Enhancing Motivation for
Change in Substance Abuse
Treatment Part 2
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
~ Learn about the nautre of change
~ Explore the different stages of readiness for change
~ Learn about goals and interventions for each stage fo readiness for change
~ Identify ways to identify a clients change in readiness for chage
~ Explore ways to identify barriers to recovery
~ Learn how to explore expectations regarding recovery and how to use that to enhance motivation
~ Briefly review how to develop a relapse prevention plan
~ Is Constant
~ Occurs all the time
~ In the natural environment
~ Among people
~ In relation to behaviors
~ Occurs without professional intervention
~ The change process is cyclical, and people typically move back and forth between the stages and cycle through the stages at different rates.
~ It is not uncommon for people to linger in the early stages.
~ Recurrence of at least some symptoms or old behaviors is a normal event, and many clients cycle through the different stages several times before achieving stable recovery.
Nature of Change
~ 6 basic stages in the process of change:
~ People typically vacillate between the stages and cycle through the stages at different rates. (Pool)
~ The client is unaware, unable, or unwilling to change.
~ Establish rapport
~ Raise doubts about patterns of use
~ Give info on risks, pros and cons of use
~ Explore reasons for unwillingness to change (.i.e fear of failure)
~ The client is likely to be wary of the counselor and of treatment.
~ Should not rub the client the wrong way
~ Should try to keep the interview informal.
~ 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.
~ Many clients are ambivalent about change.
~ Change is hard
~ 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 responding, not paying attention
~ The client is ambivalent or uncertain, considering the possibility of change.
~ Discuss and weigh pros/cons of change (Decisional Balance)
~ Emphasize client's free choice and responsibility
~ Elicit self-motivational statements
~ Reassure the client that no one can force him to change and he is in charge.
~ 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?”
~ Help the client recognize the problem(s) contributing to the current situation
~ 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 their current state
~ Reframe negative statements.
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
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).
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.
~ 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.
Help The Client Get Ready
~ Negotiate a plan
~ Offer a menu of options
~ Develop a behavior contract
~ Identify and lowering barriers
~ Enlist social support
~ With permission offer advice
~ Assist the client in negotiating finances, child care, work, transportation, or other potential barriers.
~ Have the client publicly announce plans
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
~ 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
~ The client takes steps toward change, but is still unstable.
~ Negotiate an 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
~ If relapse occurs, “back up” and apply techniques from an earlier stage.
~ 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.
~ Explore past experiences, hopes, and fears regarding
~ Confrontation, judgment
~ Costs in money or changed behavior
~ Can’t stay out late anymore because it triggers depression
~ Have to give up certain activities (at least temporarily) like cross posting
~ Family involvement, shame, guilt
~ Medications the client will have to withdraw from or take
~ Perception of rules too strict, no “wiggle room.”
~ Immunize against difficulties
~ Resolve barriers to treatment
~ 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
Examine & Interpret Noncompliant Behavior
~ Noncompliant behavior is a thinly veiled expression of dissatisfaction with treatment or the therapeutic process.
~ It may be you
~ You may be missing something
~ What are the benefits to the behavior
~ Client has met initial goals, made changes in lifestyle and now practices coping strategies.
~ Support and affirm changes
~ Rehearse new coping strategies
~ Review goals
~ Keep in contact (aftercare, support groups)
~ In this stage, clients “keep on keeping on.”
~ Remind 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 or support groups
~ Pursuit of hobbies and cultural activities
~ Volunteer opportunities
~ 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 feels symptoms returning or notices a return to old ways of thinking
~ Review long-term goals with the client.
Form a Plan.
~ Identify triggers
~ Identify effect/benefits of the old way of responding to the trigger
~ Identify alternate, helpful coping responses
~ Contingent (If/Then)
~ If you respond effectively then
~ Community (natural consequences)
~ 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.
~ 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
~ 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
~ 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.
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
~ 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
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
~ Even one session can make a positive impact on a client
~ Lasting change takes time and effort
~ All clients have the ability to make positive choices and changes
~ Clients will be at different stages of readiness for change for different issues and symptoms and may vacillate between conflicting goals
~ Clients with low motivation begin arguing, ignoring or becoming apathetic
~ Sometimes enhancing motivation means focusing first on barriers to recovery instead of the problem itself.
~ Explore expectations regarding recovery to enhance motivation
~ Develop a relapse prevention plan that helps clients identify triggers and vulnerabilities and ways to prevent and address them