Chapter 25. Motivational Enhancement

 

 

Chapter 25. Motivational Enhancement

MOTIVATIONAL ENHANCEMENT: INTRODUCTION

Patient motivation is a necessary ingredient in substance abuse treatment and recovery. Because of

the reinforcing nature of addictive substances and the physiological and psychological reliance they

engender, individuals with problematic and dependent patterns of substance use often refuse to

acknowledge problems or seek treatment. Even when substance abusers arrive at a treatment

program, many are ambivalent about the need to modify their substance use and resist any notion

that they need to reduce their use or abstain completely. Going to treatment is not a panacea that

turns ambivalence and lack of readiness into commitment to change—a significant number of

individuals who enter a treatment facility fail to complete the treatment and many drop out after

intake or a single session (Simpson and Joe 1993; Wickizer et al. 1994). Engagement in substance

and alcohol abuse treatment is sporadic. Even those who comply and complete treatment do not

always achieve stated goals. Reluctance to seek help, attrition, and relapse are significant problems

facing treatment providers as they try to help individuals who abuse drugs and alcohol along the

path to recovery. All of these barriers are connected in some way to patient motivation.

Earlier in the history of substance abuse treatment, motivation for recovery and treatment was

viewed as the total responsibility of the patient. Treatment professionals believed that

interventions would not work until the alcohol- or drug-dependent individual reached his or her

personal “bottom” and brought the needed motivation to change with him or her into treatment.

Little was done to help the unmotivated other than confronting them vigorously about their denial

or waiting until they experienced sufficient losses or consequences to admit problems and seek

help from treatment providers. Unmotivated individuals often were turned away from treatment or

told to attend mutual help meetings (Alcoholics Anonymous, Narcotics Anonymous) in the hope

that the testimony of peers would increase their motivation. Larger social systems became

frustrated with this lack of motivation and began to use incarceration or mandated treatment to

manage substance abuse problems (Loue 2003). Such coercion increased treatment attendance but

not necessarily motivation to change.

Since the late 1980s, there has been a significant shift in how society and the treatment community

understand and address the problem of patient motivation in substance abuse. Public health

approaches have encouraged aggressive screening of vulnerable populations (DiClemente 2005;

Fleming et al. 2002). Courts, private companies, and professional sporting leagues have begun

referring patients to treatment and seeking the collaboration of treatment providers in managing

substance abuse (Turner et al. 2002). A more recent model of behavior change enumerated five

stages of change and outlined specific tasks that occur even before individuals begin to take action

(DiClemente 2003; Prochaska et al. 1992). More and more frequently, treatment providers are

being asked to motivate and not just educate or medicate substance-abusing patients.

Fortunately, demands on providers to become more involved in patient motivation have been

accompanied by advances in treatment perspectives and strategies that focus on increasing patient

motivation (Miller and Rollnick 2002; Petry 2006; Smith and Meyers 2004). Motivational

considerations are now viewed as critical for engagement in treatment and modification of

substance use (e.g., American Society of Addiction Medicine [ASAM] Patient Placement Criteria)

and motivational enhancement approaches are becoming an integral part of most outreach,

detoxification, and treatment programs. This chapter offers an overview of motivational

considerations, highlights how motivational enhancement approaches are being used, and briefly

reviews research regarding the application and efficacy of these approaches in the managementPrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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and treatment of alcohol and drug abuse problems.

WHAT IS MOTIVATION?

Motivation is a complex phenomenon and should not be compared to an on-off mechanism. Most

patients are not unmotivated to quit their drug or alcohol use but are simply more motivated to

engage in behaviors other than those desired by treatment providers. The challenge is to engage

substance abusers in treatment and assist them in moving through a multidimensional process of

change that leads to recovery. This process is described as the “stages of change” (DiClemente

