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Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35.)
Enhancing Motivation for Change in Substance Abuse Treatment.
Show detailsContemplation is often a very paradoxical stage of change...[and] ambivalence can make contemplation a chronic [and extremely frustrating] condition... Clearly, interest [in change] is not commitment... Ambivalence is the archenemy of commitment and a prime reason for chronic contemplation. Helping the client to work through the ambivalence, to anticipate the barriers, to decrease the desirability of the problem behavior, and to gain some increased sense of self-efficacy to cope with this specific problem are all stage-appropriate strategies. DiClemente, 1991
This chapter describes strategies to increase clients' commitment to change by enhancing their decisionmaking capabilities. Central to most of the strategies is the process of eliciting and exploring through open-ended questioning and reflective listening skills, as described in earlier chapters. The chapter begins with a discussion of extrinsic (external) and intrinsic (internal) motivation, describing ways to help clients connect with internal motivators to enhance decisionmaking and thereby commitment. The second section focuses on decisional balancing strategies--effective ways to explore the benefits and costs of change and clients' values about changes they might make. The third section highlights the importance of personal choice and responsibility as clients get closer to making a decision to change.
Exploring and setting goals can also be effective in strengthening commitment, primarily because the process of envisioning what one's life would be like after change has been accomplished may strongly tip the decisional balance toward positive change. Finally, the important role of self-efficacy in client goal-setting is reemphasized. Although these strategies are introduced here in linear fashion, with each process of exploration unfolding from the last, in discussions with clients these processes can occur simultaneously or in a different order from that used here. For example, clients may begin to set goals or formulate a specific change plan (see Chapter 6) while continuing to explore their ambivalence (see Figure 5-1).
Changing Extrinsic to Intrinsic Motivation
To help your clients prepare for change, seek to understand 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. As discussed in Chapter 4, many different external motivators may cajole or coerce clients into treatment, including a spouse, an employer, a physician, or family and criminal courts. Although extrinsic motivators can be useful in bringing a client into treatment and increasing retention, self- or intrinsic motivation is important for substantive and abiding change.
Intrinsic motivation often begins at the point when clients recognize the discrepancies between "where they are" and "where they want to be." An intensive exploration of life goals and deep-seated values can be a way to strengthen internal motivation. Some clients, as they mature, cast off the rebelliousness or apparent nonchalance of adolescence to explore more existential concerns such as, Where am I going? and Who am I? In searching for answers, clients often reevaluate past mistakes and activities that were self-destructive or harmful to others. You can encourage this soul-searching through reflective listening. Then, through motivational strategies, you can promote the client's recognition of discrepancies between the current situation and hopes for the future. As described in earlier chapters, this awareness of disparities often creates a strong desire to improve. This is an essential source of self-motivation for positive change.
Sometimes intrinsic motivation emerges from role conflicts and family or community expectations. For example, a mother who has lost custody of children because of substance use may have a strong motivation to fulfill her role as a good mother. Other clients' chronic substance use severs cultural or community ties; they stop going to church or neglect culturally affirmed roles such as helping others or serving as role models for young people. A yearning 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.
Helping clients change extrinsic to intrinsic motivation is an important part of helping them move from contemplating change to deciding to act. 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.
In addition to standard practices for motivational interviewing, several other strategies are useful for identifying and strengthening intrinsic motivation. First, show curiosity about your clients. Show interest and maintain this attention 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 functional areas of their lives and wish they could reconnect with the 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 competencies they do not want to jeopardize. Do not wait for clients to talk spontaneously about their troubles or capabilities. Show interest and ask about 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 thus strengthen the therapeutic alliance.
Another useful strategy is to reframe clients' negative statements about perceived coercion by re-expressing their resentment with a positive connotation. A classic example is to reinterpret a client's hostility toward a threatening wife as a manifestation of his continued caring and investment in the marriage, which is pushing him to resolve and change the problem behavior and save the relationship.
