Drug Abuse

8 Enhancing motivation for change in drug treatment

Enhancing motivation for change in drug treatment

Guidelines for treatment improvement

Moretreat-project
ITACA Rome Italy
October 2008
EUROPEAN COMMISSION
HEALTH    &    CONSUMER    PROTECTION
DIRECTORATE-GENERAL
Directorate C - Public Health and Risk Assessment
The content of this report does not necessarily reflect the opinion of the European Commission. Neither the Commission nor anyone acting on its behalf shall be liable for any use made of the information in this publication.

Content

1 Introduction   
1.1. Definition and context   
1.2 General principles   
1.3 Important elements   
1.4 Client group served    

2 Evidence Base    
2.1 Relevance of motivation and change   
2.1 Incorporation of motivational approaches   

3 Recommendations  
3.1 Access  
3.2 Assessment   
3.3 Treatment phases   
3.4 Motivational Counselling Strategies  
3.5 Core management standards 
3.6 Performance and outcome monitoring  
3.7 Location   
3.8 Programme duration   
3.9 Staffing/competencies   
References   

1    Introduction

1. 1.    Definition and context

Motivational in terviewing is a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence presented by substance/drugs users/abusers.
The concept of motivational interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioural Psychotherapy. These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures.

1.2    General principles

There are four general principles behind Motivational Interviewing:

•    Express Empathy

Expression of empathy is critical to the MI approach. When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others. The counsellor's accurate understanding of the client's experience facilitates change.

•    Support Self-Efficacy

A client's belief that change is possible is an important motivator to succeeding in making a change. As clients are held responsible for choosing and carrying out actions to change in the MI approach, counsellors focus their efforts on helping the clients stay motivated, and supporting clients' sense of self-efficacy is a great way to do that. The client can be helped to develop a belief that he or she can make a change.

•    Roll with Resistance

In MI, the counsellor does not fight client resistance, but "rolls with it." MI encourages clients to develop their own solutions to the problems that they themselves have defined. In exploring client concerns, counsellors may invite clients to examine new perspectives, but counsellors do not impose new ways of thinking on clients.

•    Develop Discrepancy

MI counsellors work to develop this situation through helping clients examine the discrepancies between their current behaviour and future goals. When clients perceive that their current behaviours are not leading toward some important future goal, they become more motivated to make important life changes.

1.3    Important elements

There are several important elements of the philosophy behind motivational interviewing:

•    Client resistance typically is a behaviour evoked by environmental conditions. MI views denial and resistance as behaviours evoked by environmental conditions, not as traits characteristic of substance abusers. Resistance is primarily viewed as a reaction to the in-session behaviour of the counsellor.

Additionally, the client's behaviour over the course of treatment is affected in part by the counsellor's reactions to the early, negative communications of the client. It is important for the counsellor using the MI approach to remember that agreeing with the counsellor's views does not indicate motivation on the client's part, and, more importantly, disagreeing with the counsellor's views does not indicate a lack of motivation on the client's part.

•    The client/counsellor relationship should be collaborative and friendly.

The MI framework fits best with a view that client change is best enhanced through positive reinforcement. Through positive reinforcement, a client's environment rewards him or her for trying new things, such as opening up to another person about his or her difficulties, or trying new behaviours that fit with the client's long term goals rather than continuing behaviours that provide short-term gain at the cost of long-term loss, etc.

•    Motivational Interviewing gives priority to resolving ambivalence.

As mentioned above, in the MI approach, clients are generally viewed as feeling highly ambivalent about changing. The concern about this is that clients often have mixed feelings about making changes, and counsellor who presses a client to make changes immediately risks (a) evoking client resistance, (b) promoting premature termination from counselling, and (c) encouraging clients to overlook the internal and external factors that may promote relapse even following initial success in change attempts.

•    The counsellor does not prescribe specific methods or techniques.

MI counsellors educate clients about the variety of therapeutic options available to them and, at times, the research support for particular options. These include treatment options, as well as other means of support. Clients are free to choose the elements that they believe will be most helpful to them in their efforts.

