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1. Enhancing Motivation for
Change in Substance Abuse
Treatment Part 2
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
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2. Objectives
 Learn about the nature of change
 Explore the different stages of readiness for change
 Learn about goals and interventions for each stage for
readiness for change
 Identify ways to identify a clients change in readiness for
change
 Explore ways to identify barriers to recovery
 Learn how to explore expectations regarding recovery and
how to use that to enhance motivation
 Briefly review how to develop a relapse prevention plan
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3. Change
 Is Constant
 Occurs all the time
 In the natural environment
 Among people
 In relation to behaviors
 Occurs without professional intervention
 The change process is cyclical, and people typically move back
and forth between the stages and cycle through the stages at
different rates.
 It is not uncommon for people to linger in the early stages.
 Recurrence of at least some symptoms or old behaviors is a
normal event, and many clients cycle through the different
stages several times before achieving stable recovery.
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4. Nature of Change
 6 basic stages in the process of change:
 Precontemplation
 Contemplation
 Preparation
 Action
 Maintenance
 Recurrence
 People typically vacillate between the stages and cycle
through the stages at different rates. (Pool)
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5. Precontemplation
 The client is unaware, unable, or unwilling to change.
 Establish rapport
 Raise doubts about patterns of use
 Give info on risks, pros and cons of use
 Explore reasons for unwillingness to change (.i.e fear of failure)
 The client is likely to be wary of the counselor and of
treatment.
 Should not rub the client the wrong way
 Should try to keep the interview informal.
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6. Ambivalence
 Many clients are ambivalent about change.
 Change is hard
 Ambivalence is expressed in several ways.
 Argue: Challenge or discount statements
 Interrupt: Take over or cut off conversation
 Deny: Blame, disagree, excuse, minimize
 Ignore: Not responding, not paying attention
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7. Goals/Actions
 Explore the meaning of events that brought the client to
treatment or the results of previous treatments.
 Elicit the client's perceptions of the problem.
 Offer factual information about the risks
 Provide personalized feedback about assessment
 Explore the pros and cons of substance use.
 Help a significant other intervene.
 Examine discrepancies between the client's and others’
perceptions of the problem behavior.
 Express concern and keep the door open.
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8. Contemplation
 The client is ambivalent or uncertain, considering the
possibility of change.
◦ Counselor can
 Discuss and weigh pros/cons of change (Decisional Balance)
 Emphasize client's free choice and responsibility
 Elicit self-motivational statements
 Reassure the client that no one can force him to
change and he is in charge.
 Ask questions that prompt motivation.
◦ For example, "When you want to keep up your motivation for
doing something, what are some of the things you say to
yourself?"
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9. Goals/Actions
 Help the client recognize the problem(s) contributing to
the current situation
 Help the client acknowledge concern
 Help the client generate intention to change
 Help the client develop optimism
 Convey feedback
 Help clients see a difference
 Show curiosity about client strengths. Explore how those
skills and competencies may be negated by their current
state
 Reframe negative statements.
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10. Highlight Reasons for Change
 Summarize concerns
 Explore specific pros and cons
 Allow client to explain benefits
 Assure client conflicting feelings are normal
 Review feedback from assessment
 Find out what client expects from treatment
 Provide info
 Help client connect core values to committing to
treatment
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11. Strengthen the Client's Personal Choices
 Nudge the client to make positive choices.
 "No one can decide this for you. You can choose."
 Help the client set goals and take steps.
 Provide feedback.
 Remind client of "triggers," including negative emotions
(anger), social pressures (peers), physical concerns
(headache) and extended withdrawal symptoms (craving).
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12. Reinforce the Client's Commitment
 What do you think has to change?
 What are you going to do?
 How are you going to do it?
 What are some benefits of making a change?
 How would you like things to turn out, ideally?
For more detailed information, see TIP 35, pp. 54–92.
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13. Preparation
 The client asks questions, indicates willingness and
considers options to make specific changes.
 Explore treatment expectancies and the client's role.
 Elicit from the client what has worked in the past
either for him or others whom he knows.
 At this stage, the client shifts from "thinking about it"
to "planning first steps."
 Counselor guides the steps by offering help but not
yanking the client forward.
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14. Help The Client Get Ready
 Negotiate a plan
 Offer a menu of options
 Develop a behavior contract
 Identify and lower barriers
 Enlist social support
 With permission offer advice
 Assist the client in negotiating finances, child care,
work, transportation, or other potential barriers.
 Have the client publicly announce plans
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15. Client Indicates Readiness
 Stops arguing, interrupting, denying
 No longer asks questions about the problem, but more
about how to change
 Appears calm, peaceful
 States openness to change ("I have to do something")
 Expresses optimism ("I can beat this")
 Talks about how life will be after the change
 Experiments between sessions
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16. Barriers
 Ask what has gone wrong in the past
 Find out if clients anticipate problems
 Provide all necessary information
 Sources of barriers may include
 Family relations
 Health problems
 Depression or other negative feelings
 Bureaucracy: Waiting lists, paperwork, legal
 Finances
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17. Action
 The client takes steps toward change, but is still unstable.
