This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, L.C.S.W., J.D., C.C.A.S., served as the CDM TIPs project director. Other CDM TIPs personnel included Raquel Ingraham, M.S., project manager; Jonathan Max Gilbert, M.A., managing editor; Y-Lang Nguyen, production editor; Janet G. Humphrey, M.A., editor/writer; Paddy Cook, freelance editor; Joanna Taylor, editor; Cara M. Smith, editorial assistant; Paul A. Seaman, former editorial assistant; and Kurt Olsson, former editor/writer.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance use experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Enhancing Motivation for Change in Substance Abuse Treatment, embraces a fundamentally different way to conceptualize motivation. In this approach, motivation is viewed as a dynamic and changeable state rather than a static trait. This TIP shows how clinicians can influence this change process by developing a therapeutic relationship, one that respects and builds on the client's autonomy and, at the same time, makes the treatment counselor a participant in the change process. The TIP also describes different motivational interventions that can be used at all stages of change, from precontemplation and preparation to action and maintenance. The goal of this TIP is to make readers aware of the research, results, and promise of motivational interventions in the hope that they will be used more widely in clinical practice and treatment programs across the United States.
Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, L.C.S.W., J.D., C.C.A.S., served as the CDM TIPs project director. Other CDM TIPs personnel included Raquel Ingraham, M.S., project manager; Jonathan Max Gilbert, M.A., managing editor; Y-Lang Nguyen, production editor; Janet G. Humphrey, M.A., editor/writer; Paddy Cook, freelance editor; Joanna Taylor, editor; Cara M. Smith, editorial assistant; Paul A. Seaman, former editorial assistant; and Kurt Olsson, former editor/writer.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance use experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Enhancing Motivation for Change in Substance Abuse Treatment, embraces a fundamentally different way to conceptualize motivation. In this approach, motivation is viewed as a dynamic and changeable state rather than a static trait. This TIP shows how clinicians can influence this change process by developing a therapeutic relationship, one that respects and builds on the client's autonomy and, at the same time, makes the treatment counselor a participant in the change process. The TIP also describes different motivational interventions that can be used at all stages of change, from precontemplation and preparation to action and maintenance. The goal of this TIP is to make readers aware of the research, results, and promise of motivational interventions in the hope that they will be used more widely in clinical practice and treatment programs across the United States.
Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance use experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Enhancing Motivation for Change in Substance Abuse Treatment, embraces a fundamentally different way to conceptualize motivation. In this approach, motivation is viewed as a dynamic and changeable state rather than a static trait. This TIP shows how clinicians can influence this change process by developing a therapeutic relationship, one that respects and builds on the client's autonomy and, at the same time, makes the treatment counselor a participant in the change process. The TIP also describes different motivational interventions that can be used at all stages of change, from precontemplation and preparation to action and maintenance. The goal of this TIP is to make readers aware of the research, results, and promise of motivational interventions in the hope that they will be used more widely in clinical practice and treatment programs across the United States.
Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
This TIP is based on a fundamental rethinking of the concept of motivation. Motivation is not seen as static but as dynamic. It is redefined here as purposeful, intentional, and positive--directed toward the best interests of the self. Specifically, motivation is considered to be related to the probability that a person will enter into, continue, and adhere to a specific change strategy. This TIP shows how substance abuse treatment staff can influence change by developing a therapeutic relationship that respects and builds on the client's autonomy and, at the same time, makes the treatment clinician a partner in the change process. The TIP also describes different motivational interventions that can be used at all stages of the change process, from precontemplation and preparation to action and maintenance, and informs readers of the research, results, tools, and assessment instruments related to enhancing motivation.
The primary purpose of this TIP is to link research to practice by providing clear applications of motivational approaches in clinical practice and treatment programs. This TIP also seeks to shift the conception of client motivation for change toward a view that empowers the treatment provider to elicit motivation. These approaches may be especially beneficial to particular populations (e.g., court-mandated offenders) with a low motivation for change.
Despite the preponderance of evidence supporting the efficacy of motivation-focused interventions, their use in the United States has occurred primarily in research settings. One obstacle to their implementation may be ideological: low motivation, denial, and resistance are often considered characteristic attributes of those diagnosed with substance abuse disorders. The cognitive-behavioral emphasis of motivational approaches, however, requires a different perspective on the nature of the problem and the prerequisites for change. This approach places greater responsibility on the clinician, whose job is now expanded to include engendering motivation. Rather than dismissing the more challenging clients as unmotivated, clinicians are equipped with skills to enhance motivation and to establish partnerships with their clients.
The Consensus Panel recommends that substance abuse treatment staff view motivation in this new light. Motivation for change is a key component in addressing substance abuse. The results of longitudinal research suggest that an individual's level of motivation is a very strong predictor of whether the individual's substance use will change or remain the same. Motivation-enhancing techniques are associated with increased participation in treatment and such positive treatment outcomes as reductions in consumption, higher abstinence rates, better social adjustment, and successful referrals to treatment. In addition, having a positive attitude toward change and being committed to change are associated with positive treatment outcomes. This is not a new insight. However, until relatively recently motivation was more commonly viewed as a static trait that the client either did or did not have. According to this view, the clinician has little chance of influencing a client's motivation. If the client is not motivated to change, it is the client's--not the clinician's--problem.
Recent models of change, however, recognize that change itself is influenced by biological, psychological, sociological, and spiritual variables. The capacity that each individual brings to the change process is affected by these variables. At the same time, these models recognize that although the client is ultimately responsible for change, this responsibility is shared with the clinician through the development of a "therapeutic partnership."
Chapter 1 of this TIP presents an overview of how the concepts of motivation and change have evolved in recent years and describes the "stages-of-change" model, developed by Prochaska and DiClemente and upon which this TIP is based. Chapter 2 presents interventions that can enhance clients' motivation, highlights their effective elements, and links them to the stages-of-change model. Developed by Miller and Rollnick, motivational interviewing is a therapeutic style used to interact with substance-using clients that can help them resolve issues related to their ambivalence; this is discussed in Chapter 3.
