait for treatment

A preparation for treatment to increase retention and participation

A help to clients coerced into treatment to move beyond initial feelings of anger and resentment

A means to overcome client defensiveness and resistance

A stand-alone intervention in settings where there is only brief contact

A counseling style used throughout the process of change

Often, there is a relatively short period of time in which you, the clinician, can make a beneficial impact. This may be because length of service is restricted by reimbursement policies or by the nature of a program (e.g., an employee assistance program) or the setting may allow for only a single encounter, such as an emergency department. Moreover, the average length of stay in substance abuse treatment is very short. If you do not make an impact in the first session or two, you may make no impact at all. Thus, it is wise to make the best use of the first contact with a client.

However, this may conflict with the practical demands of a clinical setting in which paperwork must be done for admission, a waiting room is full of clients, or a treatment plan must be completed by the fourth session. Nevertheless, it is usually a mistake to start a session with filling out forms. Take some time at the very beginning just to listen to your client, to understand him, and enhance motivation for change. If one contact is all you get with this client, filling out a questionnaire alone is unlikely to help. Research shows that even a single session of motivational interviewing does make a difference.

The rest of this chapter describes creative ways in which the motivational approaches described in this TIP have been implemented.

In the Emergency Department

One of the first demonstrations of the power of brief interventions was implemented in the emergency department at Massachusetts General Hospital in the late 1950s. Morris Chafetz was concerned that many of the patients treated in the emergency department were there because of health problems and injuries related to their drinking. Yet nothing was being done about it. A resident might shake a finger at the patient and say, "You really have to quit drinking," but never follow up. In fact, less than 5 percent of these patients sought treatment for their alcohol problems.

Chafetz wondered what would happen if an empathic counselor were present to listen to these patients after they had been treated medically, encouraging them to come back for treatment. Thus, he conducted two studies in which patients coming into the emergency department with alcohol-related medical problems were assigned, at random, to meet with a counselor for a short conversation (15 to 20 minutes) following their medical treatment. In both studies (Chafetz et al., 1962, 1964), patients were 12 times more likely to return for treatment of their alcohol problems if they had talked with an empathic counselor (65 and 78 percent), compared with patients receiving only emergency department care (5 and 6 percent).

At Boston Medical Center's Emergency Department, doctors developed Project ASSERT (an acronym for Alcohol and Substance abuse Services and Educating providers to Refer patients to Treatment), originally funded by the Center for Substance Abuse Treatment. Project ASSERT employs health promotion advocates who screen emergency department patients for substance use, establish rapport, explore change issues, assess readiness to change using the readiness ruler, negotiate a plan, and facilitate access to the substance abuse treatment system.

The program also trains and involves the residents in emergency medicine. Published followup data show a 45-percent reduction in severity of drug problems, a 56-percent reduction in alcohol use, and a 64-percent reduction in frequency of binge drinking. Additionally, 50 percent of the patients reported keeping an appointment for treatment (Bernstein et al., 1997a).

In Obstetric Clinics

Another example of an effective motivational intervention is the pilot study conducted by Nancy Handmaker with pregnant women who attended obstetric clinics. Women who reported some drinking in the past month underwent a structured assessment and were assigned to receive either a motivational intervention or written materials informing them of the risks of drinking during pregnancy.

In the nonjudgmental personal interviews the women reported considerably more drinking than they did on screening questionnaires. Among women with higher estimated peak blood alcohol concentrations, motivational intervention was more effective in reducing consumption during the next 2 months of pregnancy (Handmaker et al., 1999).

In Medical Settings

Several studies have used motivational interventions in medical settings. Hospitalized teen smokers benefited from brief motivational interviews in their smoking dependence and number of days they smoked (Colby et al., 1998). Researchers determined the stage of change of patients in a primary care clinic who gave at least one positive response to the CAGE. Although the researchers had expected most of these individuals to be in the contemplation stage, the patients were found to be primarily in the action stage, and most were no longer using alcohol (Samet and O'Connor, 1998).

