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Enhancing Motivation for Change in Substance Use Disorder Treatment: Updated 2019 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2019. (Treatment Improvement Protocol (TIP) Series, No. 35.)
“Motivation to initiate and persist in change fluctuates over time regardless of the person's stage of readiness. From the client's perspective, a decision is just the beginning of change.”
—Miller & Rollnick, 2013, p. 293
Motivation is the key to substance use behavior change.
Counselor use of empathy, not authority and power, is essential to enhancing client motivation to change.
The Transtheoretical Model (TTM) of the Stages of Change (SOC) approach is a useful overarching framework that can help you tailor specific counseling strategies to the different stages.
Why do people change? How is motivation linked to substance use behavior change? How can you help clients enhance their motivation to engage in substance use disorder (SUD) treatment and initiate recovery? This Treatment Improvement Protocol (TIP) will answer these and other important questions. Using the TTM of behavioral change as a foundation, Chapter 1 lays the groundwork for answering such questions. It offers an overview of the nature of motivation and its link to changing substance use behaviors. It also addresses the shift away from abstinence-only addiction treatment perspectives toward client-centered approaches that enhance motivation and reduce risk.
In the past three decades, the addiction treatment field has focused on discovering and applying science-informed practices that help people with SUDs enhance their motivation to stop or reduce alcohol, drug, and nicotine use. Research and clinical literature have explored how to help clients sustain behavior change in ongoing recovery. Such recovery support helps prevent or lessen the social, mental, and health problems that result from a recurrence of substance use or a relapse to previous levels of substance misuse.
This TIP examines motivational enhancement and substance use behavior change using two science-informed approaches (DiClemente, Corno, Graydon, Wiprovnick, & Knobloch, 2017):
Motivational interviewing (MI), which is a respectful counseling style that focuses on helping clients resolve ambivalence about and enhance motivation to change health-risk behaviors, including substance misuse
The TTM of the SOC, which provides an overarching framework for motivational counseling approaches throughout all phases of addiction treatment
| KEY TERMS | |
|---|---|
| Addiction:* The most severe form of SUD, associated with compulsive or uncontrolled use of one or more substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and recovery. | |
| Alcohol misuse: The use of alcohol in any harmful way, including use that constitutes alcohol use disorder (AUD). | |
| Alcohol use disorder: Per the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013), a diagnosis applicable to a person who uses alcohol and experiences at least 2 of the 11 symptoms in a 12-month period. Key aspects of AUD include loss of control, continued use despite adverse consequences, tolerance, and withdrawal. AUD covers a range of severity and replaces what DSM-IV, termed “alcohol abuse” and “alcohol dependence” (APA, 1994). | |
| Health-risk behavior: Any behavior (e.g., tobacco or alcohol use, unsafe sexual practices, nonadherence to prescribed medication regimens) that increases the risk of disease or injury. | |
| Recovery:* A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, with help, overcome their disorder and regain health and social function. This is called remission. When those positive changes and values become part of a voluntarily adopted lifestyle, that is called “being in recovery.” Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the only healthy, pro-social feature. | |
| Recurrence: An instance of substance use that occurs after a period of abstinence. Where possible, this TIP uses the terms “recurrence” or “return to substance use” instead of “relapse,” which can have negative connotations (see entry below). | |
| Relapse:* A return to substance use after a significant period of abstinence. | |
| Substance:* A psychoactive compound with the potential to cause health and social problems, including SUDs (and their most severe manifestation, addiction). The table at the end of this exhibit lists common examples of such substances. | |
| Substance misuse:* The use of any substance in a manner, situation, amount, or frequency that can cause harm to users or to those around them. For some substances or individuals, any use would constitute misuse (e.g., underage drinking, injection drug use). | |
| Substance use:* The use—even one time—of any of the substances listed in the table at the end of this exhibit. | |
| Substance use disorder:* A medical illness caused by repeated misuse of a substance or substances. According to DSM-5 (APA, 2013), SUDs are characterized by clinically significant impairments in health, social function, and impaired control over substance use and are diagnosed through assessing cognitive, behavioral, and psychological symptoms. SUDs range from mild to severe and from temporary to chronic. They typically develop gradually over time with repeated misuse, leading to changes in brain circuits governing incentive salience (the ability of substance-associated cues to trigger substance seeking), reward, stress, and executive functions like decision making and self-control. Multiple factors influence whether and how rapidly a person will develop an SUD. These factors include the substance itself; the genetic vulnerability of the user; and the amount, frequency, and duration of the misuse. A severe SUD is commonly called an addiction. |
| Substance Category | Representative Examples |
|---|---|
| Alcohol |
|
| Illicit Drugs |
|
| Over-the-Counter Drugs and Other Substances |
|
As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use, for states have legalized retail marijuana sales, and the District of Columbia has legalized personal use and home cultivation (both medical and recreational). It should be noted that none of the permitted uses under state laws alter the status of marijuana and its constituent compounds as illicit drugs under Schedule I of the federal Controlled Substances Act. See the section on Marijuana: A Changing Legal and Research Environment in the Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health (Office of the Surgeon General, 2016). The report is available online (https://addiction
These substances are not included in NSDUH and are not discussed in the Surgeon General's Report. However, important facts about these drugs are included in Appendix D - Important Facts About Alcohol and Drugs.