2003) and involves five distinct steps that individuals take in order to create a sustainable

behavioral change. The first stage is precontemplation, in which the individual is not interested in

change and the therapist’s task is to help the patient become interested and concerned about the

need for change. Once interested, the individual moves through the contemplation stage by

engaging in a risk-reward analysis that leads to a firm decision to change. This is followed by the

preparation stage, in which the patient creates an effective and acceptable change plan while

increasing commitment for implementing the plan. All of the mentioned tasks must be

accomplished to some degree in order for a substance abuser to move through the stages of

precontemplation, contemplation, and preparation before actually taking successful action to

modify substance use. The action stage includes stopping the problematic pattern of behavior and

beginning to establish a new pattern of abstinence or modified drinking or drug use behaviors,

which is estimated to take 3–6 months. Maintenance, the final stage and task of the process, is

when the new behavior is integrated into the lifestyle of the recovering substance abuser and

maintained over time. Patient motivation involves the completion of all of these stages well enough

to support and sustain successful recovery (Carbonari and DiClemente 2000).

It is important to acknowledge that there are other perspectives on motivation. Some believe that

individuals can engage in a behavior without being completely motivated or, “fake it until they

make it.” This can be a strategy to deal with ambivalence, but eventually, it seems reasonable to

assume that the tasks of the change process need to be completed as the individual moves from

faking to making the change (Fletcher 2001).

A behavioral economics perspective uses contingency management techniques (rewarding

drug-free urine tests) to get people to stop engaging in a behavior for a time and has been effective

in helping patients achieve abstinence from drugs and alcohol (Vuchinich and Heather 2003).

However, an individual must ultimately find or identify some personal contingencies or internal

reasons to stop abusing substances in order to maintain abstinence once external contingencies are

terminated (Petry 2006).

MOTIVATIONAL ENHANCEMENT INTERVENTIONS

Motivational enhancement most specifically refers to the motivational interviewing strategies and

approaches that focus on patient ambivalence, decision making, and commitment in order to

stimulate movement through the initial stages of the patient process of change (Miller and Rollnick

2002). However, motivation is needed to sustain action and prevent relapse, as well as to move

through the initial stages of making the decision to change, increasing commitment, and planning.

Thus, motivational enhancement is probably best defined as employing strategies and approaches

that enhance the ability of an individual to achieve key tasks of the stages of change and advance

in the change process (DiClemente 2003). Although mental health care providers have to be ready

to help problematic or unmotivated patients progress though each of the stages of change, they

may not have to assist with every one of these tasks; many individuals accomplish some or all of

the tasks on their own prior to, during, or following treatment, and at times even without the

assistance of treatment (DiClemente 2006).

A number of interventions and strategies that focus on internal and external dimensions of

motivation have been developed and are designed to influence patient engagement in and

movement through the process of recovery and change. The most well-known approach to

addressing patient motivation is motivational interviewing (MI), developed by Miller and Rollnick

(2002). MI encompasses a style of patient–provider interaction that includes strategies focusedPrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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specifically on motivation, decision making, and resolving ambivalence. Initially, MI approaches

were used in brief interventions that gave Feedback to patients about the problem, emphasized

personal Responsibility, offered Advice and a Menu of options, used an Empathic approach, and

supported the patient’s sense of Self-efficacy or confidence that he or she could make the change

(FRAMES). In interventions such as the drinker checkup program, for example, individuals with

alcohol problems were evaluated and given feedback and advice over short periods of time or in

one or two sessions of consultation (Bien et al. 1993; Miller et al. 1988).

MI approaches have been incorporated into more formal intervention or treatment programs in a

number of ways. Adaptations of MI include brief interventions in opportunistic settings, such as

emergency departments (Longabaugh et al. 2001), developing treatment engagement strategies to

be used prior to more extensive treatment (Carroll et al. 2006), and developing a motivational

enhancement therapy (MET) that has been manualized and used in research projects and treatment

programs. MET was first used in outpatient and aftercare settings in the large multisite alcoholism

treatment trial called Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity;

Miller et al. 1992). Other researchers and clinicians have developed interventions that integrate MI

approaches into stage-based approaches, thereby matching the interventions to stages of change

(DiClemente et al. 1992; Substance Abuse and Mental Health Services Administration 1999;

Velasquez et al. 2001). In an effort to incorporate family members into the process, Smith and

Meyers (2004) have created family- and community-based approaches of MI to increase motivation

and encourage treatment entry with patients in the early stages of change. Additionally, the ARISE

approach (A Relational Intervention Sequence for Engagement; Landau et al. 2004) uses family

members to assist in engaging patients in treatment and promoting change. Finally, contingency

management approaches use monetary and other rewards to reinforce abstinence behaviors,

thereby creating incentives for movement toward change and initiation of abstinence (Petry 2006;

Vuchinich and Heather 2003). Although there are a number of ways to manipulate and increase

patient motivation, this chapter will focus primarily on stimulating change through MI and

stage-based approaches because these have become widespread among the treatment community

and have been studied in a variety of intervention settings. We will use the term motivational

enhancement to describe the various types of intervention and treatment strategies that use MI

and stage-based approaches.

