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Enhancing Motivation for Change in Substance Use Disorder Treatment: Updated 2019 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2019. (Treatment Improvement Protocol (TIP) Series, No. 35.)

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Enhancing Motivation for Change in Substance Use Disorder Treatment: Updated 2019 [Internet].

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Chapter 5—From Contemplation to Preparation: Increasing Commitment

“The reasons for change need to be important and substantive enough to move the individual into deciding to make the effort to change. The task for individuals in Contemplation is to resolve their decisional balance consideration in favor of change. The decision to change marks the transition out of the Contemplation stage and into Preparation.”

DiClemente, 2018, p. 29

KEY MESSAGES

Clients in Contemplation begin to recognize concerns about substance use but are ambivalent about change.

You can use motivational counseling strategies to help clients resolve ambivalence about change.

When using a decisional balance (DB) strategy, you briefy refect clients' reasons for continuing substance use (i.e., sustain talk) but emphasize clients' reasons for change (i.e., change talk).

Motivational counseling strategies to enhance commitment to change move clients closer to the Preparation stage and taking steps to change.

Chapter 5 describes strategies to increase clients' commitment to change by normalizing and resolving ambivalence about change and enhancing clients' decision-making capabilities. Central to most strategies is the process of evoking and exploring reasons to change through asking open question and reflective listening. The chapter begins with a discussion of ambivalence, extrinsic (external) and intrinsic (internal) motivation, and ways to help clients connect with internal motivators to enhance decision making and their commitment to change. It then focuses on DB strategies—ways to explore the costs and benefits of change and clients' values about changing substance use behaviors. Chapter 5 also addresses the importance of self-efficacy in clients' decisions to change and provides strategies for enhancing commitment to change once clients decide to change. Exhibit 5.1 presents counseling strategies for Contemplation.

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EXHIBIT 5.1. Counseling Strategies for Contemplation.

Normalize and Resolve Ambivalence

You must be prepared to address ambivalence to help clients move through the Stages of Change (SOC) process. Ambivalence is a normal part of any change process. Ambivalence is uncomfortable because it involves conflicting motivations about change (Miller & Rollnick, 2013). For example, a client may enjoy drinking because it relaxes him or her but may feel guilty about losing a job because of drinking and putting his or her family in financial risk. Clients often have conflicting feelings and motivations (Miller & Rollnick, 2013). During Contemplation, ambivalence is strong. As you help clients move toward Preparation and Action, ambivalence lessens. Miller and Rollnick (2013) use the metaphor of a hill of ambivalence wherein clients move up the hill during Precontemplation/Contemplation and then journey down the hill through the resolution of ambivalence, which moves them into Preparation and Action (Exhibit 5.2). Chapter 2 provides a thorough description of DARN CAT (Desire, Ability, Reasons, Need, Commitment Activation, Taking steps) change talk.

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EXHIBIT 5.2. The Motivational Interviewing (MI) Hill of Ambivalence.

The two key motivational strategies you can use to resolve ambivalence in Contemplation are:

1.

Normalizing ambivalence. As they move closer to a decision to change, clients often feel increasing conflict and doubt about whether they can or want to change. Reassure clients that conflicting feelings, uncertainties, and reservations are common. Normalize ambivalence by explaining that many clients experience similar strong ambivalence at this stage, even when they believe they have resolved their mixed feelings and are nearing a decision. Clients need to understand that many people go back and forth between wanting to maintain the status quo and wanting to change and yet have been able to stay on track by continuing to explore and discuss their ambivalence.

2.

Evoking DARN change talk. DARN refers to clients' desire, ability, reasons, and need to change. During Contemplation, help clients move up the hill of ambivalence and guide them toward Preparation by evoking and reflecting DARN change talk. Use open questions: “How would you like things to change so you don't feel scared when you can't remember what happened after drinking the night before?” Exhibit 3.8 in Chapter 3 offers more examples of open questions that evoke DARN change talk. Use reflective listening responses to highlight the change talk. Remember that the goal is to guide clients to make the arguments for change (Miller & Rollnick, 2013). The key is to avoid jumping too quickly into evoking CAT (i.e., commitment, activation, and taking steps) change talk, solving problems in response to ambivalence, or making a plan of action. The client has to climb up the hill of ambivalence before easing down the other side.