This implies that primary care physicians can perhaps contribute best to their patients' sobriety by providing positive feedback about remaining abstinent and using relapse prevention techniques. Primary care providers who received a brief training program on patient-centered alcohol counseling improved their counseling skills and were much better prepared to intervene with problem drinkers (Ockene et al., 1997).

Motivational Interviewing and the Marijuana Checkup

A study conducted at the University of Washington offered a two-session Marijuana Checkup, publicized through the local media with a telephone number for inquiries. In the initial weeks of the program, the staff noticed that 60 percent of eligible callers who scheduled an assessment session failed to keep their appointments. This rate was reduced by half when the initial telephone intake protocol was modified. The new approach involved a 3- to 5-minute dialog during which the staff person asked a series of open-ended questions and, using reflective listening, discussed the caller's reasons for being interested in the program.

The Matrix Model for Drug Users

In 1994, the National Institute on Drug Abuse funded the development of a model intensive outpatient treatment program that was to be constructed from research-supported elements (Rawson et al., 1995). The first version of this model, intended for persons with stimulant use disorders, contained specific instructions for therapists and an articulated philosophy of treatment that emphasized a motivational approach:

The therapist fosters a positive, healthy relationship with the patient and uses that relationship to reinforce positive behavior change. The interaction is realistic and direct but not confrontational or parental. Therapists are trained to view the treatment process as an exercise that will promote self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is a critical element for patient retention. (p. 120)

The basic motivation-enhancing philosophy that characterized the original Matrix model of outpatient treatment for stimulant users has since been broadened to include protocols for substances. The model continues to be evaluated and refined according to the results of ongoing outcome studies.
   

Motivational Enhancement Therapy

The Commonwealth of Virginia has developed and is using a multicomponent model that incorporates Motivational Enhancement Therapy (MET). The program is called SATOE for its origins in the Substance Abuse Treatment Outcome Evaluation work group--a statewide gathering of clients and representatives from Virginia's local public substance abuse treatment agencies, universities, and the Department of Mental Health, Mental Retardation and Substance Abuse Services.

The evolving elements of the SATOE model include

Assessments of clients
Placements of clients in appropriate levels and types of services
Utilization review and improvements of service delivery
Treatment outcome evaluations

The SATOE model currently consists of five primary components:

Diagnoses of substance abuse disorders according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
MET assessments and interventions
Addiction Severity Index (ASI) evaluation
Standardized client placement criteria, such as the Patient Placement Criteria of the American Society of Addiction Medicine
Utilization review using treatment services review

In the SATOE model, clients are typically given the University of Rhode Island Change Assessment (URICA)--a 32-item, self-report questionnaire that assesses the client's readiness to change problematic behaviors (see Chapter 8). URICA scores guide clinicians' judgment regarding clients' readiness for treatment. This instrument was selected because many public sector clients have diagnoses of a substance abuse disorder coexisting with mental health disorders, and this instrument allows respondents to specify the target problem, in contrast to other readiness instruments that are specific to substance use.

In one implementation version of the model, clients identified as precontemplators (and sometimes contemplators) by URICA-supported clinical assessments are placed in a separate, time-limited (4 to 8 weeks) motivationally oriented treatment track that uses MET principles and interventions. Although some clients find this course of MET-based treatment sufficient for them to make desired behavioral changes, the MET-based treatment is more typically expected to increase clients' readiness for more traditional substance abuse treatment that also incorporates MET principles. Other approaches to implementing MET under the SATOE involve integrating MET principles throughout traditional outpatient and intensive outpatient models of treatment.

After the client completes the brief course of MET-based treatment, the program calls for a reevaluation of the client using such behavioral indicators as treatment compliance or urinalysis results in addition to another URICA assessment or an informal clinical assessment of readiness for change. Based on the findings, the client can be discharged or a new treatment plan can be developed that involves additional motivationally oriented treatment, traditional substance abuse treatment, other services such as case management or individual therapy and, in the case of clients referred by the criminal justice system, referral to criminal justice agencies for graduated sanctions.