MOTIVATIONAL ENHANCEMENT IN ALCOHOL TREATMENT

To date, there have been two very large, multisite, randomized controlled trials with

alcohol-abusing and dependent participants that examined the effectiveness of MET compared with

other nonpharmacological interventions. The first of these, Project MATCH, consisted of two parallel

studies, each consisting of 12 weeks of treatment delivered as outpatient or aftercare, that were

designed to examine the differential effects of three manualized treatments in alcohol-dependent

or alcohol-abusing participants (Project MATCH Research Group 1997a). Participants were

randomly assigned to receive 12 sessions of cognitive-behavioral therapy (CBT), 4 sessions of MET,

or 12 sessions of an individual therapy called 12-step facilitation (TSF) delivered over 12 weeks. All

participants were followed for 1 year posttreatment, and outpatients also received follow-up at 3

years posttreatment. Although there was little support for matching, which would have indicated

differential effects of treatments based on participant characteristics, all three of these treatments

improved alcohol-related outcomes at follow-up and there were no substantial differences between

the treatments. With this alcohol-dependent population, a four-session MET intervention performed

as well as the more comprehensive 12-session treatments in improving drinking outcomes,

although patients in MET drank more during the treatment period.

The second large, multisite, randomized controlled study was the United Kingdom Alcohol

Treatment Trial (UKATT), which compared the effects of MET and social behavior and network

therapy (SBNT) on alcohol-related outcomes in alcohol-dependent or alcohol-abusing participants

(UKATT Research Team 2001). Treatment for the SBNT group consisted of eight sessions using

cognitive-behavioral strategies and techniques to help participants create positive social support

networks that were meant to help change drinking behaviors. The MET group received threePrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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sessions over an 8-week period. Participants were followed for 1 year. The results of this study

indicated that both MET and SBNT were effective interventions in producing reductions in drinking

and improving abstinence outcomes (UKATT Research Team 2005).

The findings from Project MATCH and UKATT are consistent in demonstrating that participants who

received three or four sessions of MET did as well as participants who received cognitive-behavioral

or social support types of treatment for a longer period of time. MET consists of an assessment of

alcohol history, patterns, problems, and consequences; provides objective feedback using empathy;

engages the patient in a discussion of drinking and lifestyle using MI techniques (reflection,

affirming, summarizing, rolling with resistance, and avoiding argumentation); and works with the

patient to overcome ambivalence and to create a patient-driven change plan. This type and amount

of support and direction appears to be sufficient to engage the change process and motivate

modification of drinking behavior. It should be noted that this approach may be more helpful when

patients are high in state/trait anger (hostility and anger control) and that patients with

drinking-saturated environments may need more long-term support for sobriety from mutual help

groups (Project MATCH 1997b, 1998).

The role of motivation and the use of motivational enhancement strategies are being explored in

alcohol-related pharmacotherapy trials as well (McCaul and Petry 2003). The COMBINE (Combining

Medications and Behavioral Interventions) study was a randomized controlled trial that examined

the independent and combined effects of medication and behavioral therapy on alcohol-related

outcomes, such as abstinence from alcohol (Anton et al. 2006). The behavioral therapy component

was called a combined behavioral intervention (CBI), and it included components of MI, CBT, and

TSF. The results of this study indicated that CBI was a useful addition to medication management

and naltrexone in improving drinking outcomes. Although this study did not examine the effects of

MET alone, it provides initial support for the use of motivation-based interventions in conjunction

with medication management to improve alcohol-related outcomes. Some brief adherence

enhancement strategies that incorporate motivation-enhancing strategies are also being developed

and used in some trials (Johnson et al. 2003; Volpicelli et al. 2001).