Shift the Focus From Extrinsic to Intrinsic Motivation

To help clients prepare for change, explore the range of both extrinsic and intrinsic motivators that have brought them to this point. Many clients move through the Contemplation stage acknowledging only the extrinsic motivators that push them to change and that brought them to treatment. External motivators may pressure clients into treatment, including a spouse, employer, healthcare provider, family member, friend, or the child welfare or criminal justice system. Extrinsic motivators can help bring clients into and stay in treatment, but intrinsic motivators are important for significant, long-lasting change (Flannery, 2017; Kwasnicka, Dombrowski, White, & Sniehotta, 2016; Mahmoodabad, Tonekaboni, Farmanbar, Fallahzadeh, & Kamalikhah, 2017).

You can help clients develop intrinsic motivation by assisting them in recognizing the discrepancies between “where they are” and “where they want to be”:

Invite clients to explore their life goals and values, which can strengthen internal motivation. In searching for answers, clients often reevaluate past mistakes and activities that were self-destructive or harmful to others.

Encourage this exploration through asking open questions about client goals: “Where would you like to be in 5 years?” and “How does your substance use fit or not fit with your goals?”

Highlight clients' recognition of discrepancies between the current situation and their hopes for the future through reflective listening. Awareness of discrepancy often evokes desire change talk, an essential source of intrinsic motivation.

Sometimes, intrinsic motivation emerges from role conflicts and family or community expectations. For example, a single mother who lost her job because of substance use may have a strong motivation to get and keep another job to provide for her children. For other clients, substance misuse has cut their cultural or community ties. For example, they stop going to church or neglect culturally affirmed roles, such as helping others or serving as role models for young people. A desire to reconnect with cultural traditions as a source of identity and strength can be a powerful motivator for some clients, as can the desire to regain others' respect. Positive change also leads to improved self-image and self-esteem.

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EXPERT COMMENT: LINKING FAMILY, COMMUNITY, AND CULTURAL VALUES TO A DESIRE FOR CHANGE.

Helping clients shift from extrinsic to intrinsic motivation helps them move from contemplating change to deciding to act. Start with clients' current situations, and find a natural link between existing external motivators and intrinsic ones that they may not be aware of or find easy to describe. Through compassionate and respectful exploration, you may discover untapped intrinsic motivation.

Along with MI techniques presented in Chapter 3, use these strategies to identify and strengthen intrinsic motivation:

Show genuine curiosity about clients. Show interest in their lives at the first meeting and over time. Because clients' desire to change is rarely limited to substance use, they may find it easier to talk about changing other behaviors. Most clients have concerns about several areas of their lives and wish to reconnect with their community, improve their finances, find work, or fall in love. Many are highly functional and productive in some aspects of their lives and take great pride in special skills, knowledge, or other abilities they do not want to lose.

Do not wait for clients to talk spontaneously about their substance use. Show interest, and ask how their substance use affects these aspects of their lives. Even with clients who do not acknowledge any problems, question them about their lives to show concern and strengthen the counseling alliance.

Reframe clients' negative statements about external pressure to get treatment. For example, help clients reframe anger expressed toward their spouse who has pressured them to enter treatment as seeing their spouse as caring and invested in the marriage.

Identify and strengthen intrinsic motivation of clients who have been mandated to treatment. Emphasize personal choice and responsibility with these clients. Help clients understand that they can freely choose to change because doing so makes good sense and is desirable, not because negative consequences will happen if they choose not to change.

Summarize Client Concerns

As you evoke DARN change talk and explore intrinsic and extrinsic motivations, you gather important information for helping the client resolve ambivalence about change. You have a working knowledge, and perhaps even a written list, of issues and areas about which the client has conflicting feelings and which are important intrinsic motivators for changing substance use behaviors. A first step in helping the client to weigh the pros and cons of change is to organize the list of concerns and present them to the client in a careful summary that expresses empathy, develops discrepancy, and shifts the balance toward change. Because you should reach agreement on these issues, the summary should end by asking whether the client agrees that these are his or her concerns about the substance use. You might ask, “Is this accurate?” or “Did I leave anything out?”