Clients who were openly coerced into entering treatment pose a special challenge. With these clients, identify and strengthen intrinsic motivation so that change can come from within, rather than from external threats. Not only can external threats provoke resistance, but any achieved change may collapse if the threatened contingencies do not happen--if, for example, the threat of divorce or separation is not carried out by the wife when her husband's drinking resumes, or a parole officer does not revoke a client's freedom when the released offender fails to continue treatment. These clients must choose positive change of their own free will because change makes good sense and is desired, not because a punishment might be exacted if a violation is detected.
Linking Family, Community, and Cultural Values to a Desire for Change
Working with a group of Hispanic men in the Southwest who were mandated into treatment as a condition of parole and had spent most of their lives in prisons, we found that as these men aged, they seemed to tire of criminal life. In counseling, some expressed concerns about losing touch with their families and culture, and many articulated a desire to serve as male role models for their sons and nephews. They all wanted to restore their own sense of pride and self-worth in the small community where many of their families had lived for generations. Newly trained in motivational interviewing, we recognized a large, untapped reservoir of self-motivation in a population that we had long before concluded did not want help. We had to change our previous conceptions of this population as not wanting treatment to seeing these men as requesting help and support to maintain themselves outside of the prison system and in the community.
Tipping the Decisional Balance
In moving toward any decision, most people weigh the costs and benefits of the action being contemplated. In behavioral 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. Research on self-change has shown that many people who have successfully modified addictive behaviors view this appraisal process as important to the resolution of their substance use problems (Sobell et al., 1996b).
At some point in the decisionmaking process, the decisional balance is redistributed, and a decision is made. The objective in moving a client toward positive change, of course, is to help that person recognize and weigh negative aspects of substance use so that the scale tips toward beneficial behavior. In examining ways in which people make major life changes, Baumeister described the inner process that seems to occur when the decisional balance is weighted toward change as a "crystallization of discontent" (Baumeister, 1994). He notes that it involves a conscious linking, perhaps for the first time, of perceptions regarding costs, problems, and other undesirable features of a situation. This conscious linking of negative aspects changes the person's perception of a situation "so that a broad pattern of dissatisfaction and shortcoming is discerned." See Chapter 8 for tools to use in decisional balancing exercises.
How do you shift the balance to the side of positive change and away from the status quo or negative change? Sobell and colleagues identified four overall objectives in using exercises to shift decisional balance with clients (Sobell et al., 1996b). The intent of such exercises, which weigh substance use and change separately, is to
- Accentuate or in a subtle manner make salient from the client's perspective the costs of the client's substance use.
- Lessen, when possible, the perceived rewards of substance use.
- Make the benefits of change apparent.
- Identify and attenuate, if possible, potential obstacles to change.
Summarize Concerns
If you have successfully elicited a client's concerns while providing personalized feedback after an assessment (see Chapter 4) or while exploring intrinsic and extrinsic motivations, you have gathered important information for influencing your client's decisional balance. You have a working knowledge, and perhaps even a written list, of issues and areas about which the client has negative feelings and which are important intrinsic motivators. 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. Some programs use a worksheet for listing pros and cons preprinted on two-copy carbonless paper so that clients can take one copy home and leave the other with the clinician for later use or revision during future sessions. A written list helps some clients quantify the factors going into the decision. Seeing a long list of reasons to change and a short list of reasons not to may finally upset the balance. On the other hand, a long list of reasons not to change and a short list of reasons to change can indicate how much work still must be done and can avert premature decisionmaking. Quantity is not the only determinant. Many clients find that one or two reasons not to change counterbalance the weight of a dozen reasons to change, creating powerful ambivalence. Knowledge about the true strength of each opposing force is important. Remember, too, that the reasons for and against continuing substance use--or the positive and negative aspects of change--are highly individual and emotional rather than rational. Factors that shift the balance toward positive change for one person may scarcely matter to another. Moreover, 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 and highlight their reasons for opposing change or thinking change is impossible. Encouraging clients to openly clarify and state their attraction to substances can be fruitful because they seldom have a chance in treatment programs to examine what they like or enjoy about substance use. In addition, asking clients to express what they like about substance use (e.g., that it is enjoyable, sociable, exciting) establishes rapport and reassures the client of your nonjudgmental perspective. Starting with positive aspects of substance use also seems to lead clients spontaneously to discussing what is less good about substance use (Saunders et al., 1991).