BRIEF MOTIVATIONAL INTERVENTIONS FOR ALCOHOL USE DISORDERS

Brief interventions for individuals with alcohol problems have become respected and empirically

supported strategies for reaching large numbers of individuals with hazardous, abusive, and

dependent patterns of drinking. These interventions are generally conducted in a variety of

settings, can occur in person or by telephone, and can be implemented in 10–15 minutes or

extended to include several (e.g., two to four) sessions or contacts. Patients discuss their drinking,

complete some assessment measures, and are given feedback and advice about their drinking

(Miller et al. 1998), which is designed to be an incentive for altering problematic drinking (Babor et

1. 2001; Holder et al. 2000). Although this type of proactive therapy has been used with a wide

range of drinking patterns, from hazardous to dependent, most research has been done with

individuals who abuse alcohol and have not yet developed a pattern reflecting alcohol dependence

(U.S. Department of Health and Human Services 1997). Unlike more traditional treatments for

problematic drinkers, this technique does not involve overtly confrontational tactics (Miller and

Rollnick 2002). The lack of explicit confrontation is thought to reduce the defensiveness of targeted

individuals who tend not to be self-referred and may not see any need for substance use treatment

(Miller et al. 1998). Oftentimes, the goal of brief interventions is harm reduction rather than

complete abstinence (U.S. Department of Health and Human Services 1997).

Overall, brief interventions generally have been found to be effective (U.S. Department of Health

and Human Services 1997). A meta-analysis of controlled studies comparing baseline with

posttreatment alcohol measures found that brief interventions were quite effective and yielded

high mean effect sizes (Cohen’s d = 0.70–0.80) for problem drinkers (Bien et al. 1993). When brief

interventions were compared with control groups that were assessed and advised, the effect size

fell to 0.38, indicating that merely asking individuals about their drinking and related correlates

may result in less drinking for some individuals (Bien et al. 1993). Moreover, this meta-analysisPrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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revealed that brief interventions were comparable to more extensive treatment in terms of

treatment success. In fact, Miller et al. (1998) conducted a large meta-analysis of the effectiveness

of treatments and found that brief motivational interventions had some of the best effect sizes in

comparison with a large number of alternative treatments. Nevertheless, additional research is

warranted to determine which individuals benefit most from these interventions, since there is

some evidence that, for men, brief interventions may be more beneficial than merely screening for

alcohol problems (this effect has not been found for women) (Babor and Grant 1992; Scott and

Anderson 1991; U.S. Department of Health and Human Services 1997).

A number of studies have examined brief interventions with problem drinkers, including drinkers

with hazardous, binge, and abusive patterns of use. In much of the research on the “drinker

checkup,” a brief evaluation and consultation program for problem drinkers from the community,

Miller et al. (1988) often excluded drinkers who met criteria for alcohol dependence and focused on

problem drinkers. However, a more recent meta-analysis that evaluated high-quality, randomized

controlled trials in primary care settings concluded that heavy drinkers had better outcomes with

brief alcohol interventions than with no intervention, with an odds ratio of almost 2:1 (1.91) (Wilk

et al. 1997). Some of the reviewed studies also suggested lower mortality and morbidity rates with

brief interventions and decreases in health care costs (Edwards and Rollnick 1997; Miller et al.

1998). The success of brief interventions has led many groups to call for including them in many

different health care settings—for example, the College of Surgeons is making screening and brief

intervention for alcohol a part of the accreditation criterion for Level I trauma units (Committee on

Trauma 2006), and other settings are recommending a stepped-care approach for working with

problem drinkers who do not respond to brief interventions (Joseph et al. 1999).

Brief interventions targeting vulnerable populations of drinkers require appropriate screening. One

of the issues that must be addressed in implementing these programs is how to define the problem

that would trigger the intervention. Problem drinking has been defined in a variety of ways in

various settings and studies. Some use “at-risk drinking in the previous month or an alcohol use

disorder in the past 12 months” as the screen (Taj et al. 1998), while others use screening

instruments such as the CAGE Questionnaire or Alcohol Use Disorders Identification Test (AUDIT)

either in part or in their entirety (for a review of instruments, see Fiellin et al. 2000). Taj et al.