•    Clients are responsible for their progress.

MI counsellors emphasize the freedom clients have to choose their behaviours, MI/MET counsellors also emphasize the responsibility that lies with clients to make those changes.

•    MI focuses on clients' sense of self-efficacy.

The MI approach increases the clients' hope that they can make substantial changes related to their substance abuse. Clients who perceive that they have substance problems in need of change may still "resist" change if they believe they cannot successfully complete the change process.

1.4    Client group served

Substance user/abuser, including adolescent; alcoholics, nicotine dependents, eating disorders, users in correctional Opiate, cocaine, cannabis problematic use.

2    Evidence Base

2.1    Relevance of motivation and change

The motivational approaches are based on the following studied assumptions about the nature of motivation 14:

Motivation is a key to change
The study of motivation is inexorably linked to an understanding of personal change a concept that has also been scrutinized by modern psychologists and theorists and is the focus of substance abuse treatment. The nature of change and its causes, like motivation, is a complex construct with evolving definitions. Few of MIÕs clinicians, for example, take a completely deterministic view of change as an inevitable result of biological forces, yet most of them accept the reality that physical growth and maturation do produce change--the baby begins to walk and the adolescent seems to be driven by hormonal changes. They recognize, too, that social norms and roles can change responses, influencing behaviours as diverse as selecting clothes or joining a gang, although few of us want to think of ourselves as simply conforming to what others expect. Certainly, they believe that reasoning and problem-solving as well as emotional commitment can promote change.
The framework for linking individual change to a new view of motivation stems from what has been termed a phenomeno logical theory of psychology, most familiarly expressed in the writings of Carl Rogers. In this humanistic view, an individual's experience of the core inner self is the most important element for personal change and growth--a process of self-actualization that prompts goal-directed behaviour for enhancing this self (Davidson 1994). In this context, motivation is redefined as purposeful, intentional, and positive--directed toward the best interests of the self. More specifically, motivation is the probability that a person will enter into, continue, and adhere to a specific change strategy (Miller and Rollnick 1991).

Motivation is multidimensional
Motivation, in this new meaning, has many complex components. It encompasses the internal urges and desires felt by the client, external pressures and goals that influence the client, perceptions about risks and benefits of behaviours to the self and cognitive appraisals of the situation.

Motivation is dynamic and fluctuating
Research and experience suggest that motivation is a dynamic state that can fluctuate over time and in relation to different situations, rather than a static personal attribute. Motivation can vacillate between conflicting objectives. Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved and goals are more clearly envisioned. In this sense, motivation can be an ambivalent, equivocating state or a resolute readiness to act--or not to act.

Motivation is influenced by social interactions
Motivation belongs to one person, yet it can be understood to result from the interactions between the individual and other people or environmental factors (Miller 1995b). Although internal factors are the basis for change, external factors are the conditions of change. An individual's motivation to change can be strongly influenced by family, friends, emotions, and community support. Lack of community support, such as barriers to health care, employment, and public perception of substance abuse, can also affect an individual's motivation.

Motivation can be modified
Motivation pervades all activities, operating in multiple contexts and at all times. Consequently, motivation is accessible and can be modified or enhanced at many points in the change process. Clients may not have to "hit bottom" or experience terrible, irreparable consequences of their behaviours to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image (Miller 1985; Miller et al. 1993).

Although there are substantial differences in what factors influence people's motivation, several types of experiences may have dramatic effects, either increasing or decreasing motivation. Experiences such as the following often prompt people to begin thinking about making changes and to consider what steps are needed:

•    Distress levels may have a role in increasing the motivation to change or search for a change strategy (Leventhal 1971  ; Rogers et al. 1978). For example, many individuals are prompted to change and seek help during or following episodes of severe anxiety or depression.
•    Critical life events often stimulate the motivation to change. Milestones that prompt change range from spiritual inspiration or religious conversion through traumatic accidents or severe illnesses to deaths of loved ones, being fired, becoming pregnant, or getting married (Sobell et al. 1993b  ; Tucker et al. 1994).
• Cognitive evaluation or appraisal, in which an individual evaluates the impact of substances in his life, can lead to change. This weighing of the pros and cons of substance use accounts for 30 to 60 percent of the changes reported in natural recovery studies (Sobell et al. 1993b).
•    Recognizing negative consequences and the harm or hurt one has inflicted on others or oneself helps motivate some people to change (Varney et al. 1995). Helping clients see the connection between substance use and adverse consequences to themselves or others is an important motivational strategy.
•    Positive and negative external incentives also can influence motivation. Supportive and empathic friends, rewards, or coercion of various types may stimulate motivation for change.