 Negotiate an action plan
 Acknowledge difficulties and support attempts
 Identify risky situations and coping strategies
 Help client find new reinforcers
 Support perseverance ("Sticking to the plan")
 In this stage, clients are receptive to the full range of
counselor techniques, but motivation can wax and wane
 If relapse occurs, "back up" and apply techniques from an
earlier stage.
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18. Goals/Actions
 Engage the client in treatment and reinforce the
importance of remaining in recovery.
 Support a view of change through small steps.
 Acknowledge difficulties for the client in early stages of
change.
 Help the client identify high-risk situations and develop
appropriate coping strategies
 Assist the client in finding reinforcers
 Help the client assess levels of social support.
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19. Explore Expectations
 Explore past experiences, hopes, and fears regarding
 Confrontation, judgment
 Costs in money or changed behavior
Can’t stay out late anymore because it triggers depression
Have to give up certain activities (at least temporarily) like cross
posting
 Family involvement, shame, guilt
 Medications the client will have to withdraw from or take
 Perception of rules too strict, no "wiggle room."
 Understanding
 Immunize against difficulties
 Resolve barriers to treatment
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20. Increase Motivations
 Help the client to see the value of both internal and
external motivating factors
 Suggest to the client that external coercions are
compatible with the client's best interests
 Support signs of internal motivation
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21. Examine & Interpret Noncompliant Behavior
 Noncompliant behavior is a thinly veiled expression of
dissatisfaction with treatment or the therapeutic
process.
 It may be you
 You may be missing something
 What are the benefits to the behavior
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22. Maintenance
 Client has met initial goals, made changes in lifestyle and
now practices coping strategies.
 Support and affirm changes
 Rehearse new coping strategies
 Review goals
 Keep in contact (aftercare, support groups)
 In this stage, clients "keep on keeping on."
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23. Cont…
 Remind the client about new tools to maintain and
reinforce recovery, such as
 Action plan
 Awareness of risky situations
 Coping strategies for each situation
 Participation in 12-Step programs or support groups
 Pursuit of hobbies and cultural activities
 Volunteer opportunities
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24. Goals/Actions
 Help the client identify and sample drug-free sources of
pleasure (i.e., new reinforcers).
 Support lifestyle changes.
 Affirm the client's resolve and self-efficacy.
 Help the client practice/use coping strategies
 Maintain supportive contact
 Develop a "fire escape" plan if the client feels symptoms
returning or notices a return to old ways of thinking
 Review long-term goals with the client.
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25. Form a Plan.
 Identify triggers
 Identify effect/benefits of the old way of responding to
the trigger
 Identify alternate, helpful coping responses
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26. Developing Reinforcers
 Competing
 Sleeping
 Crying
 Self-Harm
 Contingent (If/Then)
 If you respond effectively then you can…
 If you get out of bed by 9am each day then…
 Community (natural consequences)
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27. Recurrence
 Help the client reenter the change cycle and commend any
willingness to reconsider positive change.
 Explore the meaning and reality of the recurrence as a
learning opportunity.
 Assist the client in finding alternative coping strategies.
 Maintain supportive contact.
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28. Applications of Motivational Approaches
 A means of rapid engagement in the general medical
setting to facilitate referral to treatment
 A first session to increase the likelihood that a client will
return and to deliver a useful service if the client does
not return
 An empowering brief consultation when a client is placed
on a waiting list, rather than telling a client just to wait
for treatment
 A preparation for treatment to increase retention and
participation
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29. Applications cont…
 A help to clients coerced into treatment to move beyond
initial feelings of anger and resentment
 A means to overcome client defensiveness and resistance
 A stand-alone intervention in settings where there is only
brief contact
 A counseling style used through the process of change
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30. Other Things to Remember
 Often there is a relatively short period of time to make a
beneficial impact on the client
 The average length of stay in substance abuse treatment is
very short
 If clinicians do not make an impact in the first session or
two with clients, they may not be able to make an impact
at all
 Make the best use of the first contact
 It is usually a mistake to start a session with filling out
forms
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31. Summary
 Even one session can make a positive impact on a client
 Lasting change takes time and effort
 All clients have the ability to make positive choices and changes
 Clients will be at different stages of readiness for change for
different issues and symptoms and may vacillate between
conflicting goals
 Clients with low motivation begin arguing, ignoring or becoming
apathetic
 Sometimes enhancing motivation means focusing first on barriers to
recovery instead of the problem itself.
 Explore expectations regarding recovery to enhance motivation
 Develop a relapse prevention plan that helps clients identify
triggers and vulnerabilities and ways to prevent and address them
AllCEUs Unlimited CEUs $59 | Webinars $3 | Addiction Counselor Certification Training $149
31