TIP 35 Enhancing Motivation For Change in Substance Abuse Treatment

184 Pages·2017·7.02 MB·English

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Enhancing Motivation

For Change in

Substance Abuse

Treatment

Treatment Improvement Protocol (TIP) Series

35
Enhancing
Motivation for
Change in
Substance
Abuse
Treatment
Treatment Improvement Protocol (TIP) Series
35
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments Electronic Access and Printed Copies
This publication was prepared under contract This publication may be ordered from or
number 270-95-0013 for the Substance Abuse downloaded from SAMHSA’s Publications
and Mental Health Services Administration Ordering Web page at http://store.samhsa.gov.
(SAMHSA), U.S. Department of Health and Or, please call SAMHSA at 1-877-SAMHSA-7
Human Services (HHS). Sandra Clunies, M.S., (1-877-726-4727) (English and Español).
ICADC, served as the Contracting Officer’s
Representative. Recommended Citation
Center for Substance Abuse Treatment.
Disclaimer Enhancing Motivation for Change in Substance
The opinions expressed herein are the views of Abuse Treatment. Treatment Improvement
the consensus panel members and do not Protocol (TIP) Series, No. 35. HHS Publication
necessarily reflect the official position of No. (SMA) 13-4212. Rockville, MD: Substance
SAMHSA or HHS. No official support of or Abuse and Mental Health Services
endorsement by SAMHSA or HHS for these Administration, 1999.
opinions or for the instruments or resources
described are intended or should be inferred. Originating Office
The guidelines presented should not be Quality Improvement and Workforce
considered substitutes for individualized client Development Branch, Division of Services
care and treatment decisions. Improvement, Center for Substance Abuse
Treatment, Substance Abuse and Mental Health
Public Domain Notice Services Administration, 1 Choke Cherry Road,
All materials appearing in this volume except Rockville, MD 20857.
those taken directly from copyrighted sources
are in the public domain and may be HHS Publication No. (SMA) 13-4212
reproduced or copied without permission from First Printed 1999
SAMHSA or the authors. Citation of the source Revised 2000, 2001, 2002, 2003, 2004, 2006, 2007,
is appreciated. However, this publication may 2008, 2011, 2012, and 2013
not be reproduced or distributed for a fee

without the specific, written authorization of the

Office of Communications, SAMHSA, HHS.

ii
Contents

What Is a TIP?.......................................................................................................................................................... vii

Editorial Advisory Board........................................................................................................................................ ix

Consensus Panel ...................................................................................................................................................... xi

Foreword..................................................................................................................................................................xiii

Executive Summary and Recommendations ..................................................................................................... xv

Summary of Recommendations...................................................................................................................... xvi

To Which Clients Does This TIP Apply? ..................................................................................................... xxvi

Chapter 1—Conceptualizing Motivation and Change........................................................................................1

A New Look at Motivation..................................................................................................................................1

Changing Perspectives on Addiction and Treatment......................................................................................4

Changes in the Addictions Field.......................................................................................................................11

A Transtheoretical Model of the Stages of Change ........................................................................................15

To Whom Does This TIP Apply? ......................................................................................................................19

Summary..............................................................................................................................................................21

Chapter 2—Motivation and Intervention............................................................................................................23

Elements of Effective Motivational Interventions ..........................................................................................23

Motivational Intervention and the Stages of Change ....................................................................................29

Special Applications of Motivational Interventions.......................................................................................30

Brief Interventions ..............................................................................................................................................36

Chapter 3—Motivational Interviewing as a Counseling Style .......................................................................39

Ambivalence........................................................................................................................................................40

Five Principles of Motivational Interviewing .................................................................................................40

Five Opening Strategies for Early Sessions .....................................................................................................49

Effectiveness of Motivational Interviewing..................................................................................................... 53

Motivational Interviewing and Managed Care .............................................................................................. 55

Chapter 4—From Precontemplation to Contemplation: Building Readiness .............................................. 57

Raising the Topic ................................................................................................................................................. 58
Gentle Strategies To Use With the Precontemplator......................................................................................62

Assessment and Feedback Process ...................................................................................................................65

Intervene Through Significant Others .............................................................................................................71

Motivational Enhancement and Coerced Clients: Special Considerations .................................................80

Chapter 5—From Contemplation to Preparation: Increasing Commitment .................................................83

Changing Extrinsic to Intrinsic Motivation.....................................................................................................84

Tipping the Decisional Balance.........................................................................................................................86

Emphasizing Personal Choice and Responsibility .........................................................................................90

The Importance of Self-Efficacy ........................................................................................................................95

Chapter 6—From Preparation to Action: Getting Started ................................................................................97

Recognizing Readiness To Move Into Action .................................................................................................98