Motivation is influenced by the clinician's style
The way the clinician interacts with clients has a crucial impact on how they respond and whether treatment is successful. Researchers have found dramatic differences in rates of client dropout or completion among counsellors in the same programme who are os tensibly using the same techniques (Luborsky et al. 1985). Counsellor style may be one of the most important, and most often ignored, variables for predicting client response to an intervention, accounting for more of the variance than client characteristics (Miller and Baca 1983  ; Miller et al. 1993). In a review of the literature on counsellor characteristics associated with treatment effectiveness for substance users, researchers found that establishing a helping alliance and good interpersonal skills were more important than professional training or experience (Najavits and Weiss 1994). The most desirable attributes for the counsello r mirror those recommended in the general psychological literature and include non-possessive warmth, friendliness, genuineness, respect, affirmation, and empathy.
A direct comparison of counsellor styles suggested that a confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client -centred, supportive, and empathic style that uses reflective listening and gentle persuasion (Miller et al. 1993). In this study, the more a client was confronted, the more alcohol the client drank. Confrontational counselling in this study included challenging the client, disputing, refuting, and using sarcasm.

The clinician's task is to elicit and enhance motivation
Although change is the responsibility of the client and many people change their excessive substance-using behaviour on their own without therapeutic intervention (Sobell et al. 1993b), clinician can enhance client's motivation for beneficial change at each stage of the change process. The clinician’s task is not, however, one of simply teaching, instructing, or dispensing advice. Rather, the clinician assists and encourages clients to recognize a problem behaviour (e.g., by encouraging cognitive dissonance), to regard positive change to be in their best interest, to feel competent to change, to develop a plan for change, to begin taking action, and to continue using strategies that discourage a return to the problem behaviour (Miller and Rollnick 1991). Clinicians have to be sensitive to influences such as client's cultural background; knowledge or lack thereof can influence your client's motivation.

2.1    Incorporation of motivational approaches

Motivational Interviewing is a well-known, scientifically tested method of counselling clients developed by Miller and Rollnick and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease.
Although the demand for treatment of substance abuse continues to far exceed its availability, changes in health care economics are placing greater pressure on providers and their clients. Payors increasingly demand evidence that the services being provided are not only effective, but cost-effective. Clinicians and programmes are increasingly challenged if they do not use research-supported, current methods. Public funding is scarce, and third-party payors exert great pressure to provide treatment that is shorter, less costly, and more effective.

In sum, clinicians are asked to do more with less.

The incorporation of motivational approaches and interventions into treatment programmes may be a practical and efficacious response to many of these challenges. Recent research (Brown and Miller 1993; Kolden et al. 1997; McCaul and Svikis 1991) supports the integration of motivational interviewing modules into programmes to reduce attrition, to enhance client participation in treatment, and to increase the achievement and maintenance of positive behavioural outcomes. Other studies have shown brief interventions using motivational strategies and motivational interviewing to be more effective than no treatment or being placed on a waiting list, and not inferior to some types of more extensive care (Bien et al. 1993a, 1993b; Noonan and Moyers 1997). A review of the cost-effectiveness of treatments for alcohol use disorders concluded that brief motivational counselling ranked among the most effective treatment modalities, based on weighted evidence from rigorous clinical trials (Holder et al. 1991). Brief motivational counselling was also the least costly--making it the most cost-effective treatment modality of the 33 evaluated. Although cautioning that it was an approximation that requires refinement, the same study found a negative correlation between effectiveness and costs for the most traditional forms of treatment for alcohol use disorders and highlighted a growing trend to favour effective outpatient care over less effective or less studied--but far more expensive--inpatient, hospital-based, or residential care (Holder et al. 1991).
As already noted, MI increases the effect of another treatment, but has not itself been subjected to randomized study. Brief, motivation -enhancing treatment appears to have the same effect as more extensive treatment. The studies, with the exception of Project MATCH, have mainly recruited patients with a lower level of alcohol dependence.

