In the context of recovery from substance use, the client weighs the pros and cons of changing versus not changing substance-using behavior. You assist this process by asking your client to articulate the good and less good aspects of using substances and then list them on a sheet of paper. This process is usually called decisional balancing and is further described in Chapters 5 and 8.
The purpose of exploring the pros and cons of a substance use problem is to tip the scales toward a decision for positive change. The actual number of reasons a client lists on each side of a decisional balance sheet is not as important as the weight--or personal value--of each one. For example, a year-old smoker might not put as much weight on getting lung cancer as an older man, but he might be very concerned that his diminished lung capacity interferes with playing tennis or basketball.
One way to enhance motivation for change is to help clients recognize a discrepancy or gap between their future goals and their current behavior. You might clarify this discrepancy by asking, "How does your drinking fit in with having a happy family and a stable job? This concept is expanded in Chapters 3 and 5. Every client moves through the stages of change at her own pace.
Some will cycle back and forth numerous times between, for example, contemplating change and making a commitment to do so. Others seem stuck in an ambivalent state for a long time. A few are ready to get started and take action immediately. Therefore, assess your client's readiness for change. By determining where the individual has been and is now within the stages of change, you can better facilitate the change process. The concept of pacing requires that you meet your clients at their levels and use as much or as little time as is necessary with the essential tasks of each stage of change.
For example, with some clients, you may have to schedule frequent sessions at the beginning of treatment and fewer later. In other cases, you might suggest a "therapeutic vacation" for a client who has to take a break before continuing a particularly difficult aspect of recovery. If you push clients at a faster pace than they are ready to take, the therapeutic alliance may break down.
Motivational interventions can include simple activities designed to enhance continuity of contact between you and your client and strengthen your relationship. Such activities can include personal handwritten letters or telephone calls from you to your client. Research has shown that these simple motivation-enhancing interventions are effective for encouraging clients to return for another clinical consultation, to return to treatment following a missed appointment, to stay involved in treatment, and to increase adherence Intagliata, ; Koumans and Muller, ; Nirenberg et al.
This concept is discussed in Chapter 7. Clients need and use different kinds of motivational support according to which stage of change they are in and into what stage they are moving. If you try to use strategies appropriate to a stage other than the one the client is in, the result could be treatment resistance or noncompliance. For example, if your client is at the contemplation stage, weighing the pros and cons of change versus continued substance use, and you pursue change strategies appropriate to the action stage, your client will predictably resist.
The simple reason for this reaction is that you have taken the positive change side of the argument, leaving the client to argue the other no change side; this results in a standoff. To consider change, individuals at the precontemplation stage must have their awareness raised. To resolve their ambivalence, clients in the contemplation stage require help choosing positive change over their current situation. Clients in the preparation stage need help identifying potential change strategies and choosing the most appropriate one for their circumstances.
Clients in the action stage the stage at which most formal treatment occurs need help to carry out and comply with the change strategies. During the maintenance stage, clients may have to develop new skills for maintaining recovery and a lifestyle without substance use. Moreover, if clients resume their substance use, they can be assisted to recover as quickly as possible to resume the change process. Figure provides examples of appropriate motivational strategies you can use at each stage of change. Of course, these are not the only ways to enhance motivation for beneficial change. Chapter 3 describes some of the fundamental principles of motivational interviewing that apply to all stages.
Chapters 4 through 7 describe in more detail the motivational strategies that are most appropriate for encouraging progression to each new change stage. Chapters 4 and 8 present some tools to help you recognize clients' readiness to change in terms of their current stage. In the search for common processes--integrative models--of personal growth and change across psychotherapies and behavioral approaches, Prochaska Prochaska, initially isolated the core approaches of many therapeutic systems and further developed these in a factor analytic study Davidson, ; Prochaska and DiClemente, These fundamental processes represent cognitive, affective, behavioral, and environmental factors influencing change as they appear in major systems of therapy DiClemente and Scott, These change catalysts are derived from studies examining smoking cessation, alcohol abstinence, general psychotherapeutic problems, weight loss, and exercise adoption Prochaska et al.
For each of the 10 catalysts, several different interventions can be used to encourage change. Figure describes these catalysts for change and illustrates a few interventions often used for each. Ten Effective Catalysts for Change.
Handbook of Behavior Therapy in the Psychiatric Setting
Consciousness raising is increasing information about the problem. Interventions could include observations, interpretations, and bibliotherapy. Self-reevaluation involves assessing how one feels and more Typically, cognitive-experiential processes are used early in the cycle i. Figure suggests which catalysts are most appropriate for each change stage.
To avoid confusion for both the client and clinician, only those catalysts that are best supported or most logical are recommended for a particular stage; this does not imply, however, that the other catalysts are irrelevant. The principles underlying motivational enhancement have been applied across cultures, to different types of problems, in various treatment settings, and with many different populations. The research literature suggests that motivational interventions are associated with a variety of successful outcomes, including facilitation of referrals for treatment, reduction or termination of substance use, and increased participation in and compliance with specialized treatment Bien et al.