Although the State expects to support all of SATOE's components, initial emphasis has been placed on the readiness to change assessments and the ASI. A list of providers has been established to facilitate communication among users of the model or its components. In addition, a comprehensive evaluation of the implementation parameters and a cost-benefit analysis of the model are planned.

To facilitate implementation of SATOE, the State undertook several important activities. The first was to develop a manual of MET principles and techniques. Because the best-known protocol of MET for substance abuse treatment is the Project MATCH effort for brief individual treatment of clients, and group treatment is the prevalent modality in Virginia's public programs, the Virginia Addiction Technology Transfer Center developed a group-based model of MET treatment and produced a manual for this protocol (Ingersoll and Wagner, 1997).

This model has been demonstrated to be effective in increasing readiness to change (Wagner et al., 1998). The second activity is a large-scale training initiative in which administrative staff is introduced to basic MET principles and implications for program changes, while clinical staff is trained in MET principles and related clinical interventions.

Virginia expects the SATOE model to evolve over time in response to feedback from the field. Serious attention is now being given to alternatives within the model that will allow local agencies to adjust it to their priorities and limitations. For example, some treatment agencies in the State have chosen to integrate MET principles throughout their substance abuse disorder services continuum or in specific services such as intensive outpatient therapy, rather than to have a separate MET-based treatment track. Whereas the standard MET protocol involves four sessions, the SATOE model will explore longer term and even open-ended versions to accommodate the expectations of local criminal justice agencies.

Implementation of the SATOE model represents a potential paradigmatic change for Virginia's delivery system for substance abuse treatment. The bottom line in all SATOE-related efforts has been the development of methodologies that permit public-sector agencies to provide the most appropriate and cost-effective services.

An African-Centered Application of Motivational Intervention

In working with African-American clients, the application of motivational intervention with a culturally congruent manner can be very effective in eliciting increased self-disclosure, engagement in the treatment process, and positive treatment outcomes. For example, in the development of discrepancy, amplifying discrepancies between substance use behavior and the client's perceived purpose, reason for being, or destiny in life creates significant dissonance and reflective pause.

Other culturally significant discrepancies include the discrepancy between substance use and commitment to the well-being of the community; substance use and relationships with others; substance use and fulfillment of destiny; substance use and one's spiritual development and hardiness; substance use and acting "out of character." These discrepancies relate to culturally meaningful principles among African-Americans--cultural principles that reflect their African cultural heritage (Grills and Rowe, 1998; Longshore et al., 1998). These include principles of interconnectedness, responsibility to the community, the belief that the essential core that is the self is divine essence, the belief that each person has a God-given purpose in life, and the importance of developing good character.

Additionally, a reframing of healing (recovery) from a process of just healing the personal self to a process that stimulates healing of the community engages the client more substantively in a consideration of his substance use. One's own healing represents a healing of the community because of the essential interdependent nature of the African-American communities (Rowe and Grills, 1993).

Finally, the application of motivational intervention with African-American clients has been enhanced through the contextualization of personal substance use within a historical and societal reality. Substance use is understood not solely as a function of attributes of the individual but also within the context of very real historical and systemic forces of oppression and racism in the United States that aggressively impinge upon the well-being and life-affirming practices of the individual, the family, and the community.

The adverse effects of substance use are considered to erode life chances, family life, cultural traditions, and sense of community life for African-Americans (Goddard, 1992).

This culturally congruent application of motivational intervention has been found effective in the movement of African-American clients from precontemplation to contemplation, contemplation to action, and from action to maintenance (Longshore et al., 1998).

Adolescents with Multiple Drug Problems

The adolescent treatment program at the University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions works mostly with adolescents who have overwhelming problems. They use multiple drugs, are in trouble with the law, are failing in or have dropped out of school, have tumultuous and sometimes abusive family relationships, sometimes belong to gangs, and are engaged in many kinds of risky behavior.

Almost none of them come for treatment of their own accord. They are sent by the courts, brought by a parent, or transported from a custodial setting. They are often angry, silent, brooding, confrontational, or defiant. They resent being told by adults that they should say no to drugs.