3 Recommendations

3.1    Access

Access to the service

Flexible.

Referral pathways and relevant pathways of care

Flexible.

Integrate care pathways

High level of integrated pathways.

3.2    Assessment

Another strategy involves providing feedback to the client about their behaviour. Normative feedback can include information about levels of use, consequences of use or comparison to others. Standardized instruments like the ASI, SASSI, AUDIT or DrInC or InDUC provide ready resources for this type of feedback.

3.3    Treatment phases

The process of negotiation is described as a "meeting between experts" comprising five key steps:

•    establish rapport.
•    ask for permission to disc uss the pros and cons of continued substance use.
•    be open to allowing clients to self-identify potential evidence of problematic substance use.
•    invite clients to assess their readiness for change.
•    negotiate a potential strategy for change, taking into account clients' perception of their readiness to change (D'Onofrio et al. 1998b).

Values Exploration

A focus on values may stimulate motivation for change. Focusing on discrepancies between ideal life conditions and actual conditions may induce a desire to "recalibrate" daily behaviours to be more congruent with deeply held beliefs.
Ambivalence about various possibilities can be viewed in part as the experiential result of multiple conflicting values.
In addition to a general discussion of the client's values, counsellors can use a set of values cards and have the client sort through the cards and order them in accordance with his or her priorities. Counsellors sometimes report that this technique increased the ease of practice as well as client engagement.

Looking Forward

It has the client envision two futures. The first is if they continue on the same path without any changes where they might be five or ten years from now. The second future is if they decided to make a change in their behaviour, what that future might look like. The therapist's job is not argue one position or another, but rather just elicit the information and then ask the client to comment on these imaginings.

Exploring Importance and Confidence

This strategy essentially explores the clien t's impressions of how important is to make a change and how confident he or she is that he or she can succeed in changing.

Decisional Balance

Counsellors ask clients to identify the anticipated "pros" and "cons" of changing a behaviour, then compare this with the pros and cons of not changing the behaviour.

Change Planning

A change plan is a technique that can be quite helpful with clients that are ready to do this type of work.

Monitoring the effectiveness ofyour use of MI Strategies

Observe client behaviour during MI sessions for adapting strategy.

Interaction Techniques

The basic approach to interactions in motivational interviewing is captured by the acronym OARS: (1) Open-ended questions, (2) Affirmations, (3) Reflective listening and (4) Summaries.

Open-ended questions are those therapist utterances that client's cannot answer with a "yes", "no" or "three times in the last week".
An open -ended question allows the client to create the impetus for forward movement. Affirmations are statements of recognition about client strengths.
Affirmations. If the client thinks the counsellor is insincere, then rapport can be damaged rather than built.
Reflective listening. The goal in MI is to create forward momentum and to then harness that momentum to create change. Reflective listening keeps that momentum moving forward.

Summaries. The structure of the summary is straightforward. Miller and Rollnick organize this talk into four categories: problem recognition, concern about the problem, commitment to change and belief that change is possible.

Aftercare and support

Standard MI is used for improve compliance and effectiveness of different following treatments.

3.4    Motivational Counselling Strategies

Reviewing a Typical Day

Here, the counsellor builds rapport while gathering information. The counsellor avoids a focus on "problem behaviours," focusing instead on how substance use fits in to the person's life. Proceed to help the client tell a story of the day, focusing on feelings and behaviours. If the client is receptive, summarize, the move to the next strategy.

Looking Back

This strategy simply involves engaging in a conversation with the client about what life was like "before." Before substance use problems, before legal, work or relationship difficulties, etc. The goal is for the client to obtain some perspective from the immediacy of his or her circumstance and to observe either how things have changed over time.