Motivational strategies have been used primarily with problem alcohol drinkers and cigarette smokers, but also have yielded encouraging results in marijuana and opiate users with serious substance-related problems Bernstein et al. Special applications of motivational approaches have been or are currently being explored with diabetic patients, for pain management, in coronary heart disease rehabilitation, for HIV risk reduction, with sex offenders, with pregnant alcohol drinkers, with severely alcohol-impaired veterans, with persons who have eating disorders, and with individuals with coexisting substance use and psychiatric disorders Carey, ; Noonan and Moyers, ; Ziedonis and Fisher, Populations that have been responsive to motivational interventions include persons arrested for driving under the influence and other nonviolent offenders, adolescents Colby et al.
The literature also describes successful use of these motivational techniques in primary care facilities Daley et al. These interventions have been used with individuals, couples, groups, and in face-to-face sessions or through mailed materials Miller and Rollnick, ; Sobell and Sobell, The simplicity and universality of the concepts underlying motivational interventions permit broad application and offer great potential to reach clients with many types of problems and in many different cultures or settings.
In my practice with persons who have different world views, I've made a number of observations on the ways in which culture influences the change process. I try to pay attention to cultural effects on a person's style of receiving and processing information, making decisions, pacing, and being ready to act. The more clients are assimilated into the surrounding culture, the more likely they are to process information, respond, and make choices that are congruent with mainstream beliefs and styles. The responsibility for being aware of different cultural value systems lies with the practitioner, not the client being treated.
Clients in treatment for substance abuse differ in ethnic and racial backgrounds, socioeconomic status, education, gender, age, sexual orientation, type and severity of substance use problems, and psychological health. As noted above, research and experience suggest that the change process is the same or similar across different populations. Thus, the principles and mechanisms of enhancing motivation to change seem to be broadly applicable. Nonetheless, there may be important differences among populations and cultural contexts regarding the expression of motivation for change and the importance of critical life events.
Hence, be familiar with the populations with whom you expect to establish therapeutic relationships and use your clients as teachers regarding their own culture. Because motivational strategies emphasize the client's responsibility to voice personal goals and values as well as to select among options for change, a sensitive clinician will understand and, ideally, respond in a nonjudgmental way to cultural differences. Cultural differences might be reflected in the value of health, the meaning of time, the stigma of heavy drinking, or responsibilities to community and family.
Try to understand the client's perspective rather than impose mainstream values or make quick judgments.
- Point of Indifference.
- Top Authors.
- Account Options;
- Handbook of Behavior Therapy in the Psychiatric Setting : Alan S. Bellack : ;
- .
- .
- .
This requires knowledge of the influences that promote or sustain substance use among different populations. Motivation-enhancing strategies should be congruent with clients' cultural and social principles, standards, and expectations. For example, older adults often struggle with loss of status and personal identity when they retire, and they may not know how to occupy their leisure time. Help such retired clients understand their need for new activities and how their use of substances is a coping mechanism.
Similarly, when you try to enhance motivation for change in adolescents, consider how peers influence their behaviors and values and how families may limit their emerging autonomy. In addition to understanding and using a special population's values to encourage change, identify how those values may present potential barriers to change. Some clients will identify strongly with cultural or religious traditions and work diligently to gain the respect of elders or other group leaders; others find membership or participation in groups of this type an anathema.
Some populations are willing to involve family members in counseling; others find this disrespectful, if not disgraceful. The label "alcoholic" is proudly and voluntarily adopted by members of AA but viewed as dehumanizing by others. The message is simple: Know and be sensitive to the concerns and values of your clients. Another sensitive area is matching the client with the clinician.
Although the literature suggests that warmth, empathy, and genuine respect are more important in building a therapeutic partnership than professional training or experience Najavits and Weiss, , nevertheless, programs can identify those clinicians who may be optimally suited because of cultural identification, language, or other similarities of background, to work with clients from specific populations.
Programs will find it useful to develop a network of bilingual clinicians or interpreters who can communicate with non--English-speaking clients. Finally, know what personal and material resources are available to your clients and be sensitive to issues of poverty, social isolation, and recent losses.
In particular, recognize that access to financial and social resources is an important part of the motivation for and process of change. Prolonged poverty and lack of resources make change more difficult, both because many alternatives are not possible and because despair can be pervasive. It is a challenge to affirm self-efficacy and stimulate hope and optimism in clients who lack material resources and have suffered the effects of discrimination. The facts of the situation should be firmly acknowledged. Nevertheless, clients' capacity for endurance and personal growth in the face of dire circumstances can be respected and affirmed and then drawn on as a strength in attempting positive change.
Over the last two decades, there has been a growing trend worldwide to view substance-related problems in a much broader context than diagnosable abuse and dependence syndromes. The recognition that persons with substance-related problems compose a much larger group--and pose a serious and costly public health threat--than the smaller number of persons needing traditional, specialized treatment is not always reflected in the organization and availability of treatment services.