Motivation is a critical element of behavior change (Flannery, 2017) that predicts client abstinence and reductions in substance use (DiClemente et al., 2017). You cannot give clients motivation, but you can help them identify their reasons and need for change and facilitate planning for change. Successful SUD treatment approaches acknowledge motivation as a multidimensional, fluid state during which people make difficult changes to health-risk behaviors, like substance misuse.
The following factors define motivation and its ability to help people change health-risk behaviors.
Motivation is a key to substance use behavior change. Change, like motivation, is a complex construct with evolving meanings. One framework for understanding motivation and how it relates to behavior changes is the self-determination theory (SDT). SDT suggests that people inherently want to engage in activities that meet their need for autonomy, competency (i.e., self-efficacy), and relatedness (i.e., having close personal relationships) (Deci & Ryan, 2012; Flannery, 2017). SDT describes two kinds of motivation:
Intrinsic motivation (e.g., desires, needs, values, goals)
Extrinsic motivation (e.g., social influences, external rewards, consequences)
Contingency management is a counseling strategy that can reinforce extrinsic motivation. It uses external motivators or reinforcers (e.g., expectation of a reward or negative consequence) to enhance behavior change (Sayegh, Huey, Zara, & Jhaveri, 2017).
Motivation helps people resolve their ambivalence about making difficult lifestyle changes. Helping clients strengthen their own motivation increases the likelihood that they will commit to a specific behavioral change plan (Miller & Rollnick, 2013). Research supports the importance of SDT-based client motivation in positive addiction treatment outcomes (Wild, Yuan, Rush, & Urbanoski, 2016). Motivation and readiness to change are consistently associated with increased help seeking, treatment adherence and completion, and positive SUD treatment outcomes (Miller & Moyers, 2015).
Motivation is multidimensional. Motivation includes clients' internal desires, needs, and values. It also includes external pressures, demands, and reinforcers (positive and negative) that influence clients and their perceptions about the risks and benefits of engaging in substance use behaviors. Two components of motivation predict good treatment outcomes (Miller & Moyers, 2015):
The importance clients associate with changes
Their confidence in their ability to make changes
Motivation is dynamic and fluctuates. Motivation is a dynamic process that responds to interpersonal influences, including feedback and an awareness of different available choices (Miller & Rollnick, 2013). Motivation is a strong predictor of addiction treatment outcomes (Miller & Moyers, 2015). Motivation can fluctuate over different stages of the SOC and varies in intensity. It can decrease when the client feels doubt or ambivalence about change and increase when reasons for change and specific goals become clear. In this sense, motivation can be an ambivalent state or a resolute commitment to act—or not to act.
Motivation is influenced by social interactions. An individual's motivation to change can be positively influenced by supportive family and friends as well as community support and negatively influenced by lack of social support, negative social support (e.g., a social network of friends and associates who misuse alcohol), and negative public perception of SUDs.