Help Tip the Decisional Balance Toward Change

For any decision, most people naturally weigh costs and benefits of the potential action. In behavioral change, these considerations are called “decisional balancing.” This is a process of appraising or evaluating the “good” aspects of substance use—the reasons not to change (expressed through sustain talk)—and the “less-good” aspects—the reasons to change (expressed through change talk). DB originated with Janis and Mann (1977) as a motivational counseling strategy. It is used widely in substance use disorder (SUD) treatment to explore benefits and costs of continued substance use and of changing substance use behaviors. Research on DB in SUD treatment has shown that DB is associated with increased motivation to change in diverse client populations and favorable client outcomes (Elliot & Carey, 2013; Foster & Neighbors, 2013; Hennessy, Tanner-Smith, & Steinka-Fry, 2015).

Motivation to reduce or stop substance use increases when the costs of use outweigh the benefits and when the pros of changing substance use outweigh the cons (Connors, DiClemente, Velasquez, & Donovan, 2013). Your task is to help clients recognize and weigh negative aspects of substance use to tip the scale in favor of change.

Assess Where the Client Is on the Decisional Scale

Start by getting a sense of where the client is with regard to the decision-making process. The Alcohol Decisional Balance Scale and the Drug Use Decisional Balance Scale in Appendix B are validated instruments that ask clients to rate, on a scale of 1 to 5, the importance of statements like “Having to lie to others about my drinking bothers me” in making a decision about changing substance use behaviors (Prochaska et al., 1994). The scores give you and the client a sense of where the client is with regard to reporting more pros versus more cons for continued substance use. You can also explore specific items on the measure on which the client scores high (e.g., “Some people close to me are disappointed in me because of my drug use”) as a way to build discrepancy between the client's values and substance use, thus evoking change talk.

Explore the Pros and Cons of Substance Use and Behavior Change

Weighing benefits and costs of substance use and change is at the heart of DB work. To accomplish this, invite the client to write out a list of positives and negatives of substance use and changing substance use behaviors. This can be a homework assignment that is discussed at the next session, or the list can be generated during a session. Putting the items on paper makes it seem more “real” to the client and can help structure the conversation. You can generate a list of the pros and cons of substance use and a list of pros and cons of changing substance use behaviors separately or use a grid like the one in Exhibit 5.3.

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EXHIBIT 5.3. Decisional Balance Sheet for Substance Use.

Presenting to clients a long list of reasons to change and a short list of reasons not to change may finally upset the balance and tip the scale toward change. However, the opposite (i.e., a long list of reasons not to change and a short life of reason to change) can show how much work remains and can be used to prevent premature decision making.

Recognize that many clients find that one or two reasons to change counterbalance the weight of many reasons not to change and vice versa. Therefore, it is not just the number of reasons to change or not change but the strength of each reason that matters. Explore the relative strength of each motivational factor, and highlight the weight clients place on each change factor. Reasons for and against continuing substance use, or for and against aspects of change, are highly individual. Factors that shift the balance toward positive change for one person may barely matter to another. Also, the value or weight given to a particular item in this inventory of pros and cons is likely to change over time.

Whether or not you use a written worksheet, always listen carefully when clients express ambivalence. Both sides of ambivalence, expressed through sustain talk and change talk, are present in clients at the same time (Miller & Rollnick, 2013). You may hear both in a single client statement—for example, “I get so energized when I snort cocaine, but it's so expensive. I'm not sure how I'll pay the bills this month.” Although discussing with clients what they like about drinking or using drugs may establish rapport, increasing expressions of sustain talk is associated with negative client outcomes (Foster, Neighbors, & Pai, 2015; Houck & Moyers, 2015; Lindqvist, Forsberg, Enebrink, Andersson, & Rosendahl, 2017; Magill et al., 2014).

In DB, explore both sides of ambivalence, but avoid reinforcing sustain talk, which can be counterproductive (Krigel et al., 2017; Lindqvist et al., 2017; Miller & Rose, 2013). Once a client decides to change a substance use behavior, a DB exercise on the pros and cons of change may increase commitment to change (Miller & Rose, 2013). Carefully consider your own intention and the client's stage in the SOC before using a structured DB that explores both sides of client ambivalence equally.

