Motivation Therapy

Elizabeth Howell, MD

Disclosures

March 29, 2004

Editorial Collaboration

Medscape &

Introduction

Carlo DiClemente, PhD,[1] Professor and Chair of the Department of Psychology, University of Maryland, College Park, Maryland, presented on motivational enhancement therapy at the American Society of Addiction Medicine's 2003 State-of-the-Art conference. Dr. DiClemente is the codeveloper of the Transtheoretical Model of Behavior Change.[2,3,4]

He emphasized that motivation is often the missing dimension in addition treatment, but it must be a treatment focus. Motivation is a modifiable, dynamic process, a state of readiness to change that may be substance-specific or behavior-specific, and is a substantial predictor of treatment participation and change. Motivational problems are increasing in addiction treatment settings, as more patients are identified by early interventions, and are court-ordered, ambivalent, and unmotivated. The earlier the intervention occurs, the less the motivation.

Motivation may be substance-specific and behavior-specific; a patient compliant with methadone maintenance may continue to use other drugs and be unmotivated to change those behaviors. People who are motivated to change and people who are motivated for treatment are not necessarily the same. Addictions and other behaviors can change without treatment. Treatment providers need to appreciate that change is a process individuals move through, either with treatment or through self-change, and to learn how to enhance motivation.

The "old way" of categorizing addicted patients is to label patients who succeeded in treatment as "motivated" and treatment failures as "unmotivated" or "in denial." Dr. DiClemente thinks that denial is not a very helpful concept. He sees resistance not as a trait of the patient, but as a function of the interaction between the patient and the care provider. Any of us would be "in denial" and "resistant" if asked to make a major change we were not ready to make.

Motivation is part of the process of change, and can be influenced but not totally coerced. Mandated treatment outcomes are not worse than voluntary treatment outcomes. There are intrinsic and extrinsic motivation factors. How can we change intrinsic and extrinsic factors to increase motivation for change?

Dr. DiClemente next summarized the Stages of Change model, which provides a helpful framework for understanding and staging the process of behavior change for any behavior, not just alcohol or drug use or addiction. The model divides the process of change into several stages, each with certain tasks and characteristics:

  • Precontemplation -- Not ready to change;

  • Contemplation -- Thinking about change;

  • Preparation -- Getting ready to make a change, planning and commitment;

  • Action -- Making the change, implementing the plan, taking the action;

  • Maintenance -- Sustaining behavior change until integrated into lifestyle, maintaining, integrating;

  • Relapse/recycling -- Slipping back to previous behavior and re-entering the cycle of change; and

  • Termination -- Leaving the cycle of change

Relapse is not a problem of addiction; it is a problem of behavior change. Dr. DiClemente reviewed data on compliance with different medical disorders. Compliance with diabetic care is actually a bit worse than compliance rates with addiction. Heart patients are no less compliant than addicted patients. He then commented on the apparently dismal smoking cessation rates discussed by Dr. Kosten. In Dr. DiClemente's view (from the context of stages of change), smoking cessation is one of the most successful behavior changes in the United States. In 1964, 42% of US citizens were smokers; now 21% to 22% are current smokers and 40 to 50 million Americans have quit smoking. But if you look at the results of one trial of smoking cessation, you will see quit rates of only 3% to 6% over a year, or up to 13% with treatment. However, people make successive attempts to quit smoking; they recycle back through, try again, and many eventually quit.

Relapse (for addiction or any other behavior) is part of a learning process; people may find abstinence only after several attempts. Relapse can happen because of problems in any area of the stages of change -- lack of decisional balance, an inadequate plan, lack of commitment, lack of revision of the plan, etc. Successive approximation is the way people learn and change.

Treatment providers can increase motivation for change and help move people at least one step forward through the process. When assessing motivation in a clinical setting, consider the following questions: Where is the person in the change process and in the decision-making process? What is the person doing behaviorally? Are they making any attempts to modify behavior? What is their attitude about changing the behavior? What are the reasons for changing? How important is it for them to make the change?