As part of a movement toward early identification of hazardous drinking patterns and the development of effective and low-cost methods to ameliorate this widespread problem, brief interventions have been initiated and evaluated, primarily in the United Kingdom Institute of Medicine, a and Canada but also in many other nations. They have been tried in the United States and elsewhere with great success, although they have not been widely adopted outside research settings Drummond, ; Kahan et al. The impetus to expand the use of this shorter form of treatment is a response to The need for a broader base of treatment and prevention components to serve all segments of the population who have minimal to severe substance-related problems and consumption patterns The need for cost-effective interventions that will not further deplete public coffers and will also satisfy cost-containment policies in an era of managed health care although research indicates that intensive treatment for nicotine dependence is more cost effective [Agency for Health Care Policy and Research, ] A growing body of research findings that consistently demonstrate the efficacy of brief interventions relative to no intervention.
When I apply a motivational interviewing style in my practice of emergency medicine, I experience considerable professional satisfaction. Honestly, it's a struggle to let go of the need to be the expert in charge.
Deciphering Motivation in Psychotherapy - David M. Allen - Google Книги
It helps to recognize that the person I'm talking with in these medical encounters is also an expert--an expert in her own lifestyle, needs, and choices. Brief interventions for substance-using individuals are applied most often outside traditional treatment settings in what are often referred to as opportunistic settings , where clients are not seeking help for a substance abuse disorder but have come, for example, to seek medical attention, to pick up a welfare check, or to respond to a court summons. These settings provide an opportunity to meet and engage with individuals with substance abuse disorders "where they are at.
Those found to have risky or excessive patterns of substance use or related problems receive a brief intervention of one or more sessions, each lasting a few minutes to an hour. Urgent care may involve just one brief encounter, with possible referral to other services. These brief interventions are usually conducted by professionals from the service area where the person seeks services, not by substance abuse treatment specialists.
Elements of Effective Motivational Interventions
The purpose of a brief intervention is usually to counsel individuals about hazardous substance use patterns and to advise them to limit or stop their consumption altogether, depending on the circumstances. If the initial intervention does not result in substantial improvement, the professional can make a referral for additional specialized substance abuse treatment.
A brief intervention also can explore the pros and cons of entering treatment and present a menu of options for treatment, as well as facilitate contact with the treatment system. Brief interventions have been used effectively within substance abuse treatment settings with persons seeking assistance but placed on waiting lists, as a motivational prelude to engagement and participation in more intensive treatment, and as a first attempt to facilitate behavior change with little additional clinical attention.
A series of brief interventions can constitute brief therapy, a treatment strategy that applies therapeutic techniques specifically oriented toward a limited length of treatment, making it particularly useful for certain populations e. Turn recording back on. National Center for Biotechnology Information , U. Chapter 2—Motivation and Intervention.
Noonan and Moyers, Motivational intervention is broadly defined as any clinical strategy designed to enhance client motivation for change. Elements of Effective Motivational Interventions To understand what prompts a person to reduce or eliminate substance use, investigators have searched for the critical components--the most important and common elements that inspire positive change--of effective interventions. Feedback The literature describing successful motivational interventions confirms the persuasiveness of personal, individualized feedback Bien et al.
Responsibility Individuals have the choice of continuing their behavior or changing. Advice A Realistic Model of Change: Advice to Clients Throughout the treatment process, it is important to give clients permission to talk about their problems with substance use. The PIES Approach In World War I, military psychiatrists first realized that motivational interventions, done at the right time, could return a great number of dysfunctionally stressed soldiers to duty.
- Bestselling Series.
- Enhancing Motivation for Change in Substance Abuse Treatment..
- The Chief Culprit: Stalins Grand Design to Start World War II?
- Exodus Village: Return of the African Diaspora;
- Journey, Meant to Be.
Options Compliance with change strategies is enhanced when clients choose--or perceive that they can choose--from a menu of options. Empathic counseling Empathy is not specific to motivational interventions but rather applies to many types of therapies Rogers, ; Truax and Carkhuff, Self-efficacy To succeed in changing, clients must believe they are capable of undertaking specific tasks and must have the necessary skills and confidence Bandura, ; Marlatt and Gordon, Check out the top books of the year on our page Best Books of Product details Format Paperback pages Dimensions x x Looking for beautiful books?
Visit our Beautiful Books page and find lovely books for kids, photography lovers and more. Other books in this series. Drug and Alcohol Abuse M. Evaluation of the Psychiatric Patient Seymour L. Mood Disorders Peter C. Law in the Practice of Psychiatry Seymour L. Drug and Alcohol Abuse Marc A. Child and Adult Development Calvin A. Ethnic Psychiatry Charles B. Adult Development Calvin A. Research in Psychiatry L. Galapagos Marine Invertebrates Matthew J.
Family Functioning John J. Adolescent Substance Abuse Yifrah Kaminer.