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Interventions for Addiction

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1

Treatment

Chapter 1 Brief Feedback-Focused Interventions

Chapter 2 Motivational Enhancement Approaches

Chapter 3 Cognitive Behavioral Therapies

Chapter 4 Cue Exposure Treatments for Substance Use Disorders

Chapter 5 Contingency Management

Chapter 6 Community Reinforcement Approaches

Chapter 7 Behavioral Couples Therapy for Alcoholism

Chapter 8 Network Support Treatment for Alcohol Dependence

Chapter 9 Multisystemic Therapy for Adolescent Substance Use

Chapter 10 Multidimensional Family Therapy for Adolescent Substance Abuse

Chapter 11 Brief Strategic Family Therapy for Adolescent Drug Abuse

Chapter 12 Functional Family Therapy for Adolescent Substance Use Disorders

Chapter 13 Individual and Group Counseling for Substance Use Disorders

Chapter 14 Self-Help Groups

Chapter 15 Twelve-Step Facilitation Therapy

Chapter 16 Faith-Based Substance Abuse Programs

Chapter 17 Behavioral Treatments for Smoking

Chapter 18 Behavioral Treatments for Adolescents with Substance Use Disorders

Chapter 19 Gender-Specific Treatments for Substance Use Disorders

Chapter 20 PTSD and Substance Abuse Treatment

Chapter 21 Criminal Justice Interventions

Chapter 22 Driving While Impaired (Treatments)

Chapter 23 Mindfulness

Chapter 24 Psychological Treatments for Pathological Gambling

Chapter 25 HIV/AIDS and Substance Abuse

Chapter 26 Treatment-as-Usual for Substance Abuse in Community Settings

Chapter 27 Disparities in Health Services for the Treatment of Substance Use Disorders

Chapter 28 A Decade of Research on Recovery Management Checkups

Chapter 29 Technology-Delivered Treatments for Substance Use Disorders

Chapter 30 Screening and Interventions in Medical Settings Including Brief Feedback-Focused Interventions

Chapter 31 Screening and Assessment of Comorbidity

Chapter 32 Diagnostic Dilemmas in Comorbidity

Chapter 33 Treatment for Co-occurring Substance Abuse and Mental Health Disorders

Chapter 34 Implications of Comorbidity for Clinical Practice

Chapter 1

Brief Feedback-Focused Interventions

Brian Borsari∗,$, Nadine R. Mastroleo$, ∗Mental Health and Behavioral Sciences Service, Providence, RI, USA, $Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA

Outline

Definition

The Development of Brief Feedback-Focused Interventions

Role in Overall Treatment

Goals of BFIs

Proposed Active Ingredients of BFIs

FRAMES

MI

Readiness to Change

Assessment Reactivity

Behaviors Addressed by BFIs

Smoking

Gambling

Sexual Risk

Other Behaviors

Feedback Content

Occurrence of Target Behavior

Personal Problems Associated with Target Behavior

Norms

Alcohol-Related Expectancies

Strategies to Reduce Risk

Other Feedback

Modalities

Individual

Group

Mailed

Internet

Peer-Based Intervention Approaches

Populations

Adolescents

College Students

Noncollege Adults

Summary

Definition

Opinions vary regarding what exactly constitutes a brief intervention – many terms and definitions have been developed over the years, such as brief advice, feedback interventions, feedback evaluations, brief intervention, and minimal intervention. For the purpose of this entry, a brief feedback-focused intervention (BFI) will be defined as an interaction addressing an addictive behavior lasting typically from 15 min to an hour in duration. The number of sessions can range from one to six, with the potential for follow-up contacts used to monitor the individual’s progress. BFIs have been used therapeutically with a wide range of problem behaviors (e.g. alcohol and other drug use), with a typical goal of identifying a real or possible problem and motivating the individual to take steps to change the behavior. These BFIs are delivered by trained interventionists, who provide the recipient personalized information regarding his or her substance use. The source of this feedback is typically an assessment of the behavior of interest. The complexity of this assessment varies as some assess only basic information (e.g. quantity and frequency of drinking), while others may also include problems and beliefs the individual may have related to their addictive behavior. Other BFIs may include laboratory analysis of blood or urine to evaluate the individual’s health (e.g. liver damage).

BFIs can be confused with minimal interventions due to their shared emphasis on limited contact with the individual. Minimal interventions are defined as consisting of one contact with the individual, resulting in a therapeutic effect, which can be as short as 5 min. These treatments are usually based on self-help principles, and in some minimal interventions there is no face-to-face contact with a therapist: bibliotherapy (the use of books or written materials to address a behavioral or emotional problem) is an example. Minimal interventions have also been called simple or brief advice because it prescribes a certain change, yet does not specify a specific way to achieve this objective. In contrast, BFIs provide specific information regarding the behavior of interest as well as recommendations and strategies for change.

The Development of Brief Feedback-Focused Interventions

Over the past 30 years, BFIs have emerged as a promising option for reducing addictive behaviors. For example, such interventions have been used in the treatment of heroin addiction, helping individuals quit smoking, promoting cardiovascular health. Brief interventions have been used extensively in the treatment of alcohol abuse, with clients ranging from adolescent to elderly.

Since 1980, the World Health Organization (WHO) has been developing and implementing BFIs for individuals experiencing problems with alcohol. These efforts began with the recognition that there was not an efficient way to identify individuals who were experiencing a problem with alcohol. Therefore, Phase I of the WHO Collaborative Project in Identification and Treatment of Persons with Harmful Alcohol Consumption began in 1982, and led to the development of the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT was developed to identify individuals who could benefit from a BFI in primary care settings. Phase II consisted of implementing a randomized clinical trial implementing screening and BFI in primary health care settings, and Phase III focused on identifying the barriers to the widespread adoption of the BFI by general practitioners. Phase IV, currently underway, is to develop and implement strategies that would successfully implement the BFI in primary care settings in 13 countries around the world.

The Drinker’s Check-Up (DCU) represents one of the first applications of administering BFIs in the general population. Advertisements were placed in newspapers and on a college campus that described the check-up as follows: The check-up is not part of any treatment program, and it is not intended for alcoholics. Rather, it is an informal health service. Participants will not be labeled or diagnosed, and consultation is completely confidential. Objective personal feedback of results will be provided. It is up to the participant to determine what, if anything, to do about the feedback received. Individuals who responded to the advertisements were given the DCU, which consisted of a 2-h assessment followed by a 1-h feedback session. The assessment component consisted of measures that evaluated the quantity and frequency of alcohol consumption, blood tests designed to detect alcohol-related liver damage, and neuropsychological tests that were sensitive to drinking-related impairment. At a later date, the results of these tests were then provided to the individual in an empathetic, nonjudgmental way. Then, the participant was asked to discuss his or her feelings about the assessment results. Finally, the interviewer discussed possible change options with the participant.