Chapters 4 through 7 address the five stages of change and provide guidelines for clinicians to tailor their treatment to clients' stages of readiness for change. Various tools and instruments used to measure components of change are summarized in Chapter 8. Chapter 9 provides examples of integrating motivational approaches into existing treatment programs. As motivational interventions are still a relatively new field, there are many unanswered questions; Chapter 10 offers directions for future research.
In order to avoid awkward construction and sexism, this TIP alternates between "he" and "she" for generic examples.
Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, commencing with this TIP, it will be used to denote both substance dependence and substance abuse disorders. The term does relate to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders as described by the DSM-IV.
The Consensus Panel's recommendations, summarized below, are based on both research and clinical experience. Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2). References for the former are cited in the body of this document, where the guidelines are presented in detail.
In the past 15 years, considerable research has focused on ways to better motivate substance-using clients to initiate and continue substance abuse treatment. A series of motivational approaches has been developed to elicit and enhance a substance-using client's motivation to change. These approaches are based on the following assumptions about the nature of motivation:
To incorporate these assumptions about motivation while encouraging a client to change substance-using behavior, the clinician can use the following strategies:
Motivational approaches build on these ideas. They seek to shift control away from the clinician and back to the client. They emphasize treating the client as an individual. They also recognize that treating substance abuse is a cyclical rather than a linear process and that recurrence of use does not necessarily signal failure.
Substantial research has focused on the determinants and mechanisms of personal change. Theorists have developed various models for how behavior change happens. One perspective sees external consequences as being largely responsible for influencing individuals to change. Another model views intrinsic motivations as causing substance abuse disorders. Others believe that motivation is better described as a continuum of readiness than as one consisting of separate stages of change.
The transtheoretical stages-of-change model, described in Chapter 1, emerged from an examination of 18 psychological and behavioral theories about how change occurs, including components that make up the biopsychosocial framework for understanding addiction. This model of change provides the foundation for this TIP. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. These stages can be conceptualized as a cycle through which clients move back and forth. The stages are not viewed as linear, such that clients enter into one stage and then directly progress to the next. Framing clients' treatment within the stages of change can help the clinician better understand clients' treatment progress.
This model also takes into account that for most people with substance abuse problems, recurrence of substance use is the rule, not the exception. After a return to substance use, clients usually revert to an earlier change stage--not always to maintenance or action, but many times to some level of contemplation. In this model, recurrence is not equivalent to failure and does not mean that a client has abandoned a commitment to change. Thus, recurrence is not considered a stage but an event that can occur at any point along the cycle of recovery. Based on research and clinical experience, the Consensus Panel endorses the transtheoretical model as a useful model of change (1, 2); however, it is important to note that the model's use has been primarily conceptual and that no current technology is available to definitively determine an individual's stage of readiness for change.
A motivational intervention is any clinical strategy designed to enhance client motivation for change. It can include counseling, client assessment, multiple sessions, or a 30-minute brief intervention. 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. The Consensus Panel considers the following elements of current motivational approaches to be important:
The FRAMES approach consists of the following components:
Research has shown that simple motivation-enhancing interventions are effective for encouraging clients to return for another clinical consultation, return to treatment following a missed appointment, stay involved in treatment, and be more compliant.
The simplicity and universality of the concepts underlying motivational interventions permit broad-scale application in many different settings and offer great potential to reach individuals with many types of problems and in many different cultures. This is important because treatment professionals work with a wide range of clients who differ with regard to ethnic and racial background, socioeconomic status, education level, gender, age, sexual orientation, type and severity of substance abuse problems, physical health, and psychological health. Although the principles and mechanisms of enhancing motivation to change seem to be broadly applicable, there may be important differences among populations and cultural contexts regarding the expression of motivation for change and the importance of critical life events. Therefore, clinicians should be thoroughly familiar with the populations with whom they expect to establish therapeutic relationships. (2)
Because motivational strategies emphasize clients' responsibilities to voice personal goals and values as well as to make choices among options for change, clinicians should understand and respond in a nonjudgmental way to expressions of cultural differences. They should identify elements in a population's values that present potential barriers to change. Clinicians should learn what personal and material resources are available to clients and be sensitive to issues of poverty, social isolation, or recent losses in offering options for change or probing personal values. In particular, it should be recognized that access to financial and social resources is an important part of the motivation for and process of change. (2)
This TIP is based on a fundamental rethinking of the concept of motivation. Motivation is not seen as static but as dynamic. It is redefined here as purposeful, intentional, and positive--directed toward the best interests of the self. Specifically, motivation is considered to be related to the probability that a person will enter into, continue, and adhere to a specific change strategy. This TIP shows how substance abuse treatment staff can influence change by developing a therapeutic relationship that respects and builds on the client's autonomy and, at the same time, makes the treatment clinician a partner in the change process. The TIP also describes different motivational interventions that can be used at all stages of the change process, from precontemplation and preparation to action and maintenance, and informs readers of the research, results, tools, and assessment instruments related to enhancing motivation.
The primary purpose of this TIP is to link research to practice by providing clear applications of motivational approaches in clinical practice and treatment programs. This TIP also seeks to shift the conception of client motivation for change toward a view that empowers the treatment provider to elicit motivation. These approaches may be especially beneficial to particular populations (e.g., court-mandated offenders) with a low motivation for change.