Information about why substance use is attractive is helpful for judging the client's degree of commitment and sense of self-efficacy. For example, some clients may enjoy little about substance use, and their ambivalence stems from a strong belief that they cannot change. Work with such a client will proceed along different lines than with a client who describes substance use in highly attractive terms and sees little reason to change.
Another reason some clients cling to excessive substance use is pharmacological dependence. Some substances, including high levels of alcohol and barbiturates, have rebound effects of withdrawal that can be not only unpleasant but also dangerous. Tolerance--needing more of the substance to achieve the same effect--also explains why some users of sleeping pills or tranquilizers, for example, increase doses beyond the prescribed level. Habits developed in relation to drug taking or drinking are another powerful source of attachment to a substance and are difficult to break. The feeling of a glass in the hand when socializing at a party comes to be associated with relaxation and conviviality. Smokers may not know what to do with their hands or want some object in their mouths when they are trying to quit cigarette smoking.
Although your client's initial reasons for wanting to change may be few, each reason is important and should be explored and supported. Because support for change is often linked to a client's intrinsic motivators, reviewing these may elicit more items for the positive side of the balance sheet. As noted earlier, concerns about identity, roles, self-esteem and self-image, and returning to traditional cultural or family values may be linked to specific reasons for change.
Doing a decisional balance exercise with clients has yet another constructive function. Clients are forced to take both sides of the argument about change and articulate the competing sides of their ambivalence. This can be a complex process, however, requiring persistence and reanalysis of each factor several times as clients vacillate between determination and ambivalence.
Normalize Ambivalence
Clients engaged in decisional balance exercises often feel themselves moving closer to a decision--closer to changing long-standing behaviors 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 your client that conflicting feelings, uncertainties, and reservations are common. Essentially, you normalize your client's ambivalence by explaining that many former clients have experienced similar strong ambivalence at this stage, even when they believed they had resolved most of their mixed feelings and were nearing a decision. Clients need your reassurance that many other people who have reached this point and seemed suddenly to lose their nerve have been able to recover their direction by continuing the work of exploration and discussion.
Reintroduce Feedback
As discussed in Chapter 4, personalized feedback following assessment can be very helpful in motivating clients. You can continue to use assessment results to influence clients' decisional considerations. 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. It has been noted that clients may become uneasy when the clinician seems more invested in their changing than they are (DiClemente and Scott, 1997). By reintroducing objective assessment data, you remind clients of their earlier insights about the need for change.
For example, a client may be intrinsically motivated to stop excessive drinking because of health concerns, yet overwhelmed by fear that quitting will prove 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 decisional balance.
Examine the Client's Understanding Of Change and Expectations of Treatment
In working toward a decision, it is important to 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 severing ties with all their friends, even their family. Some believe they have to change everything overnight--an overwhelming prospect. Based on friends' experiences with treatment, some may think treatment involves stays of several weeks in an inpatient program or even longer sojourns in a residential treatment facility or that the leader of a therapy group will use confrontational methods in an attempt to "break them down," as in boot camp. Other clients have been in numerous treatment programs and have made many unsuccessful attempts to change. To these clients, the very idea of treatment--of making another attempt to change--connotes failure.
In exploring these meanings and expectations with the client, you will sense what actions might be negotiable and what are 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 moderation of his drinking. A third client may just as strongly state that total abstinence and a stay in a therapeutic community are the only options possible because all others have failed.
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 (Brown and Miller, 1993). Thus, it is never too soon to elicit clients' expectations and begin to educate them about treatment.
Re-explore Values in Relation To Change
Decisional balance exercises offer another opportunity to help clients explore and articulate their values and to make a connection between these values and positive change. Your clients' values will be reflected both in their reasons to change and in the reasons given not to. For example, an adolescent involved in drug dealing with a gang in his neighborhood may let you know that the option of leaving the gang is nonnegotiable because of his loyalty to the other members. Loyalty and belonging are important values to him, and you can relate them to other groups that can inspire similar allegiance such as a sports team or the military--organizations that create a sense of belonging and reflect his core values. A young woman who comes from a family with a 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 your 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.