Motivation can be enhanced. Motivation is a part of the human experience. No one is totally unmotivated (Miller & Rollnick, 2013). Motivation is accessible and can be enhanced at many points in the change process. Historically, in addiction treatment it was thought that clients had to “hit bottom” or experience terrible, irreparable consequences of their substance misuse to become ready to change. Research now shows that counselors can help clients identify and explore their desire, ability, reasons, and need to change substance use behaviors; this effort enhances motivation and facilitates movement toward change (Miller & Rollnick, 2013).
Motivation is influenced by the counselor's style. The way you interact with clients impacts how they respond and whether treatment is successful. Counselor interpersonal skills are associated with better treatment outcomes. In particular, an empathetic counselor style predicts increased retention in treatment and reduced substance use across a wide range of clinical settings and types of clients (Moyers & Miller, 2013). The most desirable attributes for the counselor mirror those recommended in the general psychology literature and include nonpossessive warmth, genuineness, respect, affirmation, and empathy. In contrast, an argumentative or confrontational style of counselor interaction with clients, such as challenging client defenses and arguing, tends to be counterproductive and is associated with poorer outcomes for clients, particularly when counselors are less skilled (Polcin, Mulia, & Jones, 2012; Romano & Peters, 2016).
Your task is to elicit and enhance motivation. Although change is the responsibility of clients and many people change substance use behaviors on their own without formal treatment (Kelly, Bergman, Hoeppner, Vilsaint, & White, 2017), you can enhance clients' motivation for positive change at each stage of the SOC process. Your task is not to teach, instruct, or give unsolicited advice. Your role is to help clients recognize when a substance use behavior is inconsistent with their values or stated goals, regard positive change to be in their best interest, feel competent to change, develop a plan for change, begin taking action, and continue using strategies that lessen the risk of a return to substance misuse (Miller & Rollnick, 2013). Finally, you should be sensitive and responsive to cultural factors that may influence client motivation. For more information about enhancing cultural awareness and responsiveness, see TIP 59: Improving Cultural Competence (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014a).
COUNSELOR NOTE: ARE YOU READY, WILLING, AND ABLE?
Although much progress has been made in identifying people who misuse substances and who have SUD and in using science-informed interventions such as motivational counseling approaches to treat them, the United States is still facing many SUD challenges. For example, the National Survey on Drug Use and Health (SAMHSA, 2018) reports that, in 2017, approximately:
140.6 million Americans ages 12 and older currently consumed alcohol, 66.6 million engaged in past-month binge drinking (defined as 5 or more drinks on the same occasion on at least 1 day in the past 30 days for men and 4 or more drinks on the same occasion on at least 1 day in the past 30 days for women), and 16.7 million drank heavily in the past month (defined as binge drinking on 5 or more days in the past 30 days).
30.5 million people ages 12 and older had past-month illicit drug use.
11.4 million people misused opioids (defined as prescription pain reliever misuse or heroin use) in the past year.
8.5 million adults ages 18 and older (3.4 percent of all adults) had both a mental disorder and at least one past-year SUD.
18.2 million people who needed SUD treatment did not receive specialty treatment.
One-third of people who perceived a need for addiction treatment did not receive it because they lacked health insurance and could not pay for services.
Enhancing motivation can improve addiction treatment outcomes. In the United States, millions of people with SUDs are not receiving treatment. Many do not seek treatment because their motivation to change their substance use behaviors is low. Motivational counseling approaches are associated with greater participation in treatment and positive treatment outcomes. Such outcomes include increased motivation to change; reductions in consumption of alcohol, tobacco, cannabis, and other substances; increased abstinence rates; higher client confidence in ability to change behaviors; and greater treatment engagement (Copeland, McNamara, Kelson, & Simpson, 2015; DiClemente et al., 2017; Lundahl et al., 2013; Smedslund et al., 2011).
The benefits of motivational enhancement approaches include:
Enhancing motivation to change.
Preparing clients to enter treatment.
Engaging and retaining clients in treatment.
Increasing participation and involvement.
Improving treatment outcomes.
Encouraging rapid return to treatment if clients return to substance misuse.