The feedback interview in the DCU was done in the style known as motivational interviewing (MI). Such an interview approach is defined as a counseling style that is both client centered and directive and seeks to explore and resolve the client’s ambivalence about engaging in a particular behavior. This exploration and resolution of ambivalence is done by the individual and not the interviewer, fostering a greater awareness of his or her problems with alcohol and the need to change. The interviewer’s role is to listen and provide the necessary information and advice regarding the changes the client feels is needed. Above all, the interviewer takes care to avoid confrontation, a style that has been observed to result in client resistance and even increase in drinking.

Role in Overall Treatment

In the context of the continuum of prevention developed by the Institute of Medicine in 2004, BFIs are typically used as a selective and indicated prevention strategy. Selective prevention targets individuals who are at risk for developing the problem behavior (e.g. substance use). Indicated prevention efforts are appropriate for those who are already experiencing harm from the target behavior (e.g. individuals who are experiencing alcohol-related problems). In contrast, universal prevention efforts are provided to the entire population, and tend to be more didactic in nature and may not include the personalized feedback provided in BFIs. Furthermore, BFIs are not intended as a stand-alone treatment for individuals exhibiting alcohol dependence. Although these individuals may significantly change their alcohol use following a BFI, often the desired outcome is engagement in more intensive treatment.

Goals of BFIs

The nature of the outcome goal may play a role in the success of brief interventions. Recent BFIs, such as those conducted with college students, tend not to present abstinence as the only acceptable option. Rather, they reflect an approach more oriented toward raising the awareness of students about their drinking habits and the potential risks associated with it. This approach, identified as harm reduction, has become the focus of the majority of BFIs regardless of the target population (adults, college students, adolescents). This flexibility has been spurred by research indicating that a mandatory goal of abstinence may not be very productive for several reasons. First, the majority of individuals may not view themselves as problem drinkers, and may view abstinence as too drastic a response to their drinking, where instead, moderation of their drinking may be more appealing. Second, the limited contact the interventionist has with the BFI recipient may make it more productive to view abstinence as an ideal outcome but not as a necessary result of brief interventions. Third, long-term follow-ups of traditional alcohol treatment programs indicate that a goal of abstinence following an intervention may not be realistic. Research with adult drinkers indicates that about a third of the participants remained abstinent after 1 year; 4 years after treatment, less than 10% have remained abstinent.

For these reasons, many BFIs often adopt a harm reduction approach. Any movement of an individual on this continuum that reduces the amount of alcohol one consumes (and concordantly reduces the risk of negative consequences as a result of their drinking) is seen as a desirable result. This approach has been used with a number of addictive behaviors ranging from alcohol and drug use to gambling and has influenced several college drinking reduction efforts. An intervention approach that promotes moderate and responsible drinking may be received more positively by the individual, and may in fact help to reduce the more problematic consequences of the targeted behavior.

A harm reduction approach is not without controversy, however, especially if the behavior is risky even in moderation (e.g. IV drug use) or illegal (e.g. underage drinking and smoking). In these situations, there is an ethical trade-off between encouraging a reduction in a risky behavior as opposed to focusing on an abstinence-only goal, which in turn may result in reactance or dismissal from the recipient.

Proposed Active Ingredients of BFIs

FRAMES

In a seminal article published in 1993, Miller and Sanchez reviewed the literature and developed an acronym to capture six important components of BFIs. These six elements can be remembered by the acronym FRAMES. First, Feedback is given to the client concerning his or her current addictive behavior. This can include such components as comparing individual use with national averages, problems resulting from use, and the harmful effects the behavior has on physical and emotional well being. This information alone can often motivate the client to realize the severity of his or her behavior, resulting in a desire for change. Second, an emphasis is placed on the client’s Responsibility for bringing about such changes. The client is told that he or she alone is the one that can bring about desired changes. Third, clear Advice given to the client about how specifically to change one’s current behavior can be influential and helpful. This advice may also consist of seeking further, more involved treatment. Fourth, providing a Menu of options for the client to follow is also helpful, instead of prescribing a predetermined or uniform change strategy. This provision of a range of options to decrease one’s drinking lets the individual decide which approach is the most realistic. This decision, made by the individual and not the counselor, tends to enhance a commitment to change by one’s self-selected method. Fifth, Empathy from the person conveying the information is vital to the process. It helps reduce the suspicion that the counselor may be judgmental, or have a hidden agenda to coerce the client into a form of treatment against his or her will. Confrontational attitudes (e.g. you have a problem and you are going to listen to me) can often lead to resistance and even increased drinking. The goal of using an empathetic approach is to maintain the client’s receptivity to the feedback and avoid defensiveness. A nonconfrontational, empathetic approach is especially important as many individuals are not likely to accept labels such as alcoholic or problem drinker. Sixth, when a sense of Self-efficacy can be fostered, the client will be much more likely to change his or her behavior. Self-efficacy has been described as a person’s belief in one’s own ability to succeed in obtaining a certain goal or task. With a sense of self-efficacy, an individual can develop a sense of optimism and hope to change their addictive behavior.

The use of personalized graphic feedback summaries during the brief motivational intervention helps illustrate an individual’s drinking behaviors and associated risks as reported in previously collected self-report data. Participants may complete a comprehensive battery of instruments examining the addictive behavior and other risk factors. A personalized feedback form is then created using the participant’s most current information related to a summary of behavior, comparison to population drinking norms, risk factors (e.g. family history), cognitive factors (e.g. beliefs about the behavior’s effects), and consequences associated with the addictive behavior. The personalized feedback offers an outline and structure for client discussions about current and past behavior. It is believed that providing participants with results from survey data in a graphic form contributes to increased comprehension and retention of material.