Good Things and Less Good Things

This strategy is simply to review what is "good" about subs tance use alongside a review of what is "not-so-good" about the use of substances. The technique provides the therapist an opportunity to explore what "positives" may be sustaining a behaviour.

Discussing the Stages of Change

There is some pretty good evidence that people shouldn't skip stages. Someone who jumps right into the action stage may not spend enough time preparing for change. The result is they have trouble in keeping the changes they've made. For this reason, it is important to know which stage client is in and what things he/she needs to do to move to the next stage.

3.5    Core management standards 15

In a transtheoretical perspective, individuals move through a series of stages of change as they progress in modifying problem behaviours. This concept of stages is important in understanding change. Each stage requires certain tasks to be accomplished and certain processes to be used in order to achieve change. Six separate stages have been identified in this model (Prochaska and DiClemente, 1984, 1986):

PRECONTEMPLATION
CONTEMPLATION
DETERMINATION
ACTION
MANTEINANCE
RELAPSE

3.5.1 From precontemplation to Contemplation: Building Readiness

This chapter discusses a variety of proven techniques and gentle tactics that the clinician in a treatment facility can use to raise the topic with people not thinking of change, to create client doubt about the commonly held belief that substance abuse is "harmless" and to lead to client conviction that substance -abuse is having, or will in the future have, significant negative results. An assessment and feedback process is an important part of the motivational strategy, informing clients about how their personal substance use patterns compare with norms, what specific risks are entailed, and what damage already exists or is likely to occur if changes are not made.

Raising the Topic

The new client could be at any point in the severity continuum (from mild problem use to more severe dependence), could have few or many associated health or social problems, and could be at any stage of readiness to change. The strategies used for beginning a therapeutic dialog should be guided by assessment of the client's motivation and readiness.

In opening sessions it is important to
•    Establish rapport and trust
•    Explore events that precipitated treatment entry

Establish Rapport and Trust

The challenge is to create a safe and supportive environment in which the client can feel comfortable about engaging in authentic dialog. One way to foster rapport is first to ask the client for permission to address the topic of change; this shows respect for the client's autonomy. Next, itÕs necessary to tell the client something about how MIÕs programme operates and how therapist and client could work together. Do specify what assessments or other formal arrangements will be needed, if appropriate.

Explore the Events That Precipitated Treatment Entry

The emotional state in which the client comes to treatment is an important part of the gestalt or context in which counselling begins. Clients referred to treatment will exhibit a range of emotions associated with the experiences that brought them to counselling -- an arrest, a confrontation with a spouse or employer, or a health crisis. The situation that led an individual to treatment can increase or decrease defensiveness about change. However, clients sometimes blame the referring source or someone else for coercing them into counselling. The implication is often that this individual or agency does not view the situation accurately. To find ways to motivate change, itÕs important to ascertain what the client sees and believes is true.

Gentle Strategies to Use with the Precontemplator

There are some strategies that are useful for increasing the client's readiness to change and encouraging contemplation:

a) Agree on Direction
In helping the client who is not yet thinking seriously of change, it is important to plan your strategies carefully and negotiate a pathway that is acceptable to the client.

b) Assess Readiness to Change
There are several ways to assess a client's readiness to change:
•    Readiness Ruler
The simplest way to assess the client's willingness to change is to use a Readiness Ruler or a 1 to 10 scale, on which the lower numbers represent no thoughts about change and the higher numbers represent specific plans or attempts to change.
•    Description of a typical day
Another, less direct, way to assess readiness for change, as well as to build rapport and encourage clients to talk about substance use patterns in a non-pathological framework, is to ask them to describe a typical day. This approach also helps to understand the context of the client's substance use.
•    Provide Information About the Effects and Risks of Substance Use
Its important to provide basic information about substance use early in the treatment process if clients have not been exposed to drug and alcohol education before and seem interested.
•    Use Motivational Language in Written Materials

Its needed to remember that the effective strategies for increasing motivation in face-to-face contacts also apply to written language. Brochures, flyers, educational materials, and advertisements can influence a client to think about change.