Historically, in the United States, different views about the nature of addiction and its causes have influenced the development of treatment approaches. For example, after the passage of the Harrison Narcotics Act in 1914, it was illegal for physicians to treat people with drug addiction. The only options for people with alcohol or drug use disorders were inebriate homes and asylums. The underlying assumption pervading these early treatment approaches was that alcohol and drug addiction was either a moral failing or a pernicious disease (White, 2014).
By the 1920s, compassionate treatment of opioid addiction was available in medical clinics. At the same time, equally passionate support for the temperance movement, with its focus on drunkenness as a moral failing and abstinence as the only cure, was gaining momentum.
The development of the modern SUD treatment system dates only from the late 1950s. Even “modern” addiction treatment has not always acknowledged counselors' capacity to support client motivation. Historically, motivation was considered a static client trait; the client either had it or did not have it, and there was nothing a counselor could do to influence it.
This view of motivation as static led to blaming clients for tension or discord in therapeutic relationships. Clients who disagreed with diagnoses, did not adhere to treatment plans, or refused to accept labels like “alcoholic” or “drug addict” were seen as difficult or resistant (Miller & Rollnick, 2013).
SUD treatment has since evolved in response to new technologies, research, and theories of addiction with associated counseling approaches. Exhibit 1.1 summarizes some models of addiction that have influenced treatment methods in the United States (DiClemente, 2018).
EXHIBIT 1.1. Models of Addiction.
Although the field is evolving toward a more comprehensive understanding of SUD, earlier views of addiction still persist in parts of the U.S. addiction treatment system. For example, the psychological model of addiction treatment gave rise, in part, to the idea of an “addictive personality” and that psychological defenses (e.g., denial) need to be confronted. Remnants of earlier perspectives of addiction and their associated treatment approaches, which are not supported by research, include:
An addictive personality leads to SUDs. Although it is commonly believed that people with SUDs possess similar personality traits that make treatment difficult, no distinctive personality traits have been found to predict that an individual will develop an SUD (Amodeo, 2015). The tendencies of an addictive personality most often cited are denial, projection, poor insight, and poor self-esteem. This idea is a deficit-based concept that can lead to counselors and clients viewing addiction as a fixed part of an underlying personality disorder and therefore difficult to treat (Amodeo, 2015).
Rationalization and denial are characteristics of addiction. Another leftover from earlier psychological perspectives on addiction is that people with SUDs have strong psychological defenses, such as denial and rationalization, which lead to challenging behaviors like evasiveness, manipulation, and resistance (Connors, DiClemente, Velasquez, & Donovan, 2013). The clinical and research literature does not support the belief that people with SUDs have more or stronger defenses than other clients (Connors et al., 2013).
Resistance is a characteristic of “unmotivated” clients in addiction treatment (Connors et al., 2013). When clients are labeled as manipulative or resistant, given no voice in selecting treatment goals, or directed authoritatively to do or not to do something, the result is a predictable response of resistance or reactivity to the counselor's directives (Beutler, Harwood, Michelson, Song, & Holman, 2011). Viewing resistance—along with rationalization and denial—as characteristic of addiction and making efforts to weaken these defenses actually strengthens them. This paradox seemed to confirm the idea that resistance and denial were essential components of addiction and traits of clients.
Confrontation of psychological defenses and substance misuse behaviors is an effective counseling approach. Historically, the idea that resistance and denial are characteristic of addiction led to the use of confrontation as a way to aggressively break down these defenses (White & Miller, 2007). However, adversarial confrontation is one of the least effective methods for helping clients change substance use behaviors, can paradoxically reduce motivation for beneficial change, and often contributes to poor outcomes (Bertholet, Palfai, Gaume, Daeppen, & Saitz, 2013; Moos, 2012; Moyers & Miller, 2013; Romano & Peters, 2016). Yet there is a constructive type of confrontation. This kind of confrontation must be done within the context of a trusting and respectful relationship and is delivered it in a supportive way that also elicits hope for change (Polcin et al., 2012).
EXPERT COMMENT: A BRIEF HISTORY OF CONFRONTATION IN ADDICTION TREATMENT.
