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Enhancing Motivation for

Change in Substance Abuse
Treatment
Based on TIP 35

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Overview
• Introduction
• ‘FRAMES' and Other Approaches
• Stages of Change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Integrating Motivational Approaches
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Motivation

• Motivation is a key to change
• Motivation is multidimensional
• Motivation is dynamic and fluctuating
• Motivation is influenced by social interactions
• Motivation can be modified
• Motivation is influenced by clinician's style
• The clinician's task is to elicit and enhance
motivation

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Why enhance motivation?

• Inspiring motivation to change
• Preparing clients to enter treatment
• Engaging and retaining clients in treatment
• Increasing participation and involvement
• Improving treatment outcomes
• Encouraging a rapid return to treatment if
symptoms recur

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Desirable attributes for the counselor

• Nonpossessive warmth
• Friendliness
• Genuineness
• Respect
• Affirmation
• Empathy

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Help Increase Motivation

• Focusing on client strengths
• Using empathy more than authority
• Recognizing co-occurring disorders
• Employ client centered treatment
• Respecting the client's autonomy

• For more detailed information, see TIP 35, pp. xvi–1.

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Elements Of Current Motivational
Approaches
• The FRAMES approach
• Decisional balance exercises
• Discrepancies between personal goals and
current behavior
• Flexible pacing
• Personal contact with clients in treatment

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FRAMES
• Feedback regarding personal risk or impairment
• Responsibility for change is placed squarely and
explicitly on the client
• Advice is clearly given to the client by the
clinician in a nonjudgmental manner.
• Menus of self-directed change options and
treatment alternatives are offered to the client.
• Emphatic counseling
• Self-efficacy is engendered in the client to
encourage change.
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Decisional Balance

• Individuals naturally explore the pros and cons
of any major life choices

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Discrepancies Between Goals and Current
Behavior
• Help clients recognize a discrepancy or gap
between their future goals and their current
behavior.
• The clinician might clarify this discrepancy by
asking, "How does drinking fit in with having a
family and a stable job?"

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Flexible Pacing and Personal Contact

• Pacing
– meet clients at their levels
– use as much time as necessary with the essential
tasks of each stage of change.
• Personal Contact: letters or telephone calls

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Precontemplation
• The client is unaware, unable, or unwilling to
change.
– Counselor can
• Establish rapport
• Raise doubts about patterns of use
• Give info on risks, pros and cons of use

• The client is likely to be wary of the counselor and of
treatment.
– Counselor
• Should not rub the client the wrong way
• Should try to keep the interview informal.

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Goals/Actions
• Explore the meaning of events that brought the
client to treatment or the results of previous
treatments.
• Elicit the client's perceptions of the problem.
• Offer factual information about the risks
• Provide personalized feedback about assessment
• Explore the pros and cons of substance use.
• Help a significant other intervene.
• Examine discrepancies between the client's and
others‘ perceptions of the problem behavior.
• Express concern and keep the door open.

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• Many clients are ambivalent about change.
• Ambivalence is expressed in several ways.
– Argue: challenge or discount statements
– Interrupt: take over or cut off conversation
– Deny: blame, disagree, excuse, minimize
– Ignore: not respond, not pay attention

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Ways to Respond

• Simple: Rephrase the client statement, neutrally.
• Amplified: Exaggerate statement without
sarcasm.
• Double-sided reflection: Acknowledge statement,
but use contradictory information client reported
earlier.
• Agreement with a twist: Agree, but change
direction.

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Contemplation
• The client is ambivalent or uncertain, considering
the possibility of change.
– Counselor can
• Discuss and weigh pros/cons of using
• Emphasize client's free choice and responsibility
• Elicit self-motivational statements
• At this stage, the client usually meets the counselor
halfway, and is willing to look at the "cons" of using.
• Reassure the client that no one can force him to
change.
• Ask questions that prompt motivation.
– For example, "When you want to keep up your motivation
for doing something, what are some of the things you say
to yourself?"
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Goals/Actions
• Help the client recognize the problem
• Help the client acknowledge concern
• Help the client generate intention to change:
• Help the client develop optimism
• Convey feedback
• Help clients see a difference
• Show curiosity about client strengths. Explore how
those skills and competencies may be negated by
drinking
• Reframe negative statements.
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Highlight Reasons for Change
• Summarize concerns
• Explore specific pros and cons
• Allow client to explain benefits
• Assure client conflicting feelings are normal
• Review feedback from assessment
• Find out what client expects from treatment
• Provide info
• Help client connect core values to committing to
treatment
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Strengthen the client's personal
choices.
• Nudge the client to make positive choices.
• "No one can decide this for you. You can
choose."
• Help the client set goals and take steps.
• Provide feedback.
• Remind client of "triggers," including negative
emotions (anger), social pressures (peers),
physical concerns (headache) and extended
withdrawal symptoms (craving).
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Reinforce the client's commitment

• What do you think has to change?
• What are you going to do?
• How are you going to do it?
• What are some benefits of making a change?
• How would you like things to turn out, ideally?
• For more detailed information, see TIP 35, pp. 54–92.