c) Create Doubt and Evoke Concern
As clients move beyond a pre -contemplation stage and become aware of or acknowledge some problems in relation to their substance use, change becomes an increased possibility. Such clients become more aware of conflict and feel greater ambivalence. The major strategy for moving clients from a pre-contemplation to a contemplation stage is to raise doubts in them about the harmlessness of their substance use patterns and to evoke concerns that all is not well after all.
One way to foster concern in the client is to explore the good and less good aspects of substance use.

d) Assessment and Feedback Process
Findings from an assessment can most readily become part of the therapeutic process if the client understands the practical value of objective information and believes the results will be helpful. A variety of instruments and procedures may be used to evaluate clients. Eight major domains considered comprehensive in scope for assessing clients with primarily alcohol-related problems have been suggested:
•    Substance use patterns
•    Dependence syndrome
•    Life functioning problems
•    Functional analysis
•    Biomedical effects
•    Neuropsychological effects
•    Family history
•    Other psychological effects

e) Intervene Through Significant Others
Considerable research shows that involvement of significant others (SOs) can help move substance users to contemplation of change, entry into treatment, retention and involvement in the therapeutic process, and successful recovery. An SO can play a vital role in enhancing an individual's commitment to change by addressing a client's substance use in the following ways:
•    Providing constructive feedback to the client about the costs and benefits associated with his substance use behaviour
•    Encouraging the resolve of the client to change the negative behaviour pattern
•    Identifying the concrete and emotional obstacles to change
•    Alerting the client to social and individual coping resources that lead to a substance-free lifestyle
• Reinforcing the client for using these social and coping resources to change the substance use behaviour
Several recognized methods of involving SOs in motivational interventions are: involving them in counselling, in a face-to-face intervention, in family therapy, or as part of a community reinforcement approach.

3.5.2 From Contemplation to Preparation: Increasing Commitment

Changing Extrinsic to Intrinsic Motivation
To help the clients prepare for change, itÕs important to seek to understand the range of both extrinsic and intrinsic motivators that have brought them to this point. Helping clients change extrinsic to intrinsic motivation is an important part of helping them move from contemplating change to deciding to act. ItÕs necessary to start with the client's current situation and find a natural link between existing external motivators and intrinsic ones the client may not be aware of or find easy to articulate. Through sensitive and respectful exploration, untapped intrinsic motivation may be discovered even in clients who seem unlikely to become self-motivating.

Tipping the Decisional Balance
In moving toward any decision, most people weigh the costs and benefits of the action being contemplated. In behavioural change, these considerations are known as decisional balancing, a process of cognitively appraising or evaluating the "good" aspects of substance use--the reasons not to change, and the less good aspects--the reasons to change.

Summarize Concerns
A first step in helping the client to weigh the pros and cons is to organize the list of concerns and present them to the client in a careful summary that expresses empathy, develops discrepancy, and weights the balance toward change. Because it is important to reach agreement on these issues, the summary should end by asking whether your client agrees that these are her concerns.

Explore Specific Pros and Cons
Weighing benefits and costs of substance use and of change is at the heart of decisional balance work. Some clinicians find it helpful to ask the client to write out a two-column list. This can be done as homework and discussed during the session, or the list can be generated during a session.

Normalize Ambivalence
Clients engaged in decisional balance exercises often feel themselves moving closer to a decision--closer to changing long-standing behaviours than they may ever have ventured and, therefore, closer to inner conflict and doubt about whether they can or want to change. An important strategy at this point is to reassure client that conflicting feelings, uncertainties, and reservations are common.

Reintroduce Feedback
Objective medical, social, and neuropsychological feedback from the assessment prompts many clients to contemplate change. Reviewing the assessment information can keep clients focused on the need for change.
Examine the Client's Understanding of Change and Expectations of Treatment Exploration of treatment expectations provides an opportunity to introduce information about treatment and to begin a preliminary discussion with clients about available options. When clients' expectations about treatment correspond to what actually happens in treatment, they have better outcomes.