As the addiction treatment field has matured, it has tried to integrate conflicting theories and approaches and to incorporate research indings into a comprehensive model. The following sections address recent changes in addiction treatment with important implications for applying motivational methods.
Historically the treatment field has focused on the deficits and limitations of clients. Today, greater emphasis is placed on identifying, enhancing, and using clients' strengths, abilities, and competencies. This trend parallels the principles of motivational counseling, which affirm clients, emphasize personal autonomy, support and strengthen self-efficacy, and reinforce that change is possible (see Chapter 4). The responsibility for recovery rests with clients, and the judgmental tone, which is a remnant of the moral model of addiction, is eliminated.
In the past, clients frequently received standardized treatment, no matter what their problems or SUD severity. Today, treatment is increasingly based on clients' individual needs, which are carefully and comprehensively assessed at intake. Positive outcomes such as higher levels of engagement in psychosocial treatments, decreased alcohol use, and improved quality of life are associated with person-centered care and a focus on individualized treatment (Barrio & Gual, 2016; Bray et al., 2017; Jackson et al., 2014). In this perspective, clients have choices about desirable, suitable treatment options—they are not prescribed treatment. Motivational approaches emphasize choice by eliciting personal goals from clients and involving them in selecting the type of treatment needed or desired from a menu of options.
Historically, a diagnosis or disease defined the client and became a dehumanizing attribute of the individual. Today, individuals with asthma or a psychosis are seldom referred to as “the asthmatic” or “the psychotic.” Similarly, in the addiction treatment arena, there is a trend to avoid labeling clients with SUDs as “addicts” or “alcoholics.” Using a motivational style will help you avoid labeling clients, especially those who may not agree with the diagnosis or do not see a particular behavior as problematic. Person-first language (e.g., a person with an SUD) is the new standard; it reduces stigma, helps clients disentangle addiction from identity, and eliminates the judgmental tone left over from the moral model of addiction (SAMHSA, Center for the Application of Prevention Technologies, 2017).
In the past, especially in the medical model, the client passively received treatment. Today, treatment usually entails a partnership in which you and the client agree on treatment goals and together develop strategies to meet those goals. The client is seen as an active participant in treatment planning. Using motivational strategies fosters a therapeutic alliance with the client and elicits goals and change strategies from the client. The client has ultimate responsibility for making changes.
Historically, addiction treatment providers were placed in the position of an authority with the power to recommend client termination for rule infractions, penalties for positive urine drug screens, or promotion to a higher phase of treatment for successfully following direction. Research now demonstrates that counselors who operate from a more authority-driven way of relating to clients, such as confronting or being overly directive, are less effective than counselors who employ empathy, understanding, and support with clients (Martin & Rehm, 2012). This style of counseling is a particularly poor match for clients who are angry or reactive to counselor direction (Beutler et al., 2011). Positive treatment outcomes, including decreased substance use, abstinence, and increased treatment retention, are associated with high levels of counselor empathy, good interpersonal skills, and a strong therapeutic alliance (Miller & Moyers, 2015; Moyers & Miller, 2013).
In the past, addiction treatment consisted of detoxification, inpatient rehabilitation, long-term rehabilitation in residential settings, and aftercare. When care was standardized, most programs had not only a routine protocol of services but also a fixed length of stay. Twenty-eight days was considered the proper length of time for successful inpatient (usually hospital-based) care in the popular Minnesota model of SUD treatment. Residential facilities and outpatient clinics also had standard courses of treatment. These services were geared to clients with chronic, severe SUDs. Addiction treatment was viewed as a discrete event instead of a range of services over a continuum of care as the treatment provided for other chronic diseases like heart disease (Miller, Forehimes, & Zweben, 2011).
Recently, with the shift to a continuum of care model, a variety of treatment programs have been established to intervene earlier with those whose drinking or drug use is causing social, financial, or legal problems or increases their risk of health-related harms. These early intervention efforts range from educational programs (e.g., sentencing review or reduction for people apprehended for driving while intoxicated who participate in such programs) to brief interventions in opportunistic settings such as general hospital units, emergency departments (EDs), clinics, and doctors' offices that use motivational strategies to offer personalized feedback, point out the risks of substance use and misuse, suggest behavior change, and make referrals to formal treatment programs when necessary.