MI

Many BFIs are delivered using MI. MI is a therapeutic style of communication that is directive and client centered that facilitates behavior change through the exploration and resolution of ambivalence regarding a specific behavior (e.g. alcohol use). MI has also been described as an approach that combines both style (e.g. empathy) and technique (e.g. reflective listening). Specifically, the interviewer helps the individual explore and resolve ambivalence about reducing one’s alcohol use. The interviewer creates an atmosphere of collaboration during the session: the individual is not told what to do. Instead, the interviewer adopts the role of a consultant who listens to and gently directs the individual toward a greater understanding of problems and options for change. It is emphasized that the individual alone is responsible for any changes that are made. Above all, the interviewer avoids being confrontational, a style observed to result in client resistance and even increased drinking. Overall, this gently guided self-evaluation of personal drinking fosters a greater awareness of the individual’s problems with alcohol and the need to change. It is possible that the style of the interviewer (expressed empathy, collaboration, etc.) and the individual (e.g. disclosure, cooperation, engagement) may also influence changes that occur following an intervention.

Readiness to Change

Many recipients of BFIs are at risk for problems related to their addictive behaviors but have not looked for information or help for their problem. Individuals may be unaware that their behavior is not typical, and most likely have not sought formal treatment previously. Therefore, any BFI should be adaptable to differing willingness to recognize a drinking problem, a range of severity of problems experienced as a result of drinking, and variable motivation to change.

It has been difficult to specify exactly what process occurs when an individual seeks to change an addictive behavior. The transtheoretical model of behavior change, initially conceptualized in the early 1980s by James Prochaska and Carlo DiClemente, proposes that the individual progresses through five phases, or stages, of change. The stages of change model posit five phases of the change process. First, an individual is in the precontemplation stage when he or she is unaware of any potential problems related to his or her addictive behavior, and as a result see no reason to change. If individuals in this stage are told they have a problem, they will often react with surprise instead of evasiveness and anger. In this stage, others may see the individual as having difficulties, and may urge the individual to seek treatment (family members, concerned friends, employers). The next stage is one of contemplation, where the individual experiences more ambivalence. A student may know that he/she has a problem, but also feels changing current behavior is too drastic a response. The person can see the advantages and disadvantages of either continuing or cutting down on the addictive behavior, and feels ambivalent regarding the two options. At this point, arguments emphasizing the negative consequences of drinking can often drive the individual to defend the benefits of his/her current addictive behavior.

Eventually, the individual may arrive at the realization that he or she has to reduce the current level of use. This can be brought about by a particular event, personal enlightenment, or the BFI. The individual has entered the preparation stage, in which a willingness to cut down on the addictive behavior is present. The motivation is there, and there is likely to be some small changes in the behavior – the individual now just needs to take effective action. The next phase is the action stage, when the individual sets about changing the addictive behavior. Once the individual has initiated changes and begins moving toward reducing the addictive behavior, there are two possible paths he or she may take. The first is maintenance of the desired changes can occur. Maintenance is defined as continued commitment to sustaining a new behavior, typically lasting between 6 months or more. During this period, individuals develop a plan for follow-up support, they reinforce internal rewards, and, critical to the continued success of behavior change, they discuss coping with potential relapse. Often during the maintenance stage the integration of family, friends, and other support services is essential to sustained behavior change. The second path after an initial behavior change is a relapse. Relapse is identified as resuming old addictive behaviors and can often be the result of a trigger, a lack of motivation to maintain reductions in the addictive behavior, influence by barriers to sustained behavior change, and a lack of strong coping strategies. Once relapse has occurred, the individual may return to the earlier stages (except contemplation).

The benefit of a BFI is that it can provide a flexible mechanism to increase an individual’s readiness to change, regardless of the baseline stage occupied. Using heavy drinking as an example, those that are unconcerned about their heavy drinking could benefit from the BFI through raising personal awareness of alcohol-related problems, altering their perceptions of surrounding alcohol norms, and increasing their knowledge about alcohol’s effects on their body and mind. Being exposed to such information, especially when presented in a nonconfrontational manner, may move people farther along the stages of change. As for the individuals who recognize that they drink excessively and are prepared to change their alcohol consumption, the goal of the intervention can be to mobilize them into action. The content of their brief intervention can focus on concrete options that help them attain this goal. Therefore, a major advantage of BFIs are their flexibility in dealing with individuals at different levels of readiness to change. For those individuals who are ready to change, this type of intervention may bring about self-initiated reductions in the addictive behavior and related risks. For individuals who are precontemplative or contemplative, the awareness raising may increase their receptivity to change at a later date.

Assessment Reactivity

The simple act of collecting such information may also bring about a change following a BFI. Very often, control group individuals decrease their drinking after being evaluated. This occurs in research with adults as well as college students. Therefore, assessment does not appear to be a neutral event and its influence on alcohol use is not fully understood. In most brief interventions, the information gathered during assessment is presented to the individual in another session, and care is taken to present such material in an empathetic, nonjudgmental way. The assessment feedback is discussed, and options are formulated to reduce alcohol consumption or otherwise reduce the risk of harm to the individual.

Behaviors Addressed by BFIs

BFIs have addressed a wide range of addictive behaviors. Perhaps alcohol use has received the most attention, and there have been many BFIs developed for alcohol use, in the adult (e.g. drinker’s check-up) and adolescent population. These interventions traditionally use personalized feedback, however, the information provided varies widely (e.g. basic quantity-frequency of the behavior, consequences experienced laboratory results of liver functioning). These interventions have been associated with significant reductions in both alcohol use and alcohol-related problems.

Smoking

BFIs have also been developed for smoking, with feedback topics including costs of smoking, results of carbon dioxide levels in the lungs, and other physical markers related to cigarette use (e.g. genetic susceptibility to cancer). Perceptions about cigarette use (expectancies about use, aspects of smoking that are particularly troubling or enjoyable, motivation to quit) have also been provided in BFIs with smokers.

Gambling

Gambling has been addressed using BFIs with personalized feedback including frequency and time spent gambling, money lost and won while gambling, types of gambling activity, and costs of gambling behaviors (legal, relationships with others). Recent research suggests that these interventions can significantly reduce gambling behaviors and consequences.

Sexual Risk

BFIs have addressed sexual risk behaviors in the context of addictive behaviors and as a multi-risk approach (combined alcohol and sexual risk behaviors) to intervention. Topics of personalized feedback have included frequency and type of protected and unprotected sex, consequences of sexual behaviors, perceptions of sexual risk, expectancies regarding sexual behaviors, and the use of drugs and alcohol while engaging in risky sex. These interventions have been associated with reduction in the occurrence of risky sex and an increase in protective behaviors. To date, however, multi-risk BFIs have had limited success in reducing concurrent risky behaviors.