Other Issues in the Decisional Balance
Loss and grief
Because giving up a way of life can be as intense as the loss of a close friend, many clients need time for grieving. They have to acknowledge and mourn this loss before they are ready to move on and build a strong attachment to sobriety. Pushing them too fast toward change can ultimately weaken their determination. Patience and empathy are reassuring at this time. You can help clients believe that their losses will be replaced by gains.
Reservations or resistance
As discussed earlier, serious reservations about change, often called resistance (but more commonly misidentified as denial), can be a signal in motivational interviewing that you and your client have different perspectives. As clients move into the preparation stage, they may become defensive if pushed to commit to change before they are ready or if their goals conflict with yours. They may express this resistance in behaviors rather than words. For example, some will miss appointments, sending a message that they need more time and want to slow the process. Continue to explore ambivalence with these clients and reassess where they are in the change process.
Premature decisionmaking
Decisional balance exercises also give you a sense of whether your clients are ready for change. If clients' articulation of pros and cons is unclear, they may express goals for change at this stage that are unrealistic or reflect a poor understanding of their abilities and resources. You may sense that clients are saying what they think you want to hear. In one way or another, clients who are not ready to make a decision to change will let you know. Allowing clients to set themselves up for failure could result in their abandoning the change process altogether or losing trust in your judgment and care. Delay the commitment process and return with them to the contemplation stage.
Keeping pace
Some clients enter treatment after they have stopped using substances on their own. Others stop substance use the day they call the clinic for the first appointment. They have already made a commitment to stop. If you try to elicit these clients' concerns or conduct decisional balance exercises, you might fail to provide the encouragement, incentives, and skills needed to help the action-oriented and action-ready individual make progress. Such clients can become impatient or frustrated at having to articulate pros and cons and or describe the concerns that led to their decision. Move with these clients immediately to create a change plan and enter the action stage but be alert for ambivalence that may remain or emerge.
Free choice
Many people begin using drugs or alcohol out of rebelliousness toward their family or society, usually in adolescence. Continued substance use may be their expression of continued freedom--freedom from the demands of others to act or live in a certain way. (Tobacco advertisers often tap into this dimension of smoking as an expression of autonomy and independence.) Thus, you may hear clients say that they cannot change because they do not want to lose their freedom. Because this belief is tied to some clients' early-forged identities, it may be a strong factor in their list of reasons not to change. However, as clients age they may be more willing to explore whether the freedom to rebel is actually freedom, or its opposite. If you are attuned to this issue, you can explain that adolescent rebellion may really reflect a limitation of choices--the person must do the opposite of what is expected. As clients age, they may be more open to making a choice that represents real freedom--the freedom not to rebel, but to do what they truly choose.
Emphasizing Personal Choice and Responsibility
In a motivational approach to counseling, it is not your task to give a client a choice--choice is not yours to give but the client's to make. You do not allow a client to choose because the choice already and always belongs with the client. The client chooses. Your 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."
Exploring and Setting Goals
Once the client has decided to make a positive change and the commitment is clear, goals should be set. Goal-setting is part of the exploring and envisioning activities characteristic of the early and middle preparation stage. Having summarized and reviewed the client's decisional considerations, you are now prepared to ask about ways in which your client might want to address some of the reasons to change listed on the positive side of the balance sheet (see Figures 5-2 and 5-3 ). Although goal-setting is an interactive process, it is the client's responsibility. The process of talking about and setting goals strengthens commitment to change.
Clients may set goals in multiple areas of their life, not just for changing substance use patterns. Those who set several goals may need help with prioritization. Their goals should be as realistic and specific as possible and should address the concerns they articulated earlier about their substance use. Regaining custody of children, reentering the workforce, becoming financially independent, leaving an abusive relationship, and returning to school are all goals that clients may work toward. The more hopeful clients feel about future success in life, the more likely they are to follow through with treatment goals. Initial goals should be short-term, measurable, and realistic so that clients can begin measuring success and feeling good about themselves as well as hopeful about the change.
If your client sets goals that seem unreachable to you, discuss your concerns. This is an important part of the interactive process of goal-setting. Witnessing how your clients set goals and the types of goals they specify provides you with useful information about their sense of self-efficacy, level of commitment, and readiness for change.