Early and brief interventions demonstrate positive outcomes such as reductions in alcohol consumption and drug use, reductions in alcohol misuse, decreases in tobacco and cannabis use, lower mortality rates, reductions in alcohol-related injuries, and decreases in ED return visits (Barata et al., 2017; Blow et al., 2017; DiClemente et al., 2017; McQueen, Howe, Allan, Mains, & Hardy, 2011).
Formerly, substance misuse was viewed as a progressive condition that, if left untreated, would inevitably lead to full-blown dependence and, likely, early death. Today, the addiction treatment field recognizes that substance misuse exists along a continuum from misuse to an SUD that meets the diagnostic criteria in DSM-5 (APA, 2013). Not all SUDs increase in severity. Many individuals never progress beyond substance use that poses a health risk, and others cycle back and forth through periods of abstinence, substance misuse, and meeting criteria for SUD.
Recovery from SUDs is seen as a multidimensional process along a continuum (Office of the Surgeon General, 2016) that differs among people and changes over time within the individual. Motivational strategies can be effectively applied to a person throughout the addiction process. The crucial variable is not the severity of the substance use pattern but the client's readiness for change.
Counselors have come to recognize not only that SUDs vary in intensity but also that most involve more than one substance. Formerly, alcohol and drug treatment programs were completely separated by ideology and policy, even though most individuals with SUDs also drink heavily and many people who misuse alcohol also experiment with other substances, including prescribed medications that can be substituted for alcohol or that alleviate withdrawal symptoms. Although many treatment programs specialize in serving particular types of clients for whom their treatment approaches are appropriate (e.g., methadone maintenance programs for clients with opioid use disorder [OUD]), most now also treat other SUDs, substance use, and psychological problems or at least identify these and make referrals as necessary. Some evidence shows that motivational counseling approaches (including individual and group MI and brief interventions) demonstrate positive outcomes for clients who misuse alcohol and other substances (Klimas et al., 2014). Motivational counseling approaches with this client population should involve engaging clients and prioritizing their change goals.
In the past, addiction treatment, at least for clients having trouble with alcohol, was considered successful only if the client became abstinent and never returned to substance use following discharge. The focus of treatment was almost entirely to have the client stop using and to start understanding the nature of addiction. Today, treatment goals include a broad range of biopsychosocial measures, such as improved health and psychosocial functioning, improved employment stability, and reduction in crime. In addition, recent efforts have focused on trauma-informed care and treating co-occurring disorders in an integrated treatment setting, where client concerns are addressed simultaneously with SUDs. For more information on treating clients with trauma and co-occurring disorders, see TIP 57: Trauma-Informed Care in Behavioral Health Services (SAMHSA, 2014b) and TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (SAMHSA, 2013), respectively.
The field has expanded the definition of positive treatment outcomes to include intermediate goals of risk reduction. The goal of risk reduction is to decrease clients' risks for alcohol- and drug-related health risks, legal involvement, sexual behavior that can lead to sexually transmitted diseases, social and financial problems, ED visits, hospitalization and rehospitalization, and relapse of substance use and mental disorders. Risk-reduction interventions include medication-assisted treatment for AUD and OUD and reduction in substance use as an intermediate step toward abstinence for clients who are not ready or willing to commit to full abstinence. Risk-reduction strategies can be an important goal in early treatment and have demonstrated effectiveness in reducing substance-use-related consequences (Office of the Surgeon General, 2016).
Historically, the SUD treatment system was isolated from mainstream health care by different funding streams, health insurance restrictions, and lack of awareness and training among healthcare providers on recognizing, screening, assessing, and treating addiction as a chronic illness. Today, a concerted effort is under way to integrate addiction treatment with other behavioral health and primary care services to build a comprehensive healthcare delivery system. Key findings of Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health (Office of the Surgeon General, 2016) include the following:
The separation of SUD treatment from mainstream healthcare services has created obstacles to successful treatment and care coordination.
SUDs are medical conditions. Integration helps address health disparities, reduces healthcare costs, and improves general health outcomes.