Other Behaviors

BFIs have been implemented with marijuana use, caffeine use, smokeless tobacco, indoor tanning, and a variety of other addictive behaviors. However, these approaches have been studied much less than BFIs for alcohol use, and their efficacy has yet to be determined.

Feedback Content

Occurrence of Target Behavior

The BFI most often contains a description of the behavior the BFI is targeting. For example, in a BFI addressing alcohol use, the individual’s typical and quantity of drinking would be provided (e.g. you reported that in the past month you typically consume alcohol 5 days per week, consuming 3–5 drinks per occasion). A number of other aspects of the behavior may be reported such as peak episodes of consumption, percent days abstinent or using over a certain time frame, or types of alcohol typically consumed.

Personal Problems Associated with Target Behavior

BFIs can also include a section detailing problems related to the target behavior. This section typically consists of two types of problems – problems the individual has already experienced as a result of his/her use (e.g. fights, hangovers), and/or problems that he/she is at risk of experiencing if they continue to use substances (e.g. cancer, death).

Norms

Norms can be conceptualized as a perception of the behaviors and values that are deemed acceptable by members of a group. Two types of norms have been commonly assessed in the addictive behavior research literature: descriptive and injunctive norms. Descriptive norms refer to the perception of other’s quantity and frequency of the addictive behavior (the norms of is) – these are largely based on observations of the addictive behavior. Injunctive norms refer to the perceived approval of the addictive behavior (the norm of ought). These norms represent the perceived moral rules of the peer group. Injunctive norms assist an individual to determine what is acceptable and unacceptable social behavior. Both descriptive and injunctive norms have been linked to addictive behaviors, perhaps most extensively to alcohol use in the college setting. Descriptive and injunctive norms have therefore been incorporated most commonly in brief motivational interventions (BMI) with this population. It is hypothesized that when personal alcohol consumption levels, and their approval of drinking, are revealed to be higher than relevant norms, a decrease in alcohol use may be triggered as the individual attempts to conform to the actual, more conservative norm. Indeed, changes in estimates of drinking norms mediated reductions in alcohol use following a BMI.

Alcohol-Related Expectancies

Alcohol expectancies are beliefs about the cognitive, affective, or behavioral effects of alcohol use and can be both positive (e.g. drinking allows me to relax around others) and negative (e.g. when I drink, I often say things I regret later). Expectancies appear to have both etiological and maintaining influences on alcohol use, especially positive expectancies and social/physical pleasure expectancies. Dose-related expectancies have been addressed in expectancy challenge interventions with college students. For instance, a person who believes that he/she has to consume four to five beers in an hour to become fully relaxed and sociable is provided information on how certain amounts of alcohol affect one’s mood and judgment and how lower blood alcohol levels have corresponding positive effects on mood. In this way, expectancy challenges may prompt one to consume less alcohol without sacrificing the desired and expected positive effects of drinking. Expectancies appear linked to subsequent reduction in alcohol use following expectancy challenges with college students, although they have not yet been formally demonstrated to mediate drinking reductions following a BMI. It is possible that students with fewer positive alcohol expectancies may be more responsive to an intervention addressing their drinking.

Strategies to Reduce Risk

BFIs can often include specific strategies to reduce risk, often linked to the behaviors and consequences the recipient has endorsed. These are often identified as protective behaviors. For example, if drinking and driving have been endorsed, a provided strategy may be Always designate a sober driver at the beginning of the evening. Other feedback can endorse specific skills, such as alternating alcoholic drinks with nonalcoholic drinks (alcohol use), staying away from casinos, and not carrying a credit card or checkbook (gambling).

Other Feedback

BFIs have a wide range of topics. For example, over 60 types of feedback have been presented in BFIs addressing college student drinking, such as estimated blood alcohol levels, personal motives for drinking, caloric intake, and the financial costs of drinking. Many of these feedback components have been used to address other addictive behaviors (e.g. financial costs of smoking), as well as ones specific to the addictive behavior (e.g. gambling losses). Undoubtedly, more feedback components will be developed through advancements in our and understanding of addictive behaviors.

Modalities

Individual

The most common form of BFIs is still one-on-one, in person. In this context, the individual is provided personalized feedback and discusses it with a professional. The content and depth of discussion of these BFIs vary widely.

Group

While group therapy has a long history, group BFIs have a more recent development. Specifically, group BFIs provide the entire group of individuals with information regarding the addictive behavior of interest. Within BFIs delivered to college students surrounding alcohol use, group-based BFIs have been shown to reduce drinking behaviors with students mandated to treatment following a campus alcohol violation. To date, group-based BFIs success has been limited to this specific population; however, similar approaches for other addictive behaviors (gambling, smoking cessation) and other populations (adults, adolescents) are currently being explored. One promising approach that has been implemented is the real-time presentation of normative feedback. Specifically, members of the Greek system used personal digital assistants (PDAs) to provide estimates of their own drinking, that of their peers in the room, and of the typical student on campus. The students type in their estimates on the PDA and then the results of this survey are displayed immediately to the group. As a result, the students were able to see the accuracy of the estimates they had made seconds before regarding the drinking behaviors and approval of drinking of the individuals in the room with them. Reductions of both normative perceptions and alcohol use have been observed following this BFI in members of the Greek system. However, this innovative approach has yet to be implemented in other populations.

Mailed

In the early days of BFIs, personalized feedback forms were mailed to individuals via standard mail and the content of the feedback was discussed via telephone. However, given the advances in the Internet and concerns regarding confidentiality (e.g. someone else opening the mail), email and the use of encrypted files (which can only be opened by the intended recipient) have become much more common. Usually, these interventions have contact numbers to call to discuss the provided information or to engage in formal treatment for the behavior addressed.

Internet

In the past 10 years, there has been a considerable increase in websites that can generate personalized feedback regarding a variety of behaviors, ranging from alcohol use, marijuana use, to eating habits. These websites simply require the individual to provide personal information about their current drinking and/or other drug use behaviors. Once information is entered, a personalized web-based feedback is immediately generated offering concrete information use patterns, risk profiles, and consequences of current use. The information presented is similar to what is created for one-on-one, in person BFIs, however, no face-to-face meeting occurs and the individual views the information independently. Early research suggests this approach has some benefits with high-risk drinking populations (e.g. first-year college students).