Despite the preponderance of evidence supporting the efficacy of motivation-focused interventions, their use in the United States has occurred primarily in research settings. One obstacle to their implementation may be ideological: low motivation, denial, and resistance are often considered characteristic attributes of those diagnosed with substance abuse disorders. The cognitive-behavioral emphasis of motivational approaches, however, requires a different perspective on the nature of the problem and the prerequisites for change. This approach places greater responsibility on the clinician, whose job is now expanded to include engendering motivation. Rather than dismissing the more challenging clients as unmotivated, clinicians are equipped with skills to enhance motivation and to establish partnerships with their clients.
The Consensus Panel recommends that substance abuse treatment staff view motivation in this new light. Motivation for change is a key component in addressing substance abuse. The results of longitudinal research suggest that an individual's level of motivation is a very strong predictor of whether the individual's substance use will change or remain the same. Motivation-enhancing techniques are associated with increased participation in treatment and such positive treatment outcomes as reductions in consumption, higher abstinence rates, better social adjustment, and successful referrals to treatment. In addition, having a positive attitude toward change and being committed to change are associated with positive treatment outcomes. This is not a new insight. However, until relatively recently motivation was more commonly viewed as a static trait that the client either did or did not have. According to this view, the clinician has little chance of influencing a client's motivation. If the client is not motivated to change, it is the client's--not the clinician's--problem.
Recent models of change, however, recognize that change itself is influenced by biological, psychological, sociological, and spiritual variables. The capacity that each individual brings to the change process is affected by these variables. At the same time, these models recognize that although the client is ultimately responsible for change, this responsibility is shared with the clinician through the development of a "therapeutic partnership."
Chapter 1 of this TIP presents an overview of how the concepts of motivation and change have evolved in recent years and describes the "stages-of-change" model, developed by Prochaska and DiClemente and upon which this TIP is based. Chapter 2 presents interventions that can enhance clients' motivation, highlights their effective elements, and links them to the stages-of-change model. Developed by Miller and Rollnick, motivational interviewing is a therapeutic style used to interact with substance-using clients that can help them resolve issues related to their ambivalence; this is discussed in Chapter 3.
Chapters 4 through 7 address the five stages of change and provide guidelines for clinicians to tailor their treatment to clients' stages of readiness for change. Various tools and instruments used to measure components of change are summarized in Chapter 8. Chapter 9 provides examples of integrating motivational approaches into existing treatment programs. As motivational interventions are still a relatively new field, there are many unanswered questions; Chapter 10 offers directions for future research.
In order to avoid awkward construction and sexism, this TIP alternates between "he" and "she" for generic examples.
Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, commencing with this TIP, it will be used to denote both substance dependence and substance abuse disorders. The term does relate to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders as described by the DSM-IV.
The Consensus Panel's recommendations, summarized below, are based on both research and clinical experience. Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2). References for the former are cited in the body of this document, where the guidelines are presented in detail.
In the past 15 years, considerable research has focused on ways to better motivate substance-using clients to initiate and continue substance abuse treatment. A series of motivational approaches has been developed to elicit and enhance a substance-using client's motivation to change. These approaches are based on the following assumptions about the nature of motivation:
To incorporate these assumptions about motivation while encouraging a client to change substance-using behavior, the clinician can use the following strategies:
Motivational approaches build on these ideas. They seek to shift control away from the clinician and back to the client. They emphasize treating the client as an individual. They also recognize that treating substance abuse is a cyclical rather than a linear process and that recurrence of use does not necessarily signal failure.
Substantial research has focused on the determinants and mechanisms of personal change. Theorists have developed various models for how behavior change happens. One perspective sees external consequences as being largely responsible for influencing individuals to change. Another model views intrinsic motivations as causing substance abuse disorders. Others believe that motivation is better described as a continuum of readiness than as one consisting of separate stages of change.
The transtheoretical stages-of-change model, described in Chapter 1, emerged from an examination of 18 psychological and behavioral theories about how change occurs, including components that make up the biopsychosocial framework for understanding addiction. This model of change provides the foundation for this TIP. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. These stages can be conceptualized as a cycle through which clients move back and forth. The stages are not viewed as linear, such that clients enter into one stage and then directly progress to the next. Framing clients' treatment within the stages of change can help the clinician better understand clients' treatment progress.
This model also takes into account that for most people with substance abuse problems, recurrence of substance use is the rule, not the exception. After a return to substance use, clients usually revert to an earlier change stage--not always to maintenance or action, but many times to some level of contemplation. In this model, recurrence is not equivalent to failure and does not mean that a client has abandoned a commitment to change. Thus, recurrence is not considered a stage but an event that can occur at any point along the cycle of recovery. Based on research and clinical experience, the Consensus Panel endorses the transtheoretical model as a useful model of change (1, 2); however, it is important to note that the model's use has been primarily conceptual and that no current technology is available to definitively determine an individual's stage of readiness for change.
A motivational intervention is any clinical strategy designed to enhance client motivation for change. It can include counseling, client assessment, multiple sessions, or a 30-minute brief intervention. 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. The Consensus Panel considers the following elements of current motivational approaches to be important:
The FRAMES approach consists of the following components:
Research has shown that simple motivation-enhancing interventions are effective for encouraging clients to return for another clinical consultation, return to treatment following a missed appointment, stay involved in treatment, and be more compliant.