Your client might choose a course of action with which you do not agree or that is not in line with agency policy. A decision to reduce use, for example, may conflict with your strong belief in immediate abstinence or the agency's policy of zero tolerance for illicit substance use. Figure 5-4 addresses this in more detail.
Goal Sampling and Experimenting
Before committing to long-term change, some clients may benefit from experimenting with abstinence or cutting down their use for a short period. Success--or failure--can greatly enhance commitment to a goal of abstinence and long-term change. Presenting the trial period as a personal challenge can be particularly effective. A 3-month experimental period is recommended, based on findings that 3 months of abstinence predict long-term remission of alcohol dependence. Some clients may find this too long, and a shorter trial can be negotiated. The following list summarizes advantages of an abstinence trial (Miller and Page, 1991):
- The client receives an opportunity to learn how it feels to be clean and sober.
- Current, habitual consumption patterns are interrupted and tolerance reduced.
- You and the client are helped to discover the degree, if any, of physiological dependence.
- The client can demonstrate and experience a period of successful self-control.
- A period of recovery from acute cognitive impairment is provided.
- Others (e.g., a spouse, the court) are shown that the client is sincerely interested in changing and capable of taking a first step.
- Extra time is allowed for recovery and stabilization of health, mood, sleeping patterns, and so forth.
- You and the client are helped to ascertain situations in which the client needs additional coping skills to overcome psychological dependence on the substance.
The usefulness of a month-long abstinence trial for adult marijuana smokers has been examined (Stephens et al., 1994). The participants were assigned to a three-session intervention consisting of assessment, personalized feedback of the assessment results, and brief intervention counseling. At the end of the second session, the counselor announced that the third session would be a month later and also asked whether clients would like to try some changes during that time period so that they could discuss the results at the next meeting. A month of abstention was proposed as "do-able"--long enough to try out changes but not long enough to seem like too much commitment. In reference to marijuana use, the study found that the three-session clients had the same outcomes at periodic posttreatment followups as a group that received 18 sessions of treatment during the same period.
Besides trial abstention, two other "warm turkey" approaches have been described (Miller and Page, 1991).
Tapering down
This "warm turkey" approach has been widely used with cigarette smokers to reduce their dependence level before the quit date. This approach consists of setting progressively lower daily and weekly limits on use of the substance while working toward a long-range goal of abstinence. The client keeps careful daily records of consumption and schedules sessions with the clinician as needed.
Trial moderation
Trial moderation may be the only acceptable goal for some clients who are highly resistant to abstinence. It is important to avoid sending the message: "Go try it, and when you've failed, come back." A more friendly and motivational approach is: "If that's what you want, let's give it the best try we can and see how it works." However, seek agreement from the client that, if the moderation experiment fails after a reasonable effort, abstinence will be considered. A long-term followup of 99 problem drinkers who systematically tried to moderate drinking showed that more of them ultimately decided to abstain than maintain stable and problem-free moderation. At followup, more than half of those who ultimately abstained attributed their success to the insight gained from the moderation trial about their need to abstain (Miller et al., 1992).
Although immediate abstinence is the usual prescription, no studies have confirmed that cold turkey is the best or only way to initiate lasting sobriety. Additional studies are needed to determine who are optimal candidates for "warm turkey" approaches; clinical and research experience indicates that these methods are successful with some clients, particularly those with less severe problems (Miller et al., 1992).
Enhancing Commitment in the Late Preparation Stage
Commitment to change still must be reinforced even after your client has initially decided to change and has begun to set goals. Vacillation is to be expected at any point in the change process. Three additional strategies are available for enhancing commitment at this point: taking smaller steps, going public, and envisioning.
Taking small steps
You have asked your client key questions such as "What is next?" and have presented a variety of options (see Chapter 6) to convey the message that it is the client's choice to change and to select the areas on which to focus. Reminders that clients have choices to make and that they control the change process can reinforce commitment. If clients seem overwhelmed by the changes they are contemplating, reassure them that they can moderate the pace of change and can choose to begin with small steps. With some clients, it might be especially helpful to provide a case history of someone who made large and seemingly impossible life changes by taking one step at a time. The importance of such stories and models should not be underestimated in motivating people to change.