Exhibit 5.4 describes other issues that may arise as clients explore pros and cons of change.

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EXHIBIT 5.4. Other Issues in Decisional Balance.

Reexplore Values in Relation to Change

Use DB exercises as opportunities to help clients explore and articulate their values and to connect these values with positive change. Clients' values influence their reasons for and against change. For example, an adolescent involved in drug dealing with a neighborhood gang may say that leaving the gang is not possible because of his loyalty to the other members. Loyalty and belonging are important values to him. Relate them to other groups that inspire similar allegiance, such as a sports team or scouting—organizations that create a sense of belonging and reflect his core values. A young woman with a family history of hard work and academic achievement may wish to return to those values by finishing high school and becoming financially independent.

Hearing themselves articulate their core values helps clients increase their commitment to positive change. If they can frame the process of change within the larger context of values shared with their family, community, and culture, they may find it easier to contemplate change.

Emphasize Personal Choice and Responsibility

In a motivational approach to counseling, you don't “give” a client a choice. The choice is not yours to give; rather, it is the client's to make. Your task is to help the client make choices that are in his or her best interest and that align with his or her values and goals. Consistently emphasize the client's responsibility and freedom of choice. The client should be used to hearing you make statements such as:

“It's up to you to decide 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.”

Explore the Client's Understanding of Change and Expectations of Treatment

In working toward a decision, understand what change means to clients and what their expectations of treatment are. Some clients believe that quitting or cutting down means changing their entire life—moving from their neighborhood or cutting ties with all their friends, even their family. Some believe they have to change everything overnight. This can be overwhelming. Tell clients who have never been in treatment before about the level of motivation and openness required to get the most from their treatment experience (Raylu & Kaur, 2012).

In exploring these meanings and expectations with the client, you will get a sense of which actions the client might consider and which he or she will not. For example, a client might state that she could never move from her neighborhood, a well-known drug market, because her family is there. Another says he will not consider anything but cutting down on his drinking. A third client may just as strongly state that total abstinence and a stay in a therapeutic community are the only options, as all others have failed.

By exploring treatment expectations with clients, you introduce information about the benefits of treatment and can begin a discussion about available options. When clients' expectations about treatment match what actually happens and they have positive expectations about treatment, they have better outcomes (Kuusisto, Knuuttila, & Saarnio, 2011). It is never too soon to elicit clients' expectations about treatment through reflective listening. Show that you understand their concerns, and provide accurate information about your treatment program and the benefits of treatment using motivational strategies like Elicit-Provide-Elicit (described in hapter 3).

Reintroduce Feedback

Use personalized feedback after assessments to motivate clients. Continue to use assessment results to influence clients' decisional considerations. Objective medical, social, and neuropsychological feedback prompts many clients to contemplate change. Reviewing assessment information can refocus clients on the need for change. Reintroducing objective assessment data reminds clients of earlier insights into the need for change.

For example, a client may be intrinsically motivated to stop alcohol misuse because of health concerns yet feel overwhelmed by fear that quitting is impossible. Reintroducing feedback from the medical assessment about the risk of serious liver damage or a family history of heart disease could add significant additional weight to the DB and tip the balance in the direction of change.

Explore Self-Efficacy

By listening for self-efficacy statements from clients, you can discover what they feel they can and cannot do. Self-efficacy is a critical determinant of behavior change—it is the belief that they can act in a certain way or perform a particular task. Even clients who admit to having a serious problem are not likely to move toward positive change unless they have some hope of success. Self-efficacy can be thought of as hope or optimism, but clients do not have to have an overall optimistic view to believe a certain behavior can be changed.

Statements about self-efficacy could include the following:

“I can't do that.”

“That is beyond my powers.”

“That would be easy.”

“I think I can manage that.”

Self-efficacy is not a global measure, like self-esteem. Rather, it is behavior specific. Underlying any discussion of self-efficacy is the question “Efficacy to perform what specific behavior?” There are five categories of self-efficacy related to SUDs (DiClemente, Carbonari, Montgomery, & Hughes, 1994: Glozah, Adu, & Komesuor, 2015):

Coping self-efficacy is dealing successfully with situations that tempt one to use substances, such as by being assertive with friends or talking with someone when upset rather than using the substance.