The simplicity and universality of the concepts underlying motivational interventions permit broad-scale application in many different settings and offer great potential to reach individuals with many types of problems and in many different cultures. This is important because treatment professionals work with a wide range of clients who differ with regard to ethnic and racial background, socioeconomic status, education level, gender, age, sexual orientation, type and severity of substance abuse problems, physical health, and psychological health. Although the principles and mechanisms of enhancing motivation to change seem to be broadly applicable, there may be important differences among populations and cultural contexts regarding the expression of motivation for change and the importance of critical life events. Therefore, clinicians should be thoroughly familiar with the populations with whom they expect to establish therapeutic relationships. (2)
Because motivational strategies emphasize clients' responsibilities to voice personal goals and values as well as to make choices among options for change, clinicians should understand and respond in a nonjudgmental way to expressions of cultural differences. They should identify elements in a population's values that present potential barriers to change. Clinicians should learn what personal and material resources are available to clients and be sensitive to issues of poverty, social isolation, or recent losses in offering options for change or probing personal values. In particular, it should be recognized that access to financial and social resources is an important part of the motivation for and process of change. (2)
Motivational interviewing is a therapeutic style intended to help clinicians work with clients to address their ambivalence. While conducting a motivational interview, the clinician is directive yet client centered, with a clear goal of eliciting self-motivational statements and behavioral change from the client, and seeking to create client discrepancy to enhance motivation for positive change. The Consensus Panel recommends that motivational interviewing be seen not as a set of techniques or tools, but rather as a way of interacting with clients. (2) The Panel believes that motivational interviewing is supported by the following principles:
The motivational interviewing style facilitates an exploration of stage-specific motivational conflicts that can potentially hinder further progress. (1) However, each dilemma also offers an opportunity to use the motivational style as a way of helping clients explore and resolve opposing attitudes.
The Consensus Panel recognizes that successful motivational interviewing will entail being able to
Clinicians who adopt motivational interviewing as a preferred style have found that the following five strategies are particularly useful in the early stages of treatment:
Individuals appear to need and use different kinds of help, depending on which stage of readiness for change they are currently in and to which stage they are moving. (2) Clients who are in the early stages of readiness need and use different kinds of motivational support than do clients at later stages of the change cycle.
To encourage change, individuals in the precontemplation stage must increase their awareness. (2) To resolve their ambivalence, clients in the contemplation stage should choose positive change over the status quo. (2) Clients in the preparation stage must identify potential change strategies and choose the most appropriate one for their circumstances. Clients in the action stage must carry out change strategies. This is the stage toward which most formal substance abuse treatment is directed. During the maintenance stage, clients may have to develop new skills that help maintain recovery and a healthy lifestyle. Moreover, if clients resume their problem substance use, they need help to recover as quickly as possible and reenter the change process.
According to the stages-of-change model, individuals in the precontemplation stage are not concerned about their substance use or are not considering changing their behavior. These substance users may remain in precontemplation or early contemplation for years, rarely or never thinking about change. Often, a significant other finds the substance user's behavior problematic. Chapter 4 discusses a variety of proven techniques and gentle tactics that clinicians can use to address the topic of substance abuse with people who are not thinking of change. Use of these techniques will serve to (1) create client doubt about the commonly held belief that substance abuse is "harmless" and (2) lead to client conviction that substance abuse is having, or will in the future have, significant negative results. The chapter suggests that clinicians practice the following:
The assessment and feedback process can be an important part of the motivational strategy because it informs clients of how their own substance use patterns compare with norms, what specific risks are entailed, and what damage already exists or is likely to occur if changes are not made.
Giving clients personal results from a broad-based and objective assessment, especially if the findings are carefully interpreted and compared with norms or expected values, can be not only informative but also motivating. (1) Providing clients with personalized feedback on the risks associated with their own use of a particular substance--especially for their own cultural and gender groups--is a powerful way to develop a sense of discrepancy that can motivate change.
Considerable research shows that involvement of family members or significant others (SOs) can help move substance-using persons toward contemplation of change, entry into treatment, involvement and retention in the therapeutic process, and successful recovery. (1) Involving SOs in the early stages of change can greatly enhance a client's commitment to change by addressing the client's substance use in the following ways:
The clinician can engage an SO by asking the client to invite the SO to a treatment session. Explain that the SO will not be asked to monitor the client's substance use but that the SO can perform a valuable role by providing emotional support, identifying problems that might interfere with treatment goals, and participating in activities with the client that do not involve substance use. To strengthen the SO's belief in his capacity to help the client, the clinician can use the following strategies:
Clinicians should use caution when involving an SO in motivational counseling. Although a strong relationship between the SO and the client is necessary, it is not wholly sufficient. The SO must also support a client's substance-free life, and the client must value that support. (1) An SO who is experiencing hardships or emotional problems stemming from the client's substance use may not be a suitable candidate. (1) Such problems can preclude the SO from constructively participating in the counseling sessions, and it may be better to wait until the problems have subsided before including an SO in the client's treatment. (1)
In general, the SO can play a vital role in influencing the client's willingness to change; however, the client must be reminded that the responsibility to change substance use behavior is hers. (2)
An increasing number of clients are mandated to obtain treatment by an employer or employee assistance program, the court system, or probation and parole officers. Others are influenced to enter treatment because of legal pressures. The challenge for clinicians is to engage coerced clients in the treatment process. A stable recovery cannot be maintained by external (legal) pressure only; motivation and commitment must come from internal pressure. If you provide interventions appropriate to their stage, coerced clients may become invested in the change process and benefit from the opportunity to consider the consequences of use and the possibility of change--even though that opportunity was not voluntarily chosen. (2)
Extrinsic and intrinsic motivators should be considered when trying to increase a client's commitment to change and move the client closer to action because these motivators can be examined to enhance decisionmaking, thereby enhancing the client's commitment. Many clients move through the contemplation stage acknowledging only the extrinsic motivators pushing them to change or that brought them to treatment. Help the client discover intrinsic motivators, which typically move the client from contemplating change to acting. (2) In addition to the standard practices for motivational interviewing (e.g., reflective listening, asking open-ended questions), clinicians can help spur this process of changing extrinsic motivators to intrinsic motivators by doing the following:
Clinicians can use decisional balancing strategies to help clients thoughtfully consider the positive and negative aspects of their substance use. (1) The ultimate purpose, of course, is to help clients recognize and weigh the negative aspects of substance use so that the scale tips toward beneficial behavior. Techniques to use in decisional balancing exercises include the following:
Throughout this process, emphasize the clients' personal choices and responsibilities for change. The clinician's task is to help clients make choices that are in their best interests. This can be done by exploring and setting goals. Goal-setting is part of the exploring and envisioning activities characteristic of the early and middle preparation stage. The process of talking about and setting goals strengthens commitment to change. (1)
During the preparation stage, the clinician's tasks broaden from using motivational strategies to increase readiness--the goals of precontemplation and contemplation stages--to using these strategies to strengthen a client's commitment and help her make a firm decision to change. At this stage, helping the client develop self-efficacy is important. (2) Self-efficacy is not a global measure, like self-esteem; rather, it is behavior specific. In this case, it is the client's optimism that she can take action to change substance-use behaviors.