Going public
Disclosing the desire to change to at least one other person besides the clinician seems to be very important in helping clients become accountable as well as aware of any inner resistance. This other person can be a spouse, friend, family member, coworker, church friend, or Alcoholics Anonymous (AA) member. Telling significant others about one's desire to change usually enhances commitment to change. Going public can be a critical step for some clients in the late preparation stage who may not have been ready to tell others until this point. AA has applied the clinical wisdom of public commitment to change through use of the "white chip." An attendee at an AA meeting who is not yet ready to quit but has a strong desire to do so can pick up a white chip, as a public acknowledgment of the desire to quit drinking.
Envisioning
Specifically envisioning a different life after changes are made can be a powerful motivator and an effective means of strengthening your client's 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 is 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.
The Importance of Self-Efficacy
Even clients who acknowledge a serious problem are not likely to move toward positive change unless they have some hope of success. 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 and thereby exercise control over events. Self-efficacy can be thought of as hope or optimism, but clients do not have to have an overall optimistic perspective to believe a particular behavior can be changed.
Clients are most likely to make statements about self-efficacy when they are negotiating goals or developing a change plan (see Chapter 6). Statements about self-efficacy could include the following: "I can't do that," "That is beyond my powers," "That would be easy," or "I think I can manage that." From such statements, you can ascertain what the client feels able--and unable--to do.
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?" In relation to substance dependency, self-efficacy can be conceptualized into five categories (DiClemente et al., 1994):
- Coping self-efficacy involves successful coping with specific situations that might tempt a person to use the substance, such as 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 relevant to treatment, such as self-monitoring or stimulus control.
- Recovery self-efficacy relates to the client's ability to recover from a recurrence of the addictive behavior.
- Control self-efficacy focuses on the client's confidence in her ability to control the behavior in a variety of provocative situations.
- Abstinence self-efficacy involves the client's confidence in her ability to abstain from substance use in the various situations that are cues or triggers.
Another way to conceptualize self-efficacy is as the client's perceived ability to engage in meaningful or pleasurable, nonsubstance-related activities. This should be assessed before you engage in change strategies related to your client's daily activities.
Self-efficacy is a dynamic rather than a static construct. Self-efficacy for coping with each particular situation increases with success and decreases with failure. Thus, it is important to give clients skills to be successful in situations that present a risk for recurrence of use in order to enhance their belief that they can maintain desired changes.
Clinicians and researchers have found it useful to measure self-efficacy by examining situations or states that present a risk for recurrence of substance use. Clients may have high self-efficacy in some situations and low self-efficacy in others. (See Chapter 8 for descriptions of instruments you can use to measure a client's self-efficacy in particular situations.) According to one study, most recurrence of substance use occurs in one or more of the following four situations (Cummings et al., 1980):
- Negative emotional states such as anger, depression, or frustration
- Social pressures such as seeing others drinking at a bar or being on vacation and wanting to relax
- Physical and other concerns such as having a headache, feeling tired, or being worried about someone
- Withdrawal symptoms and urges such as craving or feeling drawn to test one's willpower
Before you and the client discuss self-efficacy for changing substance use behavior, explore other areas and activities in the client's life for which the client has demonstrated high self-efficacy. Then you can discuss how your client's skills could apply to new efforts to change. For example, a client who is working on restoring an old car may spend dozens of hours figuring out why the engine will not run smoothly--systematically taking apart and reassembling various parts of the engine until the problem is found. This persistent and patient approach to problem solving and the curiosity behind it can be reframed as valuable strengths for identifying and solving problems with substance use. Other ways to support your client's self-efficacy include the following (Marlatt and Gordon, 1985):
- Stress that change is a gradual process.
- Focus on acquisition of new skills versus cessation of "immoral" activity.
- Provide timely and specific feedback regarding progress.
- Chapter 5—From Contemplation to Preparation: Increasing Commitment - Enhancing M...Chapter 5—From Contemplation to Preparation: Increasing Commitment - Enhancing Motivation for Change in Substance Abuse Treatment
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