The tasks of the provider are different for each stage of change. For example, the provider should raise doubts for the person in the precontemplation stage, tip the decisional balance for someone in contemplation, help the person in preparation to develop a plan, support self-efficacy for someone in the action stage, help the person in maintenance to use strategies to prevent relapse, and assist someone in relapse to recycle back through the stages of change.

Dr. DiClemente emphasized that patients need a lot of commitment to get through the first stage of action. Accessible, acceptable, and manageable plans can help them move through the process more effectively. Personalized feedback is an important intervention. Feedback should be relevant, objective, personalized information about behavior with the goal of raising doubt and stimulating the patient to think differently about their behavior. Instead of calling someone an alcoholic, give personalized feedback, such as "you drink more than 95% of the people in the United States of your age and gender." Linking symptoms to behavior makes interventions more effective.

Providers can best address the concerns of individuals by working with decision-making processes and understanding the reasons for changing and for not changing. This approach will help providers hear what patients are really thinking, not what they think providers want to hear. Decision-making is "an internal process of setting a goal and then making a commitment to do something to achieve that goal." The process involves several intellectual, emotional, and valuing concerns. Decisions are not made solely from intellectual assessment -- otherwise all of us would always do what makes the most sense! As people move through the process of change, their concerns and decisional balance, or assessment of the pros and cons for changing or not changing, shift.

Motivational interviewing is the counseling approach used to enhance motivation by helping the person clarify and resolve ambivalence about behavior change. The following interventions enhance motivation for change: identify the patient's stage of change, provide an active listening environment, emphasize that the patient is in charge, provide objective feedback, and assist in developing a plan for change. In motivational interviewing, the therapist expresses empathy, develops discrepancy, avoids argumentation, rolls with resistance, and supports self-efficacy. Strategies include asking open-ended questions, listening reflectively, affirming, summarizing, and eliciting self-motivational statements.

Motivational Enhancement Therapy

Motivational enhancement therapy (MET)[5] was one treatment condition used in Project MATCH. In the MATCH study, subjects in the MET condition received 4 sessions of MET over 12 weeks, in contrast to the cognitive behavioral therapy (CBT) group and the 12-step facilitation (TSF) group, who received 12 sessions over a 12-week period. The subjects in Project MATCH were drinking 13 to 20 drinks per day, and were drinking 65% of the days prior to the study.

All 3 treatments showed significant changes; overall, subjects attained 70% to 80% days abstinent after the study, as opposed to 35% prior to the study. Drink amounts decreased. Many subjects went to complete abstinence, and 25% were totally abstinent in the following year. Project MATCH demonstrated that treatments that differ in philosophy can produce similar changes.

More research is needed to define how drug treatments interact with the process of change. One finding from the MATCH study is that patients higher in anger did better when the MET approach was used instead of CBT or TSF, suggesting that providers should use MET in patients with higher hostility or anger.

Researchers are now studying how to use motivational enhancement in other treatment settings, such as pretreatment, comprehensive treatment programs, free-standing treatment, early intervention (eg, in primary care), etc.

Dr. DiClemente suggested the Center for Substance Abuse Treatment's TIP 35[6] as an especially helpful resource for more information on stages of change and motivational enhancement.

References
  1. DiClemente C. Motivational enhancement therapy. Program and abstracts of the American Society of Addiction Medicine 2003 The State of the Art in Addiction Medicine; October 30-November 1, 2003; Washington, DC. Session I.

  2. DiClemente CC. Motivation for change: implications for substance abuse treatment. Psychol Sci. 1999;10:209-213.

  3. DiClemente CC. Addiction and Change: How Addictions Develop and Addicted People Recover. New York: Guilford Press; 2003.

  4. DiClemente CC, Bellino LE, Neavins TM. Motivation for change and alcoholism treatment. Alcohol Res Health. 1999;23:86-92. Abstract

  5. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change, 2nd edition. New York: Guilford Press; 2002.

  6. Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 35, 1999. Rockville, Md: Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 99-3354. Available at: http://www.treatment.org/externals/tips.html. Accessed March 19, 2004.

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