Even with all the external pressure from courts and family, retention is a significant problem. The average adolescent client admitted to the program stays for five outpatient sessions. To address this problem, motivational interviewing was used at intake (Aubrey, 1998). Adolescents entering the program were randomly assigned to receive the usual intake interview or one motivational interview that included personal feedback from assessment.

Aubrey found that her adolescent clients responded very well to motivational interviewing, a counseling style quite different from what they had expected. They also stayed in treatment longer. Those who had a motivational interview at intake stayed for an average of 17 sessions compared to 6 sessions for those receiving the regular intake procedure. Most important was the impact on adolescents' substance use. At the 3-month followup, adolescents who received the motivational interview had a significantly higher rate of abstinence than the control group (70 percent versus 43 percent), paralleling previous findings with adult inpatient (Brown and Miller, 1993) and outpatient populations (Bien et al., 1993b).

Women With Multiple Vulnerabilities

Individuals with substance abuse problems are more likely to have an accompanying health, mental health, or social problem than the general population. Women are especially vulnerable; studies indicate higher rates of coexisting disorders for women than men (Helzer and Pryzbeck, 1988; Regier et al., 1990). Recognizing that women may have multiple problems and that they may be prepared to change one aspect of their lives but not another, researchers in California developed the Steps of Change model, based on the stages of change (Brown et al., in press; Melchior et al., in press).

The Steps of Change assesses a woman's readiness to enter treatment by examining four categories: (1) readiness to change substance use behavior, (2) readiness to change high-risk sex practices, (3) readiness to change a domestic violence situation, and (4) readiness to deal with emotional problems. This allows a woman to consider her multiple needs and enter into appropriate types of treatment or integrated treatment.

Initial results from the study showed that the four levels of stage of change do not indicate a single underlying desire to change, thus supporting the use of the Steps of Change to evaluate readiness in various domains, and that those problems presenting the greatest potential for immediate harm to women typically induce the greatest willingness to change. These are important considerations when predicting treatment entry and outcome for women. Future studies will examine the retention of women in treatment for substance abuse based on the Steps of Change model.

A Short-Term Residential Treatment Program

In a Southwestern treatment program that serves a population that is 95 percent Native American, a number of motivational strategies are being used to enhance treatment outcome in the various program components of the 150-bed facility. For example, the facility's clinical staff members wear name badges that identify more than the name and title of the clinician. Each clinician's name badge includes reference to the ethnic group or family of origin--tribal members are identified by one of two dozen clans that comprise the tribal identity in the native language and non-Native Americans are identified by their ancestry (e.g., European, African).

Clients entering the 16-day residential program are provided material to design their own individualized name badges that contain information regarding their families of origin. Clinicians are encouraged to integrate use of clan relationships in their individual and family interventions, so it is common to hear references to a client as younger brother, grandmother, or uncle. These references enhance the motivation of clients to participate in the treatment process and become engaged in the therapeutic dynamics of the Native American program.

In a 6-month followup of three dozen former clients, this program found that 70 percent of those completing the residential program were still doing better than prior to admission; they had lower rates of alcohol consumption and improved quality of life and family interactions. Although opportunity for continued improvement in those areas of functioning remained, cases of significant client change occurred. There were followup reports of individuals establishing places of residence after a number of months or years of alcohol abuse during which these clients had become homeless.

Some clients began to build on the basic cultural teachings to which they had been exposed. Clients also attempted to find mentors outside the treatment program from whom they could learn more about traditions, such as how to run a sweat lodge and how to facilitate these ceremonies for family or friends. The importance of including familial relationships as part of the therapeutic process was key in motivating clients to begin changing drinking behaviors that standard treatment programs had deemed very difficult, if not impossible, to change.

One former client, a graduate of that followup cohort, left the region to enter a standard 30-day residential treatment program. After completing that 30-day program, the client was encouraged to volunteer and remain as a cultural advisor, as other members of the client's tribe were being admitted. Two years later, that client and volunteer returned home and obtained employment as a Traditional Counselor in the 16-day program where he originally began recovery.