Many people with SUDs do not seek specialty addiction treatment but often enter the healthcare system through general medical settings. This is an important but neglected opportunity to screen for substance misuse and provide brief interventions or referrals to specialty care.
Motivational enhancement strategies delivered in all settings can support client engagement in treatment and improve substance use outcomes, whether in EDs, primary care offices, office-based opioid treatment programs, criminal justice settings, social service programs, or specialized addiction treatment programs. Screening, brief intervention, and referral to treatment (SBIRT), which includes motivational enhancement strategies, is an early intervention approach that can be a bridge from medical settings to specialty SUD treatment in an integrated healthcare system (McCance-Katz & Satterfield, 2012). Chapter 2 provides detailed information on SBIRT.
In developing a new understanding of motivation, substantial addiction research has focused on the determinants and mechanisms of change. By understanding better how people change without professional assistance, researchers and counselors have become better able to develop and apply interventions to facilitate changes in clients' substance use behaviors.
Many adults in the United States resolve an alcohol or drug use problem without assistance (Kelly et al., 2017). This is called “natural recovery.” Recovery from SUDs can happen with limited treatment or participation in mutual-aid support groups such as Alcoholics Anonymous and Narcotics Anonymous. As many as 45 percent of participants in the National Prevalence Survey resolved their substance use problems through participation in mutual-aid support programs (Kelly et al., 2017).
Behavior change is a process that occurs over time; it is not an outcome of any one treatment episode (Miller et al., 2011). Everyone must make decisions about important life changes, such as marriage or divorce or buying a house. Sometimes, individuals consult a counselor or other specialist to help with these ordinary decisions, but usually people decide on such changes without professional assistance. Natural change related to substance use also entails decisions to increase, decrease, or stop substance use. Some decisions are responses to critical life events, others reflect different kinds of external pressures, and still others are motivated by personal values.
Exhibit 1.2 illustrates two kinds of natural change. Natural changes related to substance use can go in either direction. In response to an impending divorce, for example, one individual may begin to drink heavily whereas another may reduce or stop using alcohol. Recognizing the processes involved in natural recovery and self-directed change illustrates how changes related to substance use behaviors can be precipitated and stimulated by enhancing motivation.
EXHIBIT 1.2. Examples of Natural Changes.
Prochaska and DiClemente (1984) theorized that the change process is a journey through stages in which people typically think about behavior change, initiate behavior change, and maintain new behaviors. This model emerged from an examination of 18 psychological and behavioral theories about how change occurs, including components that compose a biopsychosocial framework for understanding addiction. In this sense, the model is “transtheoretical” (Prochaska & DiClemente, 1984). This model has come to be known as the TTM of the SOC. TTM is not the only SOC model, but it is the most widely researched (Connors et al., 2013).
SOC is not a specific counseling method but a framework that can help you tailor specific counseling strategies to clients in different stages.
Although results are mixed regarding its usefulness, in the past 30 years, TTM has demonstrated effectiveness in predicting positive addiction treatment outcomes and has shown value as an overarching theoretical framework for counseling (Harrell, Trenz, Scherer, Martins, & Latimer, 2013; Norcross, Krebs, & Prochaska, 2011). Exhibit 1.3 displays the relationship among the five stages (i.e., Precontemplation, Contemplation, Preparation, Action, and Maintenance) in the SOC approach in the original TTM.
EXHIBIT 1.3. The Five Stages in the SOC in the TTM.
The associated features of the SOC approach are (Connors et al., 2013):
Precontemplation: People who use substances are not considering change and do not intend to change in the foreseeable future. They may be partly or completely unaware that a problem exists, that they have to make changes, and that they may need help to change. Alternatively, they may be unwilling or too discouraged to change their behavior. Individuals in this stage often are not convinced that their pattern of use is problematic.
Contemplation: As these individuals become aware that a problem exists, they begin to perceive that there may be cause for concern and reasons to change. Typically, they are ambivalent, simultaneously seeing reasons to change and reasons not to change. Individuals in this stage are still using substances, but they are considering the possibility of stopping or cutting back in the near future. At this point, they may seek relevant information, reevaluate their substance use behavior, or seek help to support the possibility of changing. They typically weigh the positive and negative aspects of making a change. It is not uncommon for individuals to remain in this stage for extended periods, often for years, vacillating between wanting and not wanting to change.