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Preparation
• The client asks questions, indicates willingness
and considers options to make specific changes.
• Explore treatment expectancies and the client's
role.
• Elicit from the client what has worked in the past
either for him or others whom he knows.
• At this stage, the client shifts from "thinking
about it" to "planning first steps."
• Counselor guides the steps by offering help but
not yanking the client forward.
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Helps The Client To Get Ready
• Negotiating a plan
• Offering a menu of options
• Developing a behavior contract
• Identifying and lowering barriers
• Enlisting social support
• With permission offer advice
• Assist the client to negotiate finances, child care,
work, transportation, or other potential barriers.
• Have the client publicly announce plans
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Client Indicates Readiness
• Stops arguing, interrupting, denying
• No longer asks questions about the problem,
• but more about how to change
• Appears calm, peaceful
• States openness to change ("I have to do
something")
• Expresses optimism ("I can beat this")
• Talks about how life will be after the change
• Experiments between sessions
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Barriers

• Ask what has gone wrong in the past
• Find out if clients anticipate problems
• Provide all necessary information
• Sources of barriers may include
– Family relations
– Health problems
– Depression or other negative feelings
– Bureaucracy: Waiting lists, paperwork, legal
– Finances
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Action

• The client takes steps toward change, but is still
unstable.
– Counselor can
• Negotiate action plan
• Acknowledge difficulties and support attempts
• Identify risky situations and coping strategies
• Help client find new reinforcers
• Support perseverance ("Sticking to the plan")
• In this stage, clients are receptive to the full
range of counselor techniques, but motivation
can wax and wane
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• If relapse occurs, the ofcounselor
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Goals/Actions

• Engage the client in treatment and reinforce the
importance of remaining in recovery.
• Support a view of change through small steps.
• Acknowledge difficulties for the client in early
stages of change.
• Help the client identify high-risk situations and
develop appropriate coping strategies
• Assist the client in finding reinforcers
• Help the client assess levels of social support.
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Explore Expectations
• Explore past experiences, hopes, and fears
regarding
– Confrontation, judgment
– Costs; in money; in changed behavior.
– Family involvement; shame, guilt.
– Medications; will have to withdraw from or take
– Rules; too strict, no "wiggle room."
– Understanding
• Immunize against difficulties
• Resolve barriers to treatment
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Increase motivations

• Help the client to see the value of both internal
and external motivating factors
• Suggest to the client that external coercions are
compatible with the client's best interests
• Support signs of internal motivation

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Examine and interpret noncompliant
behavior
• Noncompliant behavior is a thinly veiled
expression of dissatisfaction with treatment or
the therapeutic process.

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Maintenance

• Client has met initial goals, made changes in
lifestyle and now practices coping strategies.
– Counselor can
• Support and affirm changes
• Rehearse new coping strategies
• Review goals
• Keep in contact
• In this stage, clients "keep on keeping on."

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Cont…

• The counselor reminds the client about new
tools to maintain and reinforce recovery, such as
– Action plan
– Awareness of risky situations
– Coping strategies for each situation
– Participation in 12-Step programs
– Pursuit of hobbies and cultural activities
– Volunteer opportunities

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Goals/Actions
• Help the client identify and sample drug-free
sources of pleasure (i.e., new reinforcers).
• Support lifestyle changes.
• Affirm the client's resolve and self-efficacy.
• Help the client practice/use coping strategies
• Maintain supportive contact
• Develop a "fire escape" plan if the client
resumes substance use.
• Review long-term goals with the client.
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Form a Plan.

• Identify triggers
• Identify effect/benefits of using in response to
the trigger
• Identify appropriate coping response

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Developing Reinforcers

• Competing
• Contingent (If/Then)
• Community (natural consequences)

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Recurrence

• Help the client reenter the change cycle and
commend any willingness to reconsider positive
change.
• Explore the meaning and reality of the
recurrence as a learning opportunity.
• Assist the client in finding alternative coping
strategies.
• Maintain supportive contact.

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Other Tools

• Consciousness raising increases information
about the problem.
• Self-reevaluation involves assessing how one
feels and thinks about oneself with respect to
problem behaviors.
• Self-liberation means choosing and committing
to act or believing in ability to change.
• Counterconditioning involves substituting coping
alternatives
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Cont…

• Stimulus control means avoiding or countering
stimuli that elicit problem behaviors.
• Reinforcement management is being rewarded
for making changes.
• Helping relationships are created by being open
and trusting about problems with caring people
• Emotional arousal and dramatic relief involve
experiencing and expressing feelings about
one's problems and solutions
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Cont…

• Environmental reevaluation is the process of
assessing how one's problems affect the
personal and physical environment.
• Social liberation involves increasing alternatives
for nonproblematic behavior.

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Applications of Motivational Approaches

• A means of rapid engagement in the general
medical setting to facilitate referral to treatment
• A first session to increase the likelihood that a
client will return and to deliver a useful service if
the client does not return
• An empowering brief consultation when a client
is placed on a waiting list, rather than telling a
client just to wait for treatment
• A preparation for treatment to increase retention
and participation
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• A help to clients coerced into treatment to move
beyond initial feelings of anger and resentment
• A means to overcome client defensiveness and
resistance
• A stand-alone intervention in settings where
there is only brief contact
• A counseling style used through the process of
change

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Other Things to Remember
• Often there is a relatively short period of time to
make a beneficial impact on the client
• The average length of stay in substance abuse
treatment is very short
• If clinicians do not make an impact in the first
session or two with clients, they may not be able
to make an impact at all
• Make the best use of the first contact
• It is usually a mistake to start a session with
filling out forms
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Summary

• There are different goals and tools for each
stage of change
• Even one session can make a positive impact
on a client
• Lasting change takes time and effort
• All clients have the ability to learn to make
positive choices and changes

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