Peer-Based Intervention Approaches

Peer-based intervention and education programs have been found to be effective in creating behavior change in college students for a variety of behaviors (e.g. safe sex, alcohol and drug use). It is possible that students relate better to peers than to older adults, peer-delivered programs have a stronger influence on students’ attitudes and behavior, and using upper class students to implement substance abuse programs may be effective for first-year students. More recently, a trend toward incorporating peer counseling into alcohol interventions has led to new applications for motivational feedback approaches. A number of studies have examined the use of peer-based techniques to effectively impact drinking behaviors and consequences. Only skills-based group approaches, an education approach based on norms information, and an individually based motivational intervention have been efficacious in reducing alcohol use and consequences. Peer-led BFIs have also been found to be efficacious for enhancing drinking behavior changes. This intervention includes a one-on-one discussion about personal drinking behaviors, accurate normative drinking information with comparisons to perceived normative beliefs, negative consequences, and information on drinking reduction techniques.

Populations

Adolescents

A range of BFIs for adolescent populations have been tested to reduce and eliminate harmful behaviors associated with substance use. Specifically, in person BFIs, family-based BFIs, and parent-based BFIs. Each approach works toward the goal of reducing harms associated with substance use.

College Students

As a reaction to high levels of alcohol use and associated negative consequences among college students, various BFIs aimed at reducing harm and high-risk drinking behaviors have been developed. Specifically, BFIs with peers and professional counselors, personal feedback (mailed or computerized) on drinking behaviors, group-based education and/or motivation feedback classes, and expectancy challenge based interventions have all been evaluated in recent years.

Noncollege Adults

Community samples, including those recruited from hospital emergency departments, in- and out-patient psychiatric hospitals, and general community members have also been the target population for a range of BFIs. These have been delivered in person, via telephone, and web-based with general success in reducing harmful behaviors.

Summary

BFIs have been implemented in a wide range of settings due to their ability to address a wide variety of behaviors. Research supports their efficacy, although further work is needed to better understand exactly how individual behavior change is facilitated. Furthermore, the different types of feedback that can be provided in the context of a BFI has increased exponentially as a result of ongoing dissemination efforts addressing different behaviors and populations. Advances in research have also led to innovative feedback topics such as genetic susceptibility to alcoholism and smoking, as well as more sophisticated presentation delivery methods (e.g. via web or video). In sum, the combination of empirical support, improved understanding of how BFIs can bring about change in recipients, increased dissemination efforts, and ongoing innovation regarding the content and presentation of feedback topics have ensured a central role of BFIs in future prevention and intervention efforts addressing addictive behaviors.

List of Abbreviations

AUDIT    

Alcohol Use Disorders Identification Test

BMI    

brief motivational interventions

DCU    

Drinker’s Check-Up

PDA    

personal digital assistant

WHO    

World Health Organization

Glossary

Brief feedback-focused Interventions (BFI)    an interaction addressing an addictive behavior lasting typically from 15 min to an hour in duration.

Feedback    

verbal or written information regarding the addictive behavior that is provided and discussed during a BFI.

Motivational interviewing (MI)    a counseling style that is both client centered and directive and seeks to explore and resolve the client’s ambivalence about engaging in a particular behavior.

Norms    

a perception of the prevalence of addictive behaviors (descriptive norms) and approval of these behaviors (injunctive norms) by members of a group.

Transtheoretical model    a theoretical conceptualization of the process the individual undergoes when attempting to reduce or cease an addictive behavior (stages of change).

Biographies

Brian Borsari received his PhD in Clinical Psychology from Syracuse University in 2003. He is currently Associate Professor in the Department of Behavioral and Social Sciences and the Department of Psychiatry and Health Behavior at Brown University. His research interests include the development and implementation of brief motivational interventions with college student drinkers, the social influences on alcohol (e.g. modeling and norms), and in-session processes of motivational interviewing related to behavior change. In 2007, Dr Borsari joined the Posttraumatic Stress Disorder (PTSD) Program at the Providence Veterans Affairs Medical Center as a clinical psychologist. His research interests there involve the assessment and treatment of PTSD and comorbid substance use disorders, improving sleep in veterans through the implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I), and working with veterans who are attending college.

Dr Mastroleo completed her PhD in Counselor Education and Supervision from the Pennsylvania State University in 2008. She is currently Assistant Professor (Research) in the Department of Behavioral and Social Sciences and the Center for Alcohol and Addiction Studies at Brown University. Dr Mastroleo’s primary area of research focus is on evaluating brief alcohol interventions and the process by which they influence behavior change with college students, as well as the implementation of multi-risk brief, behavioral interventions with Emergency Department patients.

Further Reading

1. Carey KB, Scott-Sheldon LAJ, Carey MP, DeMartini KS. Individual-level interventions to reduce college student drinking: a meta-analytic review. Addictive Behaviors. 2007;32(11):2469–2494. http://dx.doi.org/10.1016/j.addbeh.2007.05.004.

2. Conners GJ, Donovan DM, DiClemente CC. Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions. New York, NY: Guilford; 2001.

3. Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction. 2001;96(12):1725–1742. http://dx.doi.org/10.1080/09652140120089481.

4. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. second ed. Guilford Press 2002.

5. Miller WR, Sovereign RG. The check-up: a model for early intervention in addictive behaviors. In: Loberg T, Miller WR, Nathan PE, Marlatt GA, eds. Addictive Behaviors: Prevention and Early Intervention. Liss, The Netherlands: Swets & Zeitlinger Publishers; 1989;219–231.

6. Norcross JC, Krebs PM, Prochaska JO. Stages of change. Journal of Clinical Psychology. 2011;67(2):143–154. http://dx.doi.org/10.1002/jclp.20758.

7. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51(3):390–395. http://dx.doi.org/10.1037/0022-006x.51.3.390.

Relevant Websites

1. http://notes.camh.net/efeed.nsf/feedback – Centre for Addiction and Mental Health, Personalised Alcohol Use Feedback.

2. http://pubs.niaaa.nih.gov/publications/aa66/aa66.htm – National Institute on Alcohol Abuse.

3. http://nrepp.samhsa.gov/ViewIntervention.aspx?id=14 – SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

4. http://www.echeckuptogo.com/usa/ – The electronic CHECKUP TO GO, an on-line alcohol intervention and social norming program developed by San Diego State University.

5. http://www.who.int/substance_abuse/activities/sbi/en/index.html# – Wealth Health Organisation, substance abuse activities.