As clients move through the preparation stage, clinicians should be alert for signs of clients' readiness to move into action. There appears to be a limited period of time during which change should be initiated. (2) Clients' recognition of important discrepancies in their lives is too uncomfortable a state to remain in for long, and unless change is begun they can retreat to using defenses such as minimizing or denying to decrease the discomfort. (2) The following can signal a client's readiness to act:
Mere vocal fervor about change, however, is not necessarily a sign of dogged determination. Clients who are most vehement in declaring their readiness may be desperately trying to convince themselves, as well as the clinician, of their commitment.
When working with clients in the preparation stage, clinicians should try to
A motivational counseling style has most frequently been used with clients in the precontemplation through preparation stages as they move toward initiating behavioral change. Some clients and clinicians believe that formal, action-oriented substance abuse treatment is a different domain and that motivational strategies are no longer required. This is not true for two reasons. First, clients may still need a surprising amount of support and encouragement to stay with a chosen program or course of treatment. Even after a successful discharge, they may need support and encouragement to maintain the gains they have achieved and to know how to handle recurring crises that may mean a return to problem behaviors. (2) Second, many clients remain ambivalent in the action stage of change or vacillate between some level of contemplation--with associated ambivalence--and continuing action. (2) Moreover, clients who do take action are suddenly faced with the reality of stopping or reducing substance use. This is more difficult than just contemplating action. The first stages of recovery require only thinking about change, which is not as threatening as actually implementing it.
Clients' involvement or participation in treatment can be increased when clinicians
Clients who are in the action stage can be most effectively helped when clinicians
The next challenge that clients and clinicians face is maintaining change. With clients in the maintenance stage, clinicians will be most successful if they can
After clients have planned for stabilization by identifying risky situations, practicing new coping strategies, and finding their sources of support, they still have to build a new lifestyle that will provide sufficient satisfaction and can compete successfully against the lure of substance use. A wide range of life changes ultimately needs to be made if clients are to maintain lasting abstinence. Clinicians can help this change process by using competing reinforcers. (1) A competing reinforcer is anything that clients enjoy that is or can become a healthy alternative to drugs or alcohol as a source of satisfaction.
The essential principle in establishing new sources of positive reinforcement is to get clients involved in generating their own ideas. Clinicians should explore all areas of clients' lives for new reinforcers. Reinforcers should not come from a single source or be of the same type. That way, a setback in one area can be counterbalanced by the availability of positive reinforcement from another area. Since clients have competing motivations, clinicians can help them select reinforcers that will win out over substances over time.
Following are a number of potential competing reinforcers that can help clients:
Contingency reinforcement systems, such as voucher programs, have proven to be effective when community support and resources are available. (1) Research has shown that these kinds of reinforcement systems can help to sustain abstinence in drug abusers. The rationale for this type of incentive program is that an appealing external motivator can be used as an immediate and powerful reinforcer to compete with substance use reinforcers. Not all contingent incentives have to have a monetary value. In many cultures, money is not the most powerful reinforcer.
Because motivation is multidimensional, it cannot be easily measured with one instrument or scale. Instead, the Consensus Panel recommends that substance abuse treatment staff use a variety of tools to measure several dimensions of motivation, including (2):
One of the principles of current health care management is that the most intensive and expensive treatments should be used only with those with the most serious problems or with those who have not responded to lesser interventions. Motivational interventions can serve many purposes in treatment settings:
Motivational interventions are a relatively new, but favorably received, approach to encouraging positive behavioral change. As indicated earlier, motivational interventions have been successfully used with a variety of problems, client populations, and settings, and the methodology appears to be generally applicable, although it was developed primarily with heavy alcohol drinkers and cigarette smokers.
Researchers should consider some of the following questions when planning and developing future research studies (2):
Motivational interviewing was originally developed for problem alcohol drinkers in the early stages (precontemplation and contemplation) of readiness for change and was conceived as a way of initiating treatment. However, it soon became apparent that this approach constitutes an intervention in itself. Benefits have been reported with severely substance-dependent populations, polydrug-abusing adolescents, and users of heroin and marijuana. In Project MATCH, the largest clinical trial ever conducted to compare different alcohol treatment methods, a four-session motivational enhancement therapy yielded long-term overall outcomes virtually identical to those of longer outpatient methods. Clients varied widely in problem severity; the vast majority met criteria for alcohol dependence, and they represented a range of cultural backgrounds, particularly Hispanic. It is noteworthy that neither Hispanic nor African-American samples responded differentially to the motivational enhancement therapy approach. In addition, analyses of clinical trials of motivational interviewing that had substantial representation of Hispanic clients found no indication of self-identified ethnicity and socioeconomic status as predictors of outcome. Evidence strongly suggests that motivational interviewing can be applied across cultural and economic differences.
The motivational style of counseling can be useful, not only to instill motivation initially, but throughout the process of treatment in the preparation, action, and maintenance stages as well, with a range of client populations. This is reflected in the following chapters of this TIP.
Motivation can be understood not as something that one has but rather as something one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy. There are, it turns out, many ways to help people move toward such recognition and action. Miller, 1995
Why do people change? What is motivation? Can individuals' motivation to change their substance-using behavior be modified? Do clinicians have a role in enhancing substance-using clients' motivation for recovery?