Treatment behavior self-efficacy involves the client's ability to perform behaviors related to treatment, such as self-monitoring or stimulus control.

Recovery self-efficacy is the ability to recover from a recurrence of the addictive behavior.

Control self-efficacy is confidence in one's ability to control behavior in risky situations.

Abstinence self-efficacy is confidence in one's ability to abstain despite cues or triggers to use.

Explore clients' sense of self-efficacy as they move toward Preparation. This may help you determine more specifically whether self-efficacy is a potential support or obstacle to change. Remember, you can enhance client self-efficacy by using the Confidence Ruler (see Exhibit 3.10) and eliciting confidence talk (see the section “Evoking hope and confidence to support self-efficacy” in Chapter 3).

Summarize Change Talk

As the client transitions from Contemplation to Preparation, you will notice that the client has moved to the top of the MI Hill of Ambivalence (see Exhibit 5.2 above) and is expressing less sustain talk and more change talk. This is a good time to offer a recapitulation summary, as described in Exhibit 5.5.

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EXHIBIT 5.5. Recapitulation Summary.

Enhance Commitment to Change

You should still reinforce the client's commitment to change even after the client has decided to change and has begun to set goals. You should expect client indecision at any point in the change process. Additional strategies that enhance commitment at this point include asking key questions, taking small steps, going public, and envisioning.

Asking key questions

After the summary, ask a key question—for example, “What do you think you will do now?” (see the section “Asking key questions” in Chapter 3)—to help the client move over the top of the MI Hill of Ambivalence toward Preparation. Key questions will elicit CAT change talk. One of the main signs that the client is intending and committed to taking steps is an increase in CAT change talk (Miller & Rollnick, 2013). The client is making statements of commitment (e.g., “I will call the treatment facility to set up an intake”), activation (e.g., “I am willing to stop smoking marijuana for a month), and taking steps (e.g., “I looked up the schedule for Narcotics Anonymous meetings on its website”) (Miller & Rollnick, 2013). Reinforce CAT change talk through reflective listening and summarizing.

Taking small steps

You have asked the client key questions such as “What's next?” and have presented options to emphasize the client's choice to change and to select areas of focus. Remind the client that he or she has choices and can control the change process to reinforce commitment. Reassure the client who is overwhelmed by thinking of change that he or she can set the pace and begin with small steps. Some clients respond well to stories of others who made large, seemingly impossible life changes one step at a time. Don't underestimate the value of such stories and models in enhancing motivation.

Going public

Sharing a commitment to change with at least one other person besides the counselor can keep clients accountable. Telling a significant other about one's desire to change usually enhances commitment to change. “Going public” can be a critical step for a client who may not have been ready to tell others until this point. Alcoholics Anonymous (AA) has applied the clinical wisdom of public commitment to change through use of the “white chip.” An attendee at an AA meeting who has an intention to quit drinking can pick up a white chip. The white chip is also called a Beginner's Chip or Surrender Chip and is a public acknowledgment of the person's intention to start recovery.

Envisioning

Helping clients visualize their life after change can be a powerful motivator and an effective means of strengthening their commitment. In addition, stories about how others have successfully achieved their goals can be excellent motivators. An exercise for envisioning change is to ask clients to picture themselves after a year has passed, during which time they have made the changes they desire in the areas of their lives most hurt by their substance use. Some clients may find it valuable to write a letter to themselves that is dated in the future and describes what life will be like at that point. The letter can have the tone of a vacation postcard (“Wishing you were here!”). Others will be more comfortable describing these scenes to you. Chapter 3 provides more information MI strategies to strengthen commitment.

Conclusion

To help clients move from Contemplation to Preparation, explore and resolve ambivalence about change. Help clients climb the MI Hill of Ambivalence and journey down the other side toward commitment and change. DB exercises can help clients explore ambivalence, clarify reasons to change, and identify barriers to change (e.g., reasons to continue substance use). When tipping the balance in favor of change, emphasize reflections of change talk, minimize the focus on sustain talk, and use motivational strategies to enhance commitment and facilitate clients' movement into Preparation.

Copyright Notice

This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.

Bookshelf ID: NBK571064

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