(1998) investigated the effectiveness of a single question, “On any single occasion during the past

3 months, have you had more than five drinks containing alcohol?” and compared the answer with

responses to the AUDIT (Babor et al. 2001). Findings indicated that the question had a 74%

positive predictive ability and an 88% negative predictive ability for problem drinking (sensitivity =

62%; specificity = 93%). Thus, this single question appears useful in screening for problem

drinking but does not necessarily capture drinkers engaged in what are called hazardous drinking

patterns as defined by daily or weekly levels of drinking (visit the National Institute on Alcohol

Abuse and Alcoholism Web site for additional information: http://www.niaaa.nih.gov).

A second concern and difficulty in studies examining brief interventions is whether they reach the

population of individuals who need interventions the most. Edwards and Rollnick (1997), for

instance, reviewed all published studies of brief interventions for drinking that were conducted in

primary care settings and found that there were high levels of attrition in these studies. Although

researchers rarely publish attrition analyses that describe how participants who dropped out or

who were lost during study follow-up may differ from those who completed the study, this study

found some evidence to suggest that the two groups are very different from each other: the former

tended to be younger, less educated, and heavier drinkers.

MOTIVATIONAL ENHANCEMENT AND DRUG ABUSE

Although there is less research exploring the use of MI and MET approaches to reduce drug use,

there is a growing body of empirical studies that show them to be effective in motivating change

and enhancing treatment entry and engagement with patients experiencing problems with

substances other than alcohol, such as tobacco, marijuana, and cocaine. Much of the research that

finds such positive effects suggests that when motivation-enhancing components precede morePrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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intense substance abuse treatment, retention in treatment increases (Martino et al. 2000; Saunders

et al. 1995; Stotts et al. 2001; Swanson et al. 1999).

A manual for implementing MET as a precursor to outpatient drug treatment is currently being

tested in Clinical Trials Network studies of the National Institute on Drug Abuse (NIDA) (Carroll et

1. 2002). This treatment consists of three sessions based on the study by Miller et al. (1992),

which focus on problem identification and feedback, resolving ambivalence, and creating a change

plan. Although some would argue that brief MET is as effective as a stand-alone treatment for

substance use disorders, others object because of findings that link longer drug treatment to better

outcomes (Simpson et al. 1997). However, MET is consistent with long-term treatment approaches;

its philosophy can guide intervention and its techniques can be used during longer-term treatment,

as long as treatment remains based on an individual’s stage of change. Therefore, the Haight

Ashbury Free Clinics have created and are testing a “higher dose motivational enhancement”

manual (Polcin et al. 2004). The first three sessions are congruent with the ones mentioned as part

of the NIDA study. The final eight sessions continue to employ motivational enhancement

techniques and provide help in resolving continued ambivalence, reinforcing accomplishments and

progress, addressing drug use and temptations to use, and allowing for revision of the change plan.

Longer-term use of MET could be particularly beneficial if an individual does not quickly move from

early (e.g., precontemplation) to later (e.g., action) stages of change.

Nicotine

Although more research needs to be done in the area of nicotine addiction, there are a few studies

that support the potential that MET has for reducing smoking. Home health care nurses have used

MET with patients, which has led to more quit attempts and greater reductions in the number of

cigarettes smoked daily than when patients received the standard care for smoking cessation

(Borrelli et al. 2005). These benefits were maintained at 1 year posttreatment, and the percentage

of individuals in the MET condition who quit smoking was double that of the standard care group.

Other research compares adaptations of MI and MET—adapted motivational interviewing (AMI)—to

the provision of authoritarian advice to quit smoking (Butler et al. 1999; Colby et al. 1998). Adults

in an AMI group used fewer cigarettes in the 24 hours prior to assessment, increased the time

between waking up and the first cigarette of the day, had more attempts to quit that lasted one

week or more, and were more likely to move into a later stage of change (Butler et al. 1999). In an

adolescent population, a 30-minute AMI session resulted in two-thirds of the sample attempting to

quit smoking as well as significant reductions in smoking rate and dependence (Colby et al. 1998).