Emphasizing Personal Choice and Responsibility
In a motivational approach to counselling the client chooses. Therapist’s task is to help clients make choices that are in their best interests. A consistent message throughout the motivational approach is the client's responsibility and freedom of choice. At this stage of the change process, the client should be accustomed to hearing from you such statements as the following:

•    It's up to you what to do about this."
•    "No one can decide this for you."
•    "No one can change your drug use for you. Only you can."
•    "You can decide to go on drinking or to change."

3.5.3 From Preparation to Action: Getting Started

At the end of the preparation stage, clients make a plan for change to guide them into the action stage. Changing any long-standing, habitual behaviour requires preparation and planning. As clients move from contemplating to actually implementing change in their lives, they are in an intermediate stage in which they increase their commitment to change by exploring, clarifying, and resolving their ambivalence and making a decision to act. In the transtheoretical model, this stage is known as preparation. Clients must see change as in their best interest before they can move into action. The negative consequences of ignoring the preparation stage can be a brief course of action followed by rapid return to substance use.

Recognizing Readiness to Move Into Action

As clients proceed through the preparation stage, itÕs important to pay attention to signs of their readiness to take action. Clients' recognition of important discrepancies in their lives is an uncomfortable state in which to remain for long. The following are several confirming signs of readiness to act:
•    Decreased resistance. The client stops arguing, interrupting, denying, or objecting.
•    Fewer questions about the problem. The client seems to have enough information about his problem and stops asking questions.
•    Resolve. The client appears to have reached a resolution and may be more peaceful, calm, relaxed, unburdened, or settled. Sometimes this happens after the client has passed through a period of anguish or tearfulness.
•    Self-motivational statements. The client makes direct self-motivational statements reflecting openness to change ("I have to do something") and optimism ("I'm going to beat this").
•    More questions about change. The client asks what she could do about the problem, how people change once they decide to, and so forth.
•    Envisioning. The client begins to talk about how life might be after a change, to anticipate difficulties if a change were made, or to discuss the advantages of change.
•    Experimenting. If the client has had time between sessions, he may have begun experimenting with possible change approaches (e.g., going to an Alcoholics Anonymous [AA] meeting, reading a self -help book, stopping substance use for a few days)

Negotiating a Plan for Change

Creating a plan for change is a final step in readying the client to act. sound change plan can be negotiated with your client by the following means:
•    Offering a menu of change options
•    Developing a behaviour contract
•    Lowering barriers to action
•    Enlisting social support
•    Educating your client about treatment

Although the change plan is the client's, creating it is an interactive process between the therapist and the client. One of your most important tasks is to ensure that the plan is feasible. When the client proposes a plan that seems unrealistic, too ambitious, or not ambitious enough, a process of negotiation should follow. The following areas are ordinarily part of interactive discussions and negotiations:

•    Intensity and amount of help needed--for example, the use of only self-help groups, enrolling in intensive outpatient treatment, or entering a 2-year therapeutic community
•    Timeframe--a short - rather than a long -term plan and a start date for the plan
•    Available social support--including who will be involved in treatment (e.g., family, Women for Sobriety, community group), where it will take place (at home, in the community), and when it will occur (after work, weekends, two evenings a week)
•    Sequence of subgoals and strategies or steps in the plan --for example, first to stop dealing marijuana, then stop smoking it; to call friends or family to tell them about the plan, then visit them; to learn relaxation techniques, then to use them when feeling stressed at work
•    How to address multiple problems--for example, how to deal with legal, financial, and health problems.

3.5.4 From Action to Maintenance: Stabilizing Change

This chapter addresses ways in which motivational strategies can be used effectively at different points in the formal treatment process.

Develop rapport
Clinician style is an important element for establishing rapport and building a trusting relationship with clients. The principles of motivational interviewing exemplify proven methods to get in touch with and understand clients' unique perspectives and personal values, as opposed to the therapist or to his programme. Accurate empathy and reflective listening (client-centred skills for eliciting clients' concerns through an interactive process that facilitates rapport) have been well described and tested in clinical research.