Chapter 2

Motivational Enhancement Approaches

Steve Martino, Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT, USA

Outline

Introduction

What Is Motivational Interviewing?

What Is Not Motivational Interviewing?

Principles

Roll with Resistance

Express Empathy

Develop Discrepancy

Support Self-Efficacy

Techniques

Fundamental Strategies

Direct Methods

Other Useful Techniques

Handling Resistance

Empirical Support

Other Applications

Learning Motivational Interviewing

Dissemination of Motivational Interviewing

Future Research Directions

Conclusions

Introduction

Enhancement of an individual’s motivation to change is an important component of interventions for addictive behaviors. People who believe they have alcohol or drug use problems and commit to changing them are more likely to engage in treatment and have improved outcomes. Motivational enhancement approaches for substance-use disorders have become increasingly popular during the past two decades. Foremost among them is motivational interviewing (MI) developed by William Miller and Stephen Rollnick. This chapter describes what MI is and is not, its basic principles and techniques, empirical support, applications to areas likely to co-occur with addictions, how to learn MI, dissemination of the approach, and future research directions.

What Is Motivational Interviewing?

Miller and Rollnick have defined MI as a person-centered counseling method for eliciting and strengthening personal motivation for change. The approach is grounded in humanistic psychology, especially the work of Carl Rogers, in that it employs a very empathic, nonjudgmental style of interacting with peoples and presumes that the potential for change lies within everyone. MI is distinct from nondirective approaches, however, in that practitioners intentionally attend to and selectively reinforce people’s motives that support change. Over the course of the interview, practitioners help people identify these change-oriented motives, elaborate upon them, and resolve ambivalence about change. If successful, people become more likely to commit to changing their behaviors and initiating a change plan.

The process of enhancing motivation in MI can be thought of as having two different phases. The first phase involves building motivation for change. In this phase, practitioners work with people to understand and resolve their resistance to change and develop their sense of the importance and perceived ability to change. When people show signs of readiness to change (e.g. reasons for change are prominent, they ask for advice or direction, they state their intention to change), practitioners shift to the second phase of motivational enhancement in which they work toward strengthening commitment to change, most often through the development of a change plan (described below). This process activates or mobilizes people’s motivations in that individuals identify how they will try to change and begin to enact these steps to reduce or stop their addictive behaviors.

Skilled practitioners try to match their use of MI strategies to the individual’s level of motivation. For example, practitioners move more quickly to change planning with people who are already motivated to change. Extensive exploration of their motives for change might frustrate people who want to move forward. In contrast, attempting to develop change plans with people who are not yet committed to change will likely increase resistance in that this strategy would put people in a position in which they might assert in words or in actions how they are not yet ready. This latter interaction illustrates how motives to change (called change talk) and motives to stay the same (called sustain talk) can be thought of as opposite sides of the same coin, meaning that if practitioners give insufficient attention to addressing important issues that impede change, people are likely to raise these issues again during the interview. Concomitantly, practitioners expect people who initially argue against change to have some intrinsic motivation for change within them. It is the responsibility of the practitioners to look for opportunities to draw it out.

MI is best construed as a style of communication that informs the way in which practitioners interact with others throughout the change process. In this regard, MI often is discussed within the context of the stages of change model by James Prochaska and Carlo DiClemente. The stage of change model posits that behavior change occurs sequentially across recurring stages. The earlier stages include precontemplation (people are unaware or do not believe there is a problem or need to change it), contemplation (people are ambivalent about recognizing a problem and shy away from changing it), and preparation (people are ready to work toward behavior change in the near future and develop a plan for change). The later stages include action (people consistently make specific changes) and maintenance (people work to maintain and sustain longlasting change). Tailoring treatment strategies to achieve stage-related tasks is a hallmark of this model (e.g. conducting a cost-benefit analysis for someone contemplating change).

MI naturally fits into the stage of change model in that it can be used to help move people from one stage to another, especially in the early stages. Person-centered counseling skills may build rapport and engage people who are less motivated to change. Eliciting additional change talk might lead ambivalent individuals to conclude it is relatively worth it for them to change rather than to keep drinking or using drugs. Working with people to identify steps they are able to take might help them feel more prepared to initiate a change plan. In later stages, MI strategies are useful for attending to wavering motivation as people take action or try to maintain changes in stressful situations. Finally, the stages of change model illustrates how MI integrates well with other treatment approaches that are more action-oriented. For example, MI might be used to engage people in treatment that then teaches them relapse prevention skills. The combining of MI with more action-oriented treatments, such as cognitive behavioral therapy, is becoming more prevalent.

MI emerged out of early efforts to establish brief interventions for alcohol problems. These interventions shared a harm reduction approach in that they aimed to help people move toward reduced drinking to lower risks rather than to automatically advocate for total abstinence as the only acceptable goal. Common components of these brief interventions, as represented in a FRAMES acronym, were Feedback, emphasis on personal Responsibility, Advice, a Menu of options, an Empathic counseling style, and support for Self-efficacy. With FRAMES as a guidepost, William Miller and his colleagues developed the drinker’s checkup in which people received feedback about their drinking relative to population or clinical norms and then explored what it might suggest about their drinking and motivation for reducing or stopping it. Early studies found the drinker’s checkup to be quite effective. Given this success, MI with personalized assessment feedback then became adapted into a more structured and manualized format and termed motivational enhancement therapy (MET). The efficacy of MET, compared to cognitive behavior therapy and 12-step facilitation, for alcohol-dependent adults, subsequently was tested in a large-scale, multi-site study conducted in the United States called Project MATCH. MET was found to be as effective as the other treatments overall, though it achieved these effects using fewer treatment sessions.

Finally, as implied in the above discussion, MI is behaviorally specific and has direction. This means that practitioners need to be clear about what it is that they are trying to motivate people for. Motivation for change in one area does not guarantee motivation for change in another (e.g. a person may commit to cocaine abstinence, but not agree to reduce or stop drinking or smoking marijuana or to enter an addiction treatment program). Each behavior may require a separate motivational enhancement process. MI also requires that practitioners take a stance about the preferred direction for change. For addictive behaviors, this decision is relatively clear in that most people would agree that it is ethically sound to enhance motivation for the reduction or cessation of substances that are potentially harmful or hazardous. However, some behavioral issues do not have a clear change direction. For example, decisions about organ donation or pregnancy termination likely would require a nondirective approach in which practitioners suspend their own values or goals and assume a position of equipoise (i.e. indifference or no clear attachment to a position or recommendation). In these situations, a person-centered counseling approach, devoid of evocation, would allow people to explore their ambivalence without intentional practitioner influence.