Group Settings

The current context of service delivery places heavy emphasis on group treatment. Many motivation-enhancing activities can take place in group therapy that cannot be done in individual treatment (e.g., clients can receive feedback from peers); however, several significant clinical issues arise in terms of conducting groups: attrition, structure of groups, group cohesion, and handling difficult clients (Dies, 1994). Conducting group therapy is considerably more complicated than conducting individual treatment, as it involves handling multiple clients simultaneously.

Also, the use of behavioral materials and motivational strategies and techniques in groups must be done in such a way as to accomplish the same objectives as in individual therapy. Therefore, being a good clinician in an individual setting does not qualify a therapist to conduct group sessions; rather, the clinician must possess an understanding of group dynamics and have the necessary skills to conduct group therapy.

Efforts to date have yielded mixed results for motivational enhancement therapy in group settings. Some studies find that motivational interviewing in a group setting is less effective than in individual counseling; in one case, college students treated in a group actually fared slightly worse than those in a control group given no treatment (Walters et al., in press).

However, one team at the University of Washington found that heavy-drinking college students markedly reduced their drinking in response to a 6-week group program (Baer et al., 1992). Favorable results were also obtained in a recent, randomized clinical trial evaluating a motivationally based cognitive--behavioral intervention, Guided Self-Change (GSC) treatment. This trial demonstrated that motivationally based techniques and strategies were as successful in group format as in individual treatment for both alcohol and substance abuse (Sobell et al., 1995; Sobell and Sobell, 1998).

Specifically, the results from this trial were (1) no evidence of differential attrition over the course of treatment as a result of random assignment to group or individual treatment, (2) very high group cohesion, considered essential to successful group outcomes (Cota et al., 1995; MacKenzie, 1983; Satterfield, 1994), based on client reports that they were able to respond with relative openness, (3) similar outcomes for motivationally based GSC group and levels of client satisfaction as for individually treated clients, (4) a significant decrease in drinking and drug use from pretreatment to treatment in both the group and individual formats, and changes maintained 1 year following treatment, and (5) a considerable cost reduction when providing motivationally based treatment in a group rather than an individual format--41.5 percent cost savings for the actual service provision, and an eightfold reduction in missed appointments in the group format compared to individual sessions.

Additionally, 80 percent of all individual and group clients said they would recommend the GSC program to a friend.

Because social support is intrinsic to group treatment, clients in a group can reinforce and help maintain each others' changes. People start to open up over the course of treatment as they receive feedback and are reinforced for self-disclosure--two important elements of group treatment and motivational interviewing. When using advice feedback materials in group, a "round robin" procedure can be used whereby clients engage in reflective listening and comment in a way that promotes discrepancy as well as points out observed ambivalence in their peers.

In group therapy, all clients act as agents of change by helping each other, through a peer-based process, to strengthen their motivation and commitment to change. The group rather than the individual clinician is the agent of change (Dies, 1994).

Although this study offers much promise, it is the first study to use a motivationally based intervention in a group format. It seems reasonable that motivational approaches could be adapted for use in groups to increase cost effectiveness, yet it is clear that some efforts at group motivational intervention have failed or even been detrimental. Until effective group treatment methods are clarified, it would be wise to evaluate new programs to make sure they are accomplishing what is intended.

Motivational Enhancement in Group Therapy

Conducting motivational interventions in a group versus individual format is more difficult, more complex, and more challenging. Personally, however, I find it much more rewarding. In group therapy, particularly using motivational techniques and strategies, clients learn through the group.

It is like a hall of mirrors; clients get the feel of how they come across. For me, when a client uses reflective listening with another client or points out another client's ambivalence, the group is like a living, learning laboratory of experiences practiced first in a safe environment before being tried in the real world.

In the end, what the members have is a common goal to reduce or stop substance abuse, and it is here that their mutual support and peer pressure is effective.

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From SAMHSA/CSAT Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Chapter 9 Integrating Motivational Approaches Into Treatment Programs