Over the past 15 years, considerable research and clinical attention have focused on ways to better motivate substance users to consider, initiate, and continue substance abuse treatment, as well as to stop or reduce their excessive use of alcohol, cigarettes, and drugs, either on their own or with the help of a formal program. A related focus has been on sustaining change and avoiding a recurrence of problem behavior following treatment discharge. This research represents a paradigmatic shift in the addiction field's understanding of the nature of client motivation and the clinician's role in shaping it to promote and maintain positive behavioral change. This shift parallels other recent developments in the addiction field, and the new motivational strategies incorporate or reflect many of these developments. Coupling a new therapeutic style--motivational interviewing--with a transtheoretical stages-of-change model offers a fresh perspective on what clinical strategies may be effective at various points in the recovery process. Motivational interventions resulting from this theoretical construct are promising clinical tools that can be incorporated into all phases of substance abuse treatment as well as many other social and health services settings.
In substance abuse treatment, clients' motivation to change has often been the focus of clinical interest and frustration. Motivation has been described as a prerequisite for treatment, without which the clinician can do little (Beckman, 1980). Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment (Appelbaum, 1972; Miller, 1985b). Until recently, motivation was viewed as a static trait or disposition that a client either did or did not have. If a client was not motivated for change, this was viewed as the client's fault. In fact, motivation for treatment connoted an agreement or willingness to go along with a clinician's or program's particular prescription for recovery. A client who seemed amenable to clinical advice or accepted the label of "alcoholic" or "drug addict" was considered to be motivated, whereas one who resisted a diagnosis or refused to adhere to the proffered treatment was deemed unmotivated. Furthermore, motivation was often viewed as the client's responsibility, not the clinician's (Miller and Rollnick, 1991). Although there are reasons why this view developed that will be discussed later, this guideline views motivation from a substantially different perspective.
The motivational approaches described in this TIP are based on the following assumptions about the nature of motivation:
The study of motivation is inexorably linked to an understanding of personal change--a concept that has also been scrutinized by modern psychologists and theorists and is the focus of substance abuse treatment. The nature of change and its causes, like motivation, is a complex construct with evolving definitions. Few of us, for example, take a completely deterministic view of change as an inevitable result of biological forces, yet most of us accept the reality that physical growth and maturation do produce change--the baby begins to walk and the adolescent seems to be driven by hormonal changes. We recognize, too, that social norms and roles can change responses, influencing behaviors as diverse as selecting clothes or joining a gang, although few of us want to think of ourselves as simply conforming to what others expect. Certainly, we believe that reasoning and problem-solving as well as emotional commitment can promote change.
The framework for linking individual change to a new view of motivation stems from what has been termed a phenomenological theory of psychology, most familiarly expressed in the writings of Carl Rogers. In this humanistic view, an individual's experience of the core inner self is the most important element for personal change and growth--a process of self-actualization that prompts goal-directed behavior for enhancing this self (Davidson, 1994). In this context, motivation is redefined as purposeful, intentional, and positive--directed toward the best interests of the self. More specifically, motivation is the probability that a person will enter into, continue, and adhere to a specific change strategy (Miller and Rollnick, 1991).
Motivation, in this new meaning, has a number of complex components that will be discussed in subsequent chapters of this TIP. It encompasses the internal urges and desires felt by the client, external pressures and goals that influence the client, perceptions about risks and benefits of behaviors to the self, and cognitive appraisals of the situation.
Research and experience suggest that motivation is a dynamic state that can fluctuate over time and in relation to different situations, rather than a static personal attribute. Motivation can vacillate between conflicting objectives. Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved and goals are more clearly envisioned. In this sense, motivation can be an ambivalent, equivocating state or a resolute readiness to act--or not to act.
Motivation belongs to one person, yet it can be understood to result from the interactions between the individual and other people or environmental factors (Miller, 1995b). Although internal factors are the basis for change, external factors are the conditions of change. An individual's motivation to change can be strongly influenced by family, friends, emotions, and community support. Lack of community support, such as barriers to health care, employment, and public perception of substance abuse, can also affect an individual's motivation.
Motivation pervades all activities, operating in multiple contexts and at all times. Consequently, motivation is accessible and can be modified or enhanced at many points in the change process. Clients may not have to "hit bottom" or experience terrible, irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image (Miller, 1985; Miller et al., 1993).
Although there are substantial differences in what factors influence people's motivation, several types of experiences may have dramatic effects, either increasing or decreasing motivation. Experiences such as the following often prompt people to begin thinking about making changes and to consider what steps are needed:
The way you, the clinician, interact with clients has a crucial impact on how they respond and whether treatment is successful. Researchers have found dramatic differences in rates of client dropout or completion among counselors in the same program who are ostensibly using the same techniques (Luborsky et al., 1985). Counselor style may be one of the most important, and most often ignored, variables for predicting client response to an intervention, accounting for more of the variance than client characteristics (Miller and Baca, 1983; Miller et al., 1993). In a review of the literature on counselor characteristics associated with treatment effectiveness for substance users, researchers found that establishing a helping alliance and good interpersonal skills were more important than professional training or experience (Najavits and Weiss, 1994). The most desirable attributes for the counselor mirror those recommended in the general psychological literature and include nonpossessive warmth, friendliness, genuineness, respect, affirmation, and empathy.
A direct comparison of counselor styles suggested that a confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centered, supportive, and empathic style that uses reflective listening and gentle persuasion (Miller et al., 1993). In this study, the more a client was confronted, the more alcohol the client drank. Confrontational counseling in this study included challenging the client, disputing, refuting, and using sarcasm.