Preparation: When individuals perceive that the envisioned advantages of change and adverse consequences of substance use outweigh the benefits of maintaining the status quo, the decisional balance tips in favor of change. Once initiation of change occurs, individuals enter the Preparation stage and strengthen their commitment. Preparation entails more specific planning for change, such as making choices about whether treatment is needed and, if so, what kind. Preparation also entails examining clients' self-efficacy or confidence in their ability to change. Individuals in the Preparation stage are still using substances, but typically they intend to stop using very soon. They may already be making small changes, like cutting down on their substance use. They begin to set goals for themselves and make commitments to stop using, even telling close associates or significant others about their plans.
Action: Here, individuals choose a strategy for change and begin to pursue it. Clients are actively engaged in changing substance use behaviors. They are making lifestyle changes and may face challenging situations (e.g., temptations to use, physiological effects of withdrawal). Clients may begin to reevaluate their self-image as they move from substance misuse to nonuse or safe use. Clients are committed to the change process and are willing to follow suggested change strategies.
Maintenance: This stage entails efforts to sustain gains made during the Action stage and to prevent recurrence. Extra precautions may be necessary to keep from reverting to health-risk behaviors. Individuals learn to identify situations that may trigger a return to substance use and develop coping skills to manage such situations. During Maintenance, clients are building a new lifestyle that no longer includes the old substance use behaviors.
Most people who misuse substances progress through the stages in a circular or spiral pattern, not a linear one. Individuals typically move back and forth between the stages and cycle through the stages at different rates, as shown in the bidirectional arrows in Exhibit 1.3. As clients progress through the stages, they often have setbacks. However, most people do not typically return to the Precontemplation stage to start over again (Connors et al., 2013) and are unlikely to move from Precontemplation back to Maintenance. This movement through the stages can vary in relation to different behaviors or treatment goals. For example, a client might be in the Action stage with regard to quitting drinking but be in Precontemplation regarding his or her use of cannabis.
Relapse or recurrence of substance misuse is a common part of the process as people cycle through the different stages (note the circular movement of Relapse & Recycle in Exhibit 1.3). Although clients might return to substance misuse during any of the stages, relapse is most often discussed as a setback during the Maintenance stage (Connors et al., 2013). In this model, recurrence is viewed as a normal (not pathological) event because many clients cycle through different stages several times before achieving stable change. Recurrence is not considered a failure but rather a learning opportunity. Remember that each time clients have a setback, they are learning from the experience and applying whatever skills or knowledge they have gained to move forward in the process with greater understanding and awareness.
COUNSELOR NOTE: MAKING DECISIONS.
Recent understanding of the key role motivation plays in addiction treatment has led to the development of clinical interventions to increase client motivation to change their substance use behaviors (DiClemente et al., 2017). Linking this new view of motivation, the strategies found to enhance it, and the SOC model, along with an understanding of what causes change, creates an effective motivational approach to helping clients with substance misuse and SUDs. This approach encourages clients to progress at their own pace toward deciding about, planning, making, and sustaining positive behavioral change.
In this treatment approach, motivation for change is seen as a dynamic state that you can help the client enhance. Motivational enhancement has evolved, and various myths about clients and what constitutes effective counseling have been dispelled. The notion of the addictive personality has lost credence, and a confrontational style has been discarded or significantly modified. Other factors in contemporary counseling practices have encouraged the development and implementation of motivational interventions, which are client centered and focus on client strengths. Counseling relationships are more likely to rely on empathy rather than authority and involve the client in all aspects of the treatment process. Less-intensive treatments have also become increasingly common.
Motivation is what propels people with SUDs to make changes in their lives. It guides clients through several stages of the SOC that are typical of people thinking about, initiating, and maintaining new behaviors. The remainder of this TIP examines how motivational interventions, when applied to SUD treatment, can help clients move from not even considering changing their behavior to being ready, willing, and able to do so.
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