What Is Not Motivational Interviewing?

For clarification purposes, it is helpful to consider what MI is not. Most antithetical to MI is a disease concept model of addiction in which individuals are seen as denying or rationalizing their addictive behaviors and needing to hit bottom before they will change. The use of direct confrontation, surrendering and accepting one’s powerlessness and loss of control in the face of addiction, and emphasis on total abstinence as the only acceptable goal are hallmarks of this approach and quite inconsistent with MI. Less obvious are several common misconceptions about MI. As noted above, MI is not based on the stages of change model, though it is complementary to it. Stages of change is more of a comprehensive way of thinking about how people change, whereas MI is a clinical method that helps people prepare for change. Likewise, MI is not cognitive behavioral therapy. The latter approach supplies people with education and coping skill development and encourages the repeated practice of these skills to better manage their problems. MI is fundamentally humanistic, not behavioral, in origin in that it elicits the people’s motivations for change rather than putting in place what is missing (knowledge and skills). MI also is not a way of manipulating others or making them change when they do not want to. Behavior change in MI is born out of a person’s intrinsic motivations. Practitioners can only call forth motivations that already exist within people, not impose upon them other people’s concerns or wishes when individuals do not see these issues as in their best interests. Finally, MI does not require that practitioners conduct a decisional balance or provide personalized feedback. These are techniques that often are helpful for eliciting change talk, but they are not essential to the conduct of MI, and they often are used in other treatment approaches. In this regard, MI is not a series of techniques, but rather a way of being with people in which principles organize the practice, as Miller and Rollnick put it, like music to words of a song.

Principles

Four key principles, embodied in the REDS (rolling with resistance, express empathy, develop discrepancy, support self-efficacy) acronym, compose the manner in which practitioners interact with people when using MI.

Roll with Resistance

Resistance in MI traditionally has referred to people’s statements about what sustains their problematic behaviors. These expressions may be about the reasons for the behaviors (Drinking relaxes me) or the difficulties of trying to change them (I can’t resist the urge to smoke). Resistance informs practitioners about dilemmas faced by individuals, thereby providing opportunities for addressing obstacles to change. Practitioners avoid adopting a confrontational, authoritative, warning, or threatening tone (all inconsistent with MI), which might cause others to become even less engaged in treatment.

Express Empathy

Practitioners attempt to accurately understand people’s dilemmas without judgment or criticism. Being able to listen carefully to what people mean and reflect this back to them is a critical skill. People are more likely to explore their motivations for change and speak candidly when they feel comfortable with and understood by their practitioners.

Develop Discrepancy

Motivation for change often depends on the existence of a discrepancy between an individual’s current behavior and important values or goals. For example, a teacher who prides herself in being a positive role model for her students might stop smoking marijuana if she believes this behavior is discrepant with what she would want her students to know about her. In MI, practitioners reflect these discrepancies and explore how behavior change might help people feel they are acting in accordance with their preferred self-perceptions and aims.

Support Self-Efficacy

People typically become more motivated when they believe they can change their behavior. When people lack confidence, they often shy away from change. Practitioners look for opportunities to support people’s self-efficacy by helping them recognize their personal strengths and available resources. Likewise, they pay attention to people’s past successful change efforts, which might inform how these individuals approach their current dilemmas.

By embracing these principles, practitioners adopt a style of interaction, that is, (1) collaborative by demonstrating respect for people’s ideas and goals and seeing others as equal partners in the therapeutic process, (2) evocative by intentionally searching for the people’s motives that favor change, and (3) supportive of people’s autonomy and capacity to make decisions and initiate change. These three components embody the spirit of how practitioners interact with others (formally referred to MI spirit in this approach).

Techniques

While MI is more of a style or spirit of being with others based on the above principles rather than a mere application of techniques, MI incorporates several techniques that operationalize how practitioners use MI. These techniques include fundamental strategies, sometimes called microskills (open questions, affirmations, reflections, and summaries), and direct methods for evoking change talk. Practitioners attend to the balance of statements made by people that support or thwart behavior change (i.e. change versus sustain talk) to gauge individuals’ level of motivation and adjust their use of MI techniques accordingly. Practitioners’ capacities to recognize and elicit change talk and reduce sustain talk through the use of these techniques, with the aim of strengthening people’s commitment to change, are seen as necessary elements in MI.

Fundamental Strategies

Open questions, affirmations, reflections, and summaries (OARS) are the mainstay of all MI sessions. In particular, MI relies heavily on the skilled use of reflective listening in which practitioners restate or paraphrase their understanding of what people have said to express empathy, as well as to bring attention to ambivalence, highlight change talk, and explore and lessen resistance. Reflections are coined simple in MI when practitioners essentially repeat what others have said and complex when practitioners have articulated new meaning implied by the original statements. Complex reflections demonstrate a deeper understanding of people’s experiences. For example, a person concerned about her HIV status says, I’ve played around a bit in the past several months, but last year when I had a HIV test, I was negative. A practitioner could use a simple reflection to encourage more discussion about her risk behavior (You’ve played around a bit). A complex reflection would capture her implied concern and show more empathy (You’re a little worried that you have put yourself at risk for HIV).

Open questions encourage people to talk more and may be used to strategically draw out motivations for change (e.g. What would be good about not smoking?). They stand in contrast to closed questions, in which, practitioners seek specific information (e.g. demographics, history, symptoms), often with questions that can be answered with a yes or a no response. For example, a practitioner might ask, Has your depression worsened with your crystal meth use? A person’s positive response would support not using crystal methamphetamine; however, he or she would not have fully elaborated on the negative effects of depression resulting from drug use, which an open question might have elicited (e.g. How has using crystal meth negatively impacted your depression?). Affirmations (i.e. acknowledgment of a person’s strengths, attitudes, and efforts that promote behavior change) build collaboration between practitioners and others and promote self-efficacy. Sometimes, this entails reframing a behavior in a manner that helps people see it in a more positive light (e.g. You were quite determined to get high, and now you are trying to use that same determination to stop using cocaine).