Negotiating a Plan for Change..........................................................................................................................98

Initiating the Plan..............................................................................................................................................109

Chapter 7—From Action to Maintenance: Stabilizing Change.....................................................................111

Engaging and Retaining Clients in Treatment..............................................................................................112

Planning for Stabilization ................................................................................................................................118

Developing and Using Reinforcers.................................................................................................................123

Chapter 8—Measuring Components of Client Motivation ...........................................................................135

Self-Efficacy........................................................................................................................................................136

Readiness To Change .......................................................................................................................................137

Decisional Balancing.........................................................................................................................................141

Motivation for Using Substances....................................................................................................................143

Goals and Values...............................................................................................................................................144

Chapter 9—Integrating Motivational Approaches Into Treatment Programs............................................147

The Treatment Continuum and Stepped Care..............................................................................................148

Applications of Motivational Approaches in Specific Treatment Settings ...............................................149

Chapter 10—Directions for Future Research ....................................................................................................159

Conclusion .........................................................................................................................................................162

Appendix A—Bibliography.................................................................................................................................163

Appendix B—Screening and Assessment Instruments..................................................................................185

Alcohol and Drug Consequences Questionnaire (ADCQ)..........................................................................186

Alcohol (and Illegal Drugs) Decisional Balance Scale..................................................................................189

Alcohol Effects Questionnaire.........................................................................................................................192

Alcohol Expectancy Questionnaire—III (Adult) ..........................................................................................195

Alcohol Use Disorders Identification Test (AUDIT) ....................................................................................202

Brief Situational Confidence Questionnaire (BSCQ)...................................................................................204

Personal Feedback Report................................................................................................................................206

Readiness To Change Questionnaire (Treatment Version) (RCQ-TV) ......................................................214
#ONTENTS�

Situational Confidence Questionnaire (SCQ-39) .......................................................................................... 217 

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES 8A) .......................................220 

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES 8D) .......................................222 

University of Rhode Island Change Assessment Scale (URICA) ...............................................................226 

What I Want From Treatment .........................................................................................................................230 

Appendix C—Ordering Information for Assessment Instruments. .............................................................235 

Other Resources ................................................................................................................................................ 237 

Appendix D—Resource Panel .............................................................................................................................239 

Appendix E—Field Reviewers ............................................................................................................................241

Figures
1-1 Examples of Natural Changes ........................................................................................................................16 

1-2 Five Stages of Change ...................................................................................................................................... 17 

2-1 Specific FRAMES Components of 32 Evaluated Brief Trials ......................................................................24 

2-2 Appropriate Motivational Strategies for Each Stage of Change ................................................................31 

2-3 Ten Effective Catalysts for Change ................................................................................................................33 

2-4 Catalysts and the Stages of Change ...............................................................................................................34 

3-1 Stage-Specific Motivational Conflicts ............................................................................................................40 

3-2 Four Types of Client Resistance .....................................................................................................................47 

3-3 How To Ask Open-Ended Questions ............................................................................................................51 

3-4 How To Recognize Self-Motivational Statements .......................................................................................53 

3-5 Sample Questions To Evoke Self-Motivational Statements ........................................................................54 

4-1 Where Does Your Drinking Fit In?: Health Risks ........................................................................................69 

4-2 Where Does Your Drinking Fit In?: AUDIT Score .......................................................................................70 

5-1 Tips for Moving Clients Through Contemplation to Preparation.............................................................84 

5-2 Recapitulation ................................................................................................................................................... 91 

5-3 Key Questions ................................................................................................................................................... 92 

5-4 When Goals Collide .........................................................................................................................................9 3 

6-1 Change Plan Worksheet ................................................................................................................................ 100 

7-1 Options for Responding to a Missed Appointment ...................................................................................117 

7-2 Coping Strategies ............................................................................................................................................ 120 

7-3 Case Study 1: Client With Drug-Using Social Support .............................................................................122 

7-4 Case Study 2: Client Lacking Social Support ..............................................................................................123 

7-5 Case Study 3: Payday as a Trigger ...............................................................................................................124 

7-6 Using Cultural Values as Motivators ........................................................................................................... 128 

7-7 Therapeutic Workplaces for Individuals With Substance Abuse Disorders.......................................... 130 

8-1 20-Item Alcohol Abstinence Self-Efficacy Scale ......................................................................................... 138 

8-2 Readiness Ruler .............................................................................................................................................. 139 

8-3 Deciding To Change ....................................................................................................................................... 142 

V�
What Is a TIP?

