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TITLE Enhancing Motivation for Change in Substance Abuse Treatment DOCUMENT RESUME ED 443 042 CG 030 102 TITLE Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 35. INSTITUTION CDM Group, Inc.; Substance Abuse and Mental Health Services Administration (DHHS/PHS), Rockville, MD. Center for Substance Abuse Treatment. REPORT NO SMA-99-3354 PUB DATE 1999-00-00 NOTE . 263p.; For other documents in the TIP Series, see CG 030 099-103 and CG 030 130-134. CONTRACT 270-95-0013 AVAILABLE FROM National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20847-2345. Tel: 800-729-6686 (Toll Free). PUB TYPE Guides Non-Classroom (055) Tests/Questionnaires (160) EDRS PRICE MF01/PC11 Plus Postage. DESCRIPTORS *Behavior Modification; *Cognitive Restructuring; Counselor Client Relationship; Counselor Training; *Drug Rehabilitation; Early Identification; Emotional Adjustment; Evaluation; Intervention; *Motivation; *Substance Abuse ABSTRACT This TIP on the guidelines for treatment of substance use disorders is based on a fundamental rethinking of the concept of motivation. It suggests that the cognitive-behavioral approach to treatment requires a different perspective on the problem and on the prerequisites for change, while placing greater responsibility on the counselor whose job now includes engendering motivation. Chapter 1 presents an overview of the concepts of motivation and change and describes the model, developed by Prochaska and DiClemente, upon which this TIP is based. Chapter 2 presents interventions that can enhance clients' motivation. Chapter 3 discusses motivational interviewing, developed by Miller and Rollnick, which can be used to help clients resolve issues related to their ambivalence. Chapters 4 through 7 address the stages of change and provide guidelines for clinicians to tailor treatment to clients' stages of readiness for change. Tools and instruments used to measure change are summarized in Chapter 8. Chapter 9 provides examples of integrating motivational approaches into existing treatment programs. Chapter 10 offers directions for future research. Appendixes include "Bibliography," "Screening and Assessment Instruments," "Ordering Information for Assessment Instruments," "Resource Panel," and "Field Reviewers." (Contains 28 figures and approximately 450 resources.) (JDM) Reproductions supplied by EDRS are the best that can be made from the original document. US. DEPARTMENT ':s.6, OF HEAL1H AND Substance Abuse and Mental Health Services Administration HUMAN SERVICES Public Health Service Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Enhancing Motivation for Change in Substance Abuse Treatment Treatment Improvement Protocol (TIP) Series 35 11111MI11=116111 ziiifoommormorm 11111111111MINNI 11111111111111 =MEM aftamiffifixosit 810/1MitifilMiffiffaiN 111111111111 OF:=2=19 ei U.S. DEPARTMENT OF EDUCATION - CP Office of Educational Research and Improvement !mli EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) ("r*M".-7"Zr7W41 CP This document has been reproduced as received from the person or organization en originating it. CP 1:1 Minor changes have been made to improve reproduction quality. Cuil co) Points of view or opinions stated in this document do not necessarily represent official OERI position or policy. BEST COPY AVAILABLE The Brief Situational Confidence Questionnaire is a measure of efficacy for resisting drinking or drug use in the situations described. It can be administered in a short time, is easy to score, and provides immediate feedback to the client. Listed below are 8 types of situations in which some people experience substance use problems. Imagine yourself as you are right now in each of the following types of situations. Indicate on the scale provided how confident you are right now that you will be able to resist drinking heavily or resist the urge to use your primary drug in each situation by placing an "X" along the line, from 0% "Not at all confident" to 100% "Totally confident." Right now I would be able to resist the urge to drink heavily or use my primary drug in situations involv- ing... 1.UNPLEASANT EMOTIONS (e.g., if I were depressed about things in general; if everything were going badly for me) I feel... 0°/0 100% Not at all confident Totally confident 2.PHYSICAL DISCOMFORT (e.g., if I were to have trouble sleeping; if I felt jumpy and physically tense) I feel... 0°/0 100% Not at all confident Totally confident 3.PLEASANT EMOTIONS (e.g., if something good happened and I felt like celebrating; if everything were going well) I feel... 0°/0 100% Not at all confident Totally confident 4.TESTING CONTROL OVER MY USE OF ALCOHOL OR DRUGS (e.g., if I were to