Summaries provide opportunities for practitioners to demonstrate fuller understanding of other people’s experiences and help them consider the bigger picture of their motivations for change. Summaries also allow practitioners to collect multiple change talk statements as a strategy to enhance motivation, link discrepant statements that capture ambivalence, and shift focus to other behavioral areas (e.g. move from discussing drinking to prescription opiate use). The following is an example of a collection summary of change talk: You’re concerned that you have been taking more pain meds than you are prescribed, and you’ve noticed you need more pills to get the same effect. You feel badly about going to a doctor other than your primary care physician to get percocet when you ran out. Most importantly, you almost fell asleep at the wheel last week with your kid in the car, and you think that this literally is your wake-up call to do something about this problem before something terrible happens to you and others.

Direct Methods

Direct methods for evoking change talk hinge on the capacity of practitioners to recognize how people talk about change. Practitioners’ selection of direct methods for motivational enhancement depends on the type and strength of change talk provided by people as the interview unfolds. Hence, an individual’s statements continuously signal the practitioner about how to conduct the interview.

Change talk is embodied in the acronym DARN-CAT (desire, ability, reasons, need, commitment, activation, taking steps). DARN (desire, ability, reasons, need) is sometimes referred to as preparatory language in that these statements represent the building of motivation that prepares people to make a commitment to change (consistent with the first phase of motivational enhancement). Desire statements indicate a clear wish for change (I don’t want my liver disease to get worse or I want to get my life back). Ability statements indicate people’s beliefs that they can change, given their skills and available resources (I was able to stop using speed 5 years ago, so maybe I have a chance now). Reason statements note the benefits of change and the costs of not changing (I will have more money in my pocket or If I don’t stop, I will go more in debt). Need statements underscore how the problem behavior interferes with important areas of an individual’s life and how changing the behavior would likely improve matters (I don’t even recognize myself; I can’t go on like this anymore).

CAT (commitment, activation, taking steps) represents statements that suggest people are mobilizing themselves for change (consistent with the second phase of motivational enhancement). Commitment statements convey the stated intention to change (My quit date will be this Thursday). Activation statements indicate how people are getting ready to change (I am going to an AA meeting tonight). Statements about taking steps to change are the strongest demonstration of commitment in that the people have put their words into action and are reporting these early efforts to the practitioner (Instead of going out to drink after work, I went to the gym and worked out).

During the interview, practitioners identify the extent to which people express motivation in each of these areas, use their fundamental skills to support and develop people’s change talk and have them elaborate further, and in a goal-oriented fashion, directly attempt to draw out more motivations for change. MI offers multiple techniques for these purposes. For example, people who consistently report obstacles to being able to stop smoking marijuana might be asked about past periods when they have smoked less marijuana or none at all (appealing to past successes to enhance ability). People who do not express much concern about their current levels of drug use might be asked to look to the future at some time interval (e.g. 1 year from now) and consider where their lives might be headed with continued use (attempting to reveal potential reasons or need to change to enhance the importance of change). Alternatively, a practitioner could ask someone to rate how important it would be to reduce or stop drug use on an 11-point scale, with zero representing not at all important and ten representing extremely important. Providing this person gives a response higher than zero, the practitioner would follow-up by asking, Why not lower, like a zero? to elicit what lends some importance to changing drug use now.

Other Useful Techniques

Addiction treatment typically requires simultaneous attention to several behavioral issues (e.g. multiple substance, HIV risk behaviors, psychiatric, and health concerns), and this reality often is overwhelming to people and their practitioners during any one appointment where time is limited. Practitioners can use a simple agenda setting chart in which they record the pertinent behavior change issues on paper and have people indicate which of them they want to discuss during the interview. These priorities are then dovetailed with any pressing practitioner concerns as a means to organize the conversation.

Education, advice-giving, and direction are commonplace in the addiction treatment, particularly because practitioners often have a natural tendency to try to fix people’s problems (referred to as the righting reflex). When people have not solicited professional input, however, they may not be receptive to it. Instead, practitioners ask permission to provide information or advice and employ an elicit-provide-elicit (or ask-tell-ask) technique in which practitioners (1) elicit from people what they know about the topic being discussed, (2) provide information as needed, and (3) elicit people’s reactions to the shared information. For example, a practitioner may wish to recommend a treatment program to someone. Instead of providing the recommendation in an unsolicited manner, the practitioner would first ask the person what he or she knows about the program and then, with permission, talks about it and concludes by getting the person’s reaction. This technique promotes collaboration and reduces the chance that people experience their practitioners as lecturing or telling them what to do.

Use of a decisional balance activity (i.e. exploring the costs and benefits of changing and not changing) is common in MI. This activity provides a structured method for understanding the basis of a person’s ambivalence in that the benefits of change (I’ll have more money if I get a job) and the costs of not changing (If I don’t seek employment, I will feel like I have given up on myself) provide reasons to change, whereas the benefits of not changing (I don’t have to present myself in an interview) and the costs of changing (I don’t have transportation") provide reasons to remain the same. By strategically eliciting more reasons for change and, to the extent possible, resolving reasons to remain the same (e.g. practice interviewing, resolving transportation issues), a practitioner might help the person tip the balance toward change.

Another important skill is how to gauge patients’ readiness to change and to transition from the first to second phase of motivational enhancement. Practitioners typically recapitulate what others have said, especially those statements that suggest how they are now ready to change. Following this summary, practitioners then pose a key question to solidify commitment to change (What’s your next step? or From what you’ve told me, how do you want to proceed?). Miller and Rollnick have used the analogy of a person as a skier standing at the summit (assisted up the mountain by the practitioner). The key question provides a supportive nudge that helps the person go down the mountain.

Change planning is an overall strategy practitioners use to negotiate a plan with people about how they will change their behavior. Critical to this process is maintaining a person-centered stance in which the plan is derived by the individual, with the assistance of the practitioner, rather than the practitioner becoming prescriptive at this point. Practitioners ask people to set their targeted behavior change goal (I am going to stop using heroin), describe steps they will take to change (I want to try buprenorphine, I need your help to get PTSD counseling), identify who might support them and how (I am going to stay with my parents), anticipate obstacles (I have to change my cell phone number to keep people from calling me), and reaffirm their commitment to the plan. If during the process of mobilizing their commitment people become uncertain again (the cold-feet phenomenon), the practitioner reflects this ambivalence rather than trying to press through it and provides another opportunity to revisit the plan in the current session or at another time. Being in a hurry to complete the plan when people are not ready is a common trap into which practitioners