Although change is the responsibility of the client and many people change their excessive substance-using behavior on their own without therapeutic intervention (Sobell et al., 1993b), you can enhance your client's motivation for beneficial change at each stage of the change process. Your task is not, however, one of simply teaching, instructing, or dispensing advice. Rather, the clinician assists and encourages clients to recognize a problem behavior (e.g., by encouraging cognitive dissonance), to regard positive change to be in their best interest, to feel competent to change, to develop a plan for change, to begin taking action, and to continue using strategies that discourage a return to the problem behavior (Miller and Rollnick, 1991). Be sensitive to influences such as your client's cultural background; knowledge or lack thereof can influence your client's motivation.
Research has shown that motivation-enhancing approaches are associated with greater participation in treatment and positive treatment outcomes. Such outcomes include reductions in consumption, increased abstinence rates, social adjustment, and successful referrals to treatment (Landry, 1996; Miller et al., 1995a). A positive attitude toward change and a commitment to change are also associated with positive treatment outcomes (Miller and Tonigan, 1996; Prochaska and DiClemente, 1992).
The benefits of employing motivational enhancement techniques include
Americans have often shown ambivalence toward excessive drug and alcohol use. They have vacillated between viewing offenders as morally corrupt sinners who are the concern of the clergy and the law and seeing them as victims of compulsive craving who should receive medical treatment. After the passage of the Harrison Narcotics Act in 1914, physicians were imprisoned for treating addicts. In the 1920s, compassionate treatment of opiate dependence and withdrawal was available in medical clinics, yet at the same time, equally passionate support of the temperance movement and Prohibition was gaining momentum. These conflicting views were further manifested in public notions of who deserved treatment (e.g., Midwestern farm wives addicted to laudanum) and who did not (e.g., urban African-Americans).
Different views about the nature and etiology of addiction have more recently influenced the development and practice of current treatments for substance abuse. Differing theoretical perspectives have guided the structure and organization of treatment and the services delivered (Institute of Medicine, 1990b). Comparing substance abuse treatment to a swinging pendulum, one writer noted,
Notions of moral turpitude and incurability have been linked with problems of drug dependence for at least a century. Even now, public and professional attitudes toward alcoholism are an amalgam of contrasting, sometimes seemingly irreconcilable views: The alcoholic is both sick and morally weak. The attitudes toward those who are dependent on opiates are a similar amalgam, with the element of moral defect in somewhat greater proportion (Jaffee, 1979, p. 9).
The development of a modern treatment system for substance abuse dates only from the late 1960s, with the decriminalization of public drunkenness and the escalation of fears about crime associated with increasing heroin addiction. Nonetheless, the system has rapidly evolved in response to new technologies, research, and changing theories of addiction with associated therapeutic interventions. The six models of addiction described below have competed for attention and guided the application of treatment strategies over the last 30 years.
Addiction is viewed by some as a set of behaviors that violate religious, moral, or legal codes of conduct. From this perspective, addiction results from a freely chosen behavior that is immoral, perhaps sinful, and sometimes illegal. It assumes that individuals who choose to misuse substances create suffering for themselves and others and lack self-discipline and self-restraint. Substance misuse and abuse are irresponsible and intentional actions that deserve punishment (Wilbanks, 1989), including arrest and incarceration (Thombs, 1994). Because excessive substance use is seen as the result of a moral choice, change can only come about by an exercise of will power (IOM, 1990b), external punishment, or incarceration.
A contrasting view of addiction as a chronic and progressive disease inspired what has come to be called the medical model of treatment, which evolved from earlier forms of disease models that stressed the need for humane treatment and hypothesized a dichotomy between "normals" and "addicts" or "alcoholics." The latter were asserted to differ qualitatively, physiologically, and irreversibly from normal individuals. More recent medical models take a broader "biopsychosocial" view, consonant with a modern understanding of chronic diseases as multiply determined.
Nevertheless, emphasis continues to be placed on physical causes. In this view, genetic factors increase the likelihood for an individual to misuse psychoactive substances or to lose control when using them. Neurochemical changes in the brain resulting from substance use then induce continuing consumption, as does the development of physiological dependence. Treatment in this model is typically delivered in a hospital or medical setting and includes various pharmacological therapies to assist detoxification, symptom reduction, aversion, or maintenance on suitable alternatives.
Responsibility for resolving the problem does not rest with the client, and change can come about only through acknowledging loss of control, adhering to medical prescriptions, and participating in a self-help group (IOM, 1990b).
The spiritual model of addiction is one of the most influential in America, largely because of such 12-Step fellowships as Alcoholics Anonymous (AA), Cocaine Anonymous, Narcotics Anonymous, and Al-Anon. This model is often confused with the moral and medical models, but its emphasis is quite distinct from these (Miller and Kurtz, 1994). In the original writings of AA, there is discussion of "defects of character" as central to understanding alcoholism, with particular emphasis on issues such as pride versus humility and resentment versus acceptance. In this view, substances are used in an attempt to fill a spiritual emptiness and meaninglessness.
Spiritual models give much less weight to etiology than to the importance of a spiritual path to recovery. Twelve-Step programs emphasize recognizing a Higher Power (often called God in AA) beyond one's self, asking for healing of character, maintaining communication with the Higher Power through prayer and meditation, and seeking to conform one's life to its will. Twelve-Step programs are not wholly "self-help" programs but rather "Higher Power-help" programs. The first of the 12 steps is to recognize that one literally cannot help oneself or find recovery through the power of one's own will. Instead, the path back to health is spiritual, involving surrender of the will to a Higher Power. Clinicians follow various guidelines in supporting their clients' involvement in 12-Step programs (Tonigan et al., 1999).
Twelve-Step programs are rooted in American Protestantism, but other distinctly spiritual models do not rely on Christian or even theistic thought. Transcendental meditation, based on Eastern spiritual practice, has been widely practiced as a method for preventing and recovering from substance abuse problems (Marlatt and Kristeller, 1999). Native American spirituality has been integrated into treatment programs serving Native American populations through the use of sweat lodges and other traditional rituals, such as singing and healing ceremonies. Spiritual models all share a recognition of the limitations of the self and a desire to achieve health through a connection with that which transcends the individual.