start to believe that alcohol or drugs were no longer a problem for me; if I felt confident that I could handle drugs or several drinks) I feel... 0°/0 100% Not at all confident Totally confident 3 5. URGES AND TEMPTATIONS (e.g., if I suddenly had an urge to drink or use drugs; if I were in a situation where I had often used drugs or drank heavily) I feel... 0% 100% Not at all confident Totally confident 6.CONFLICT WITH OTHERS (e.g., if I had an argument with a friend; if I were not getting along well with others at work) I feel... 0% I 100% tr) I Not at all confident Totally confident 7.SOCIAL PRESSURE TO USE (e.g., if someone were to pressure me to "be a good sport" and drink or use drugs with him; if I were invited to someone's home and he offered me a drink or drugs) I feel... 00/0 100% Not at all confident Totally confident 8.PLEASANT TIMES WITH OTHERS (e.g., if I wanted to celebrate with a friend; if I were enjoying myself at a party and wanted to feel even better) I feel... 00/0 100% Not at all confident Totally confident Reprinted with permission from Linda Sobell, Ph.D. This instrument and other measures of self-efficacy, the importance of change, readiness to change, decisional balancing, motivations for using sub- stances, and goals and values are reproduced in an appendix to this TIP. BEST COPY AVAILABLE 4 Enhancing Motivation for Change in Substance Abuse Treatment Treatment Improvement Protocol (TIP) Series 35 William R. Miller, Ph.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 This publication is part of the Substance Abuse editor; Janet G. Humphrey, M.A., editor/writer; Prevention and Treatment Block Grant technical Paddy Cook, freelance editor; Joanna Taylor, assistance program. All material appearing in editor; Cara M. Smith, editorial assistant; Paul this volume except that taken directly from A. Seaman, former editorial assistant; and Kurt copyrighted sources is in the public domain and Olsson, former editor/writer. may be reproduced or copied without The opinions expressed herein are the views of permission from the Substance Abuse and the Consensus Panel members and do not reflect Mental Health Services Administration's the official position of CSAT, SAMHSA, or the (SAMHSA) Center for Substance Abuse U.S. Department of Health and Human Services Treatment (CSAT) or the authors. Citation of (DHHS). No official support or endorsement of the source is appreciated. CSAT, SAMHSA, or DHHS for these opinions or This publication was written under contract for particular instruments or software that may number 270-95-0013 with The CDM Group, Inc. be described in this document is intended or (CDM). Sandra Clunies, M.S., I.C.A.D.C., served should be inferred. The guidelines proffered in as the CSAT government project officer. Rose this document should not be considered as M. Urban, L.C.S.W., J.D., C.C.A.S., served as the substitutes for individualized client care and CDM TIPs project director. Other CDM TIPs treatment decisions. personnel included Raquel Ingraham, M.S., DHHS Publication No. (SMA) 99-3354 project manager; Jonathan Max Gilbert, M.A., Printed 1999 managing editor; Y-Lang Nguyen, production ii Contents What Is a TIP? vii Editorial Advisory Board ix Consensus Panel xi Foreword xiii Executive Summary and Recommendations xv Summary of Recommendations xvi To Which Clients Does This TIP Apply? xxvi Chapter 1Conceptualizing Motivation and Change 1 A New Look at Motivation 1 Changing Perspectives on Addiction and Treatment 4 Changes in the Addictions Field 11 A Transtheoretical Model of the Stages of Change 15 To Whom Does This TIP Apply? 19 Summary 21 Chapter 2Motivation and Intervention 23 Elements of Effective Motivational Interventions 23 Motivational Intervention and the Stages of Change 29 Special Applications of Motivational Interventions 30 Brief Interventions 36 Chapter 3Motivational Interviewing as a Counseling Style 39 Ambivalence 40 Five Principles of Motivational Interviewing 40 Five Opening Strategies for Early Sessions 49 Effectiveness of Motivational Interviewing 53 Motivational Interviewing and Managed Care 55 Chapter 4From Precontemplation to Contemplation: Building Readiness 57 Raising the Topic 58 iii Contents Gentle Strategies To Use With the Precontemplator 62 Assessment and Feedback Process 65 Intervene Through Significant Others 71 Motivational Enhancement and Coerced Clients: Special Considerations 80 Chapter 5From Contemplation to Preparation: Increasing Commitment 83 Changing Extrinsic to Intrinsic Motivation 84 Tipping the Decisional Balance 86 Emphasizing Personal Choice and Responsibility 90 The Importance of Self-Efficacy 95 Chapter 6From Preparation
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