Induct clients into their role
The clients must become acquainted with the therapist and the agency. ItÕs necessary to tell clients explicitly what treatment involves, what is expected, and what rules there are. If the client has not been prepared by a referring source, therapist has to review exactly what will happen in treatment so that any confusion is eliminated, has to use language the client understands. Also therapist has to be sure to encourage questions and provide clarification of anything that seems perplexing or not justified.

Explore client expectancies and determine discrepancies
One of the first things to discuss with new clients is their expectations about the treatment process, including past experiences, and whether there are serious discrepancies with the reality of the upcoming treatment.
•    The clinician will be confrontational and impose treatment goals.
•    Treatment will take too long and require the client to give up too much.
•    The rules are too strict, and the client will be discharged for the slightest infringement.
•    Medication will not be prescribed for painful withdrawal symptoms.
•    The programme does not understand women, members of different ethnic groups, or persons who take a particular substance or combination of substances.
•    A spouse or other family member will be required to participate.

"Immunize" the client against common difficulties
During treatment, clients may have negative reactions or embarrassing moments when they reveal more than they planned, react too emotionally, realize discrepancies in the information they have supplied, or pull back from painful insights about how they have hurt others or jeopardized their own futures. One way to forestall impulsive early termination in response to these situations is to "immunize" or "inoculate" client anticipating and discussing such problems before they occur, indicating they are a normal part of the recovery process, and developing a plan to handle them.

Planning for Stabilization

Conducting a Functional Analysis

Although a functional analysis can be used at various points in treatment, it can be particularly informative in preparing for maintenance. A functional analysis is an assessment of the common antecedents and consequences of substance use. Through functional analysis, the therapist help clients understand what has "triggered" them to drink or use drugs in the past and the effects they experienced from using alcohol or drugs.

Developing a Coping Plan
Developing a coping plan is a way of anticipating problems before they arise and of recognizing the need for a repertoire of alternative strategies. A list of coping strategies that others have found successful can be particularly useful in developing a plan and in brainstorming ways to deal with anticipated barriers to change.

Ensuring Family and Social Support
Clients are embedded in a social network that can be either constructive or destructive. One task for the therapist and the client is to determine which social relationships are supportive and which are risky.

Developing and Using Reinforcers

Competing reinforcers are effective in reducing substance use. A competing reinforcer is any source of satisfaction for the client that can become an alternative to drugs or alcohol. The therapist can help the client fill this void by suggesting potential activities, such as the following:

•    Do volunteer work. This alternative is a link to the community. The client can fill time, reconnect with pro -social people, and improve self-efficacy. Volunteering is a direct contribution that can help resolve guilt the client may feel about previous criminal or antisocial behaviour.
•    Become involved in 12-Step activities. Similar to volunteering, this fills a need to be involved with a group and contribute to a worthwhile organization.
•    Set goals to improve work, education, health, and nutrition.
•    Spend more time with family, significant others, and friends.
•    Participate in spiritual or cultural activities.
•    Learn new skills or improve in such areas as sports, art, music, and hobbies.

External Contingent Reinforcers
The principles of contingent reinforcement can be applied to sustain abstinence while clients work on building a substance-free lifestyle. The specific awards chosen can be tailored to the values of the clients and resources of the programme. Besides natural reinforcers, some programmes have used temporary contingencies to change substance use. Voucher incentive programmes have several benefits that recommend their use.

3.6    Performance and outcome monitoring

Instruments and tools:
•    Behaviour Change Counselling Index (BECCI)
•    R.T.C.Q.
•    MAC E (intake and discharge form)

3.7    Location

Not defined, flexible.

3.8    Programme duration

Flexible.

3.9    Staffing/competencies

Personnel must be trained in MI. Clinical supervision is suggested.

References

Essentials:
www.motivationalinterview.org
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.
Miller W. R., Enhancing Motivation for Change in Substance Abuse Treatment: Treatment Improvement Protocol (TIP) Series 35. Rockville, MD: Substance Abuse and Mental Health Services Administration - Center for Substance Abuse Treatment.
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.

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14    A comprehensive summary of corresponding results see SAMHSA (2006)

15    The following transitions between stages are summariesed based on SAMHSA 2006.

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