In the psychological model of addiction, problematic substance use results from deficits in learning, emotional dysfunction, or psychopathology that can be treated by behaviorally or psychoanalytically oriented dynamic therapies. Sigmund Freud's pioneering work has had a deep and lasting effect on substance abuse treatment. He originated the notion of defense mechanisms (e.g., denial, projection, rationalization), focused on the importance of early childhood experiences, and developed the idea of the unconscious mind. Early psychoanalysis viewed substance abuse disorders as originating from unconscious death wishes and self-destructive tendencies of the id (Thombs, 1994). Substance dependence was believed to be a slow form of suicide (Khantzian, 1980). Other early psychoanalytic writers emphasized the role of oral fixation in substance dependence. A more contemporary psychoanalytic view is that substance use is a symptom of impaired ego functioning--a part of the personality that mediates the demands of the id and the realities of the external world. Another view considers substance abuse disorders as "both developmental and adaptive" (Khantzian et al., 1990).
From this perspective, the use of substances is an attempt to compensate for vulnerabilities in the ego structure. Substance use, then, is motivated by an inability to regulate one's inner life and external behavior. Thus, psychoanalytic treatment assumes that insight obtained through the treatment process results in the strengthening of internal mechanisms, which becomes evident by the establishment of external controls; in other words, the change process shifts from internal (intrapsychic) to external (behavioral, interpersonal). An interesting psychoanalytic parallel to modern motivational theory is found in the writings of Anton Kris, who described the "conflicts of ambivalence" seen in clients that
May cast a paralyzing inertia not only upon the patient but upon the treatment method. In such instances, patient and analyst, like the driver of an automobile stuck in a snowdrift, must aim at a rocking motion that eventually gathers enough momentum to permit movement in one direction or another (Kris, 1984, p. 224).
Other practitioners view addiction as a symptom of an underlying mental disorder. From this perspective, successful treatment of the primary psychiatric disorder should result in resolution of the substance use problem. However, over the past decade, substantial research and clinical attention have revealed a more complex relationship between psychiatric and substance abuse disorders and symptoms. Specifically, substance use can cause psychiatric symptoms and mimic psychiatric disorders; substance use can prompt or worsen the severity of psychiatric disorders; substance use can mask psychiatric disorders and symptoms; withdrawal from severe substance dependence can precipitate psychiatric symptoms and mimic psychiatric disorders; psychiatric and substance abuse disorders can coexist; and psychiatric disorders can produce behaviors that mimic ones associated with substance use problems (CSAT, 1994b; Landry et al., 1991).
From the perspective of behavioral psychology, substance use is a learned behavior that is repeated in direct relation to the quality, number, and intensity of reinforcers that follow each episode of use (McAuliffe and Gordon, 1980). Addiction is based on the principle that people tend to repeat certain behaviors if they are reinforced for engaging in them. Positive reinforcers of substance use depend on the substance used but include powerful effects on the central nervous system. Other social variables, such as peer group acceptance, can also act as positive reinforcers. Negative reinforcers include lessened anxiety and elimination of withdrawal symptoms. A person's experiences and expectations in relation to the effects of selected substances on certain emotions or situations will determine substance-using patterns. Change comes about if the reinforcers are outweighed or replaced by negative consequences, also known as punishers, and the client learns to apply strategies for coping with situations that lead to substance use.
Other psychologists have emphasized the role of cognitive processes in addictive behavior. Bandura's concept of self-efficacy--the perceived ability to change or control one's own behavior--has been influential in modern conceptions of addiction (Bandura, 1997). Cognitive therapists have described treatment approaches for modifying pathogenic beliefs that may underlie substance abuse (Beck et al., 1993; Ellis and Velten, 1992).
A related, sociocultural perspective on addiction emphasizes the importance of socialization processes and the cultural milieu in developing--and ameliorating--substance abuse disorders. Factors that affect drinking behavior include socioeconomic status, cultural and ethnic beliefs, availability of substances, laws and penalties regulating substance use, the norms and rules of families and other social groups as well as parental and peer expectations, modeling of acceptable behaviors, and the presence or absence of reinforcers. Because substance-related problems are seen as occurring in interactive relations with families, groups, and communities, alterations in policies, laws, and norms are part of the change process. Building new social and family relations, developing social competency and skills, and working within one's cultural infrastructure are important avenues for change in the sociocultural model (IOM, 1990b). From the sociocultural perspective, an often neglected aspect of positive behavioral change is sorting out ethical principles or renewing opportunities for spiritual growth that can ameliorate the guilt, shame, regret, and sadness about the substance-related harm clients may have inflicted on themselves and others.
As the conflicts among these competing models of addiction have become evident and as research has confirmed some truth in each model, the addiction field has searched for a single construct to integrate these diverse perspectives (Wallace, 1990). This has led to an emerging biopsychosocial--spiritual framework that recognizes the importance of many interacting influences. Indeed, the current view is that all chronic diseases, whether substance use, cancer, diabetes, or coronary artery disease, are best treated by collaborative and comprehensive approaches that address both biopsychosocial and spiritual components (Borysenko and Borysenko, 1995; Williams and Williams, 1994). This overarching model of addiction retains the proven elements and techniques of each of the preceding models while eliminating some previous--and erroneous--assumptions, which are discussed below.
Although the field is evolving toward a more comprehensive understanding of substance misuse and abuse, earlier views of addiction still persist in parts of our treatment system. Some of these are merely anachronisms; others may actually harm clients. Recent research has shown that some types of interventions that have been historically embedded within treatment approaches in the United States may paradoxically reduce motivation for