Although AMI results were not significantly better than those following 5 minutes of brief advice,

the effectiveness of AMI was supported. However, these types of interventions are not always

effective with individuals with multiple problems (Velasquez et al. 2000), and even a four-session

MET intervention with drug-abusing pregnant women was not found to be sufficient to motivate

changes in smoking (Haug et al. 2004).

Marijuana

The use of MET components has led to significant reductions in marijuana use for adults (Marijuana

Treatment Project Research Group 2004; Sinha et al. 2003) and adolescents (Colby et al. 1998;

Monti et al. 1999). In adults, MET and skills-based relapse prevention interventions both

demonstrated decreases in marijuana-related problems and symptoms of dependence (Stephens et

1. 2000). Although neither intervention outperforme the other, only 3 hours of MET was as

effective as 28 hours of relapse prevention in increasing abstinence. The brevity of MET supports its

use as a cost-effective alternative to more extensive care, particularly if an opportunity for lengthy

care is not likely (e.g., with homeless populations not seeking treatment). Finally, a study

comparing two sessions of MET, nine sessions of MET plus CBT, and a delayed-treatment control

group showed that although the nine-session treatment performed the best, the two-session MET

condition produced significant reductions in marijuana use among dependent adults and was as

effective as MET plus CBT in increasing the use of coping skills (Litt et al. 2005).

Findings in adolescent populations have not been as convincing but reflect that continued researchPrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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is important and stronger effects may be found if more intensive treatment is provided (Melnick et

1. 1997). A one-session MET intervention to address alcohol and marijuana use in homeless

adolescents did not affect the use of these two substances, but the use of other illicit drugs at the

1-month follow-up decreased significantly (Peterson et al. 2006). A school-based study showed

that adolescent marijuana users are willing to attend an intervention for use, even though

significant decreases in marijuana use were observed in both the two-session MET intervention and

a waitlist control group (Walker et al. 2006).

Cocaine

Motivational enhancement is likely to be useful, particularly as a precursor to more intensive

treatment, for individuals seeking help for cocaine misuse (DeLeon et al. 1997). Level of motivation

has been found to influence success in treatment for cocaine abusers, suggesting that increasing

motivation will increase success. In fact, those with low initial motivation to change who received

MET reported lower rates of relapse to cocaine use and fewer days of cocaine use at the 1-year

follow-up than those with high initial motivation (Rohsenow et al. 2004). This was the case despite

lack of observable benefits at the 3- to 6-month follow-up periods, suggesting that even if

immediate benefits of MET are not observed, effects may emerge up to 1 year posttreatment. In

this study, MET was also predictive of decreased alcohol use and increased motivation, treatment

expectations, perceived negative effects of cocaine, and self-efficacy to deal with high-risk

situations. However, for individuals with high initial motivation to change, those receiving MET

reported higher frequencies of cocaine use and more severe alcohol problems than did those with

low motivation and those not receiving MET. Thus, it is possible that MET should only be used when

motivation for change is low. This is reflective of the need to match intervention strategies to stage

of change (DiClemente 2003). The type of change to which patients commit also has effects on

treatment success. Specifically, those who commit to complete abstinence are less likely to relapse

than those who commit to use reduction (Rohsenow et al. 2004). Thus, with cocaine users, it may

be helpful not only to encourage change in MET but also to stress the importance of committing to

complete abstinence.

Opiate and Polydrug

Research on the effectiveness of MET for treating opiate and multiple drug addictions is lacking.

Only one study was found that used an intervention for opiate addiction based on MI, and the

intervention did not contain all of the components necessary to define it as MET (Saunders et al.

1995). Nevertheless, this study found that one intervention session plus one follow-up session

resulted in decreased opiate-related problems and greater compliance with treatment 6 months

later. Significant reductions in actual use were not found. Individuals who injected multiple drugs

were included in a study that provided either five 30-minute sessions of MET/AMI or risk-reduction

sessions of equivalent intensity (Booth et al. 1998). The outcome, successfully completing the

intake procedure for treatment entry, did not differ between the two groups. While MET/AMI has

been shown to increase treatment entry in a number of drug use studies, strong support for the use

of these methods has not been found in the area of opiates and multiple drug use, perhaps because

of a lack of research.