T reatment Improvement Protocols (TIPs) to facilities and individuals across the country.
are developed by the Substance Abuse Published TIPs can be accessed via the Internet
and Mental Health Services at http://store.samhsa.gov.
Administration (SAMHSA) within the U.S. Although each consensus-based TIP strives
Department of Health and Human Services to include an evidence base for the practices it
(HHS). Each TIP involves the development of recommends, SAMHSA recognizes that
topic-specific best-practice guidelines for the behavioral health is continually evolving, and
prevention and treatment of substance use and research frequently lags behind the innovations
mental disorders. TIPs draw on the experience pioneered in the field. A major goal of each TIP
and knowledge of clinical, research, and is to convey "front-line" information quickly but
administrative experts of various forms of responsibly. If research supports a particular
treatment and prevention. TIPs are distributed approach, citations are provided.

vii
Editorial Advisory Board

Karen Allen, Ph.D., R.N., C.A.R.N. Thomas W. Hester, M.D.
Professor and Chair Former State Director
Department of Nursing Substance Abuse Services
Andrews University Division of Mental Health, Mental
Berrien Springs, Michigan Retardation and Substance Abuse
Georgia Department of Human Resources
Richard L. Brown, M.D., M.P.H.
Atlanta, Georgia
Associate Professor
Department of Family Medicine James G. (Gil) Hill, Ph.D.
University of Wisconsin School of Medicine Director
Madison, Wisconsin Office of Substance Abuse
American Psychological Association
Dorynne Czechowicz, M.D.
Washington, D.C.
Associate Director
Medical/Professional Affairs Douglas B. Kamerow, M.D., M.P.H.
Treatment Research Branch Director
Division of Clinical and Services Research Office of the Forum for Quality and
National Institute on Drug Abuse Effectiveness in Health Care
Rockville, Maryland Agency for Health Care Policy and Research
Rockville, Maryland
Linda S. Foley, M.A.
Former Director Stephen W. Long
Project for Addiction Counselor Training Director
National Association of State Alcohol and Office of Policy Analysis
Drug Abuse Directors
National Institute on Alcohol Abuse and
Washington, D.C.
Alcoholism

Rockville, Maryland

Wayde A. Glover, M.I.S., N.C.A.C. II
Director Richard A. Rawson, Ph.D.
Commonwealth Addictions Consultants and Executive Director
Trainers

Matrix Center and Matrix Institute on
Richmond, Virginia

Addiction
Deputy Director, UCLA Addiction Medicine
Pedro J. Greer, M.D.
Services
Assistant Dean for Homeless Education
Los Angeles, California
University of Miami School of Medicine
Miami, Florida
Ellen A. Renz, Ph.D.
Sidney H. Schnoll, M.D., Ph.D.
Former Vice President of Clinical Systems
Chairman
MEDCO Behavioral Care Corporation
Division of Substance Abuse Medicine
Kamuela, Hawaii
Medical College of Virginia
Richard K. Ries, M.D. Richmond, Virginia
Director and Associate Professor
Outpatient Mental Health Services and Dual
Disorder Programs

Harborview Medical Center

Seattle, Washington
Consensus Panel

Chair Maxine L. Stitzer, Ph.D.
Professor of Psychiatry and Behavioral
William R. Miller, Ph.D.
Biology
Regents Professor of Psychology and
Johns Hopkins University School of
Psychiatry
Medicine
Director of Research
Baltimore, Maryland
Center on Alcoholism, Substance Abuse, and
Addictions

Allen Zweben, D.S.W.
Department of Psychology
Director and Associate Professor of Social
University of New Mexico

Work
Albuquerque, New Mexico

Center for Addiction and Behavioral Health
Research
Workgroup Leaders
University of Wisconsin at Milwaukee
Milwaukee, Wisconsin
Edward Bernstein, M.D., F.A.C.E.P.
Associate Professor and Academic Affairs Panelists
Vice Chairman

Boston University School of Medicine
Ray Daw
Boston, Massachusetts

Executive Director
Northwest New Mexico Fighting Back, Inc.
Suzanne M. Colby, Ph.D.
Gallup, New Mexico
Assistant Professor of Psychiatry and
Human Behavior Jeffrey M. Georgi, M.Div., C.S.A.C., C.G.P.
Center for Alcohol and Addiction Studies Program Coordinator
Brown University Duke Alcoholism & Addictions Program
Providence, Rhode Island Clinical Associate
Department of Psychiatry and Behavioral
Carlo C. DiClemente, Ph.D.
Science

Department of Psychology
Duke University Medical Center

University of Maryland, Baltimore County
Durham, North Carolina

Baltimore, Maryland
Cheryl Grills, Ph.D.
Robert J. Meyers, M.A.
Department of Psychology
Center on Alcoholism, Substance Abuse, and
Loyola Marymount University
Addictions

Los Angeles, California
University of New Mexico

Albuquerque, New Mexico