Although numerous studies have shown support for motivational techniques, some have not found

effects on drug use outcomes (Booth et al. 1998; Donovan et al. 2001; Miller et al. 2003; Schneider

et al. 2000). For example, Schneider et al. (2000) found that MI was no more effective in an

employee assistance program than confrontational interviewing for substance abuse and thus

concluded that both would afford similar benefits; however, motivational techniques provide an

alternative for practitioners and patients who prefer to avoid a confrontational approach.

Nonsignificant effects in these studies could be attributed to mismatching strategies with the

patient’s stage of change. When treatment is incongruent with where an individual is in the process

of change (e.g., an individual is further along in the process of change than the intervention),

resistance to treatment and change and/or dropout is more likely (Booth et al. 1998; Rollnick et al.

1992). Since stage status could be an important matching variable, it could also serve as anPrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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important outcome variable, since behavior change is not the only outcome one would expect from

motivational enhancement approaches.

Positive effects are seen even when interventions based on MET are provided by clinicians who are

not substance abuse treatment specialists (Dunn et al. 2001). However, as with any other

treatment, MET “must be provided with fidelity and skill” (Madson and Campbell 2006, p. 67).

Clinicians planning to implement MET are encouraged to attend trainings and refer to primary

sources of information about MET (Miller and Rollnick 2002; Miller et al. 1992); see also

http://www.motivationalinterviewing.org).

Integrating MET into the treatment plan of new patients entering treatment for any combination of

drug problems is likely to demonstrate benefits, especially among those who report low motivation

for change (Dunn et al. 2001) and are unready, unwilling, or unable to change (DiClemente 2003).

Additionally, MET has been found to maintain its effects regardless of length of follow-up (Dunn et

1. 2001) and effects can emerge at time points subsequent to initial posttreatment assessments.

MOTIVATIONAL ENHANCEMENT WITH DUALLY DIAGNOSED POPULATIONS

Although there are concerns and skepticism regarding the severity of mental illness and cognitive

impairment of individuals with substance abuse problems with whom MET would be used, there is a

growing literature in this area. Motivational considerations and approaches are being recommended

and tested with a variety of dually diagnosed individuals with different substances of abuse.

Motivational enhancement interventions have often produced improved outcomes compared with

control conditions in a range of alcohol and drug abuse patients, some of whom had coexisting

psychiatric problems of varying degrees (Bien et al. 1993; Stotts et al. 2001). In a large, recent,

multisite effectiveness study, Carroll et al. (2006) found that integrating MET into intake

procedures increased retention but not short-term drug use outcomes. However, brief motivational

interventions prior to treatment have not always improved treatment engagement and outcomes,

particularly in populations of drug abusers who are poor, of minority status, less educated, and

have multiple problems (Donovan et al. 2001; Miller et al. 2003).

Motivational techniques based on MI principles have been viewed as promising in a systematic

literature review of interventions for improving medication adherence and viewed as superior to

more traditional psychoeducational approaches for dually diagnosed individuals (Ziedonis and

Trudeau 1997; Zygmunt et al. 2002). Swanson et al. (1999) found that adding MI techniques to

initial assessment increased the proportion of patients attending outpatient appointments overall

and for a dually diagnosed group of patients. Others have found that MI and personalized feedback

increased tobacco treatment engagement and attendance for individuals with serious mental illness

(Steinberg et al. 2004). In a pilot study, Daley et al. (1998) found that a motivational intervention

increased attendance and engagement and decreased rehospitalization among patients with

depressive disorders and cocaine dependence. There are also some very innovative proactive

programs reaching out to homeless, drug-abusing individuals with serious mental illness, where

treatment providers go onto the streets and begin discussions on behavioral change using MI

principles (Fisk et al. 2006).

These findings are promising but much more needs to be done to evaluate how to use both brief

interventions and motivational enhancement approaches with dually diagnosed individuals and, in

particular, with individuals with serious mental illness and substance abuse. Nevertheless, initial

findings indicate that it is possible to assess and intervene in order to motivate dually diagnosed

individuals to move through the process of modifying substance use in ways that are similar to

those described above, with some modifications and attention to the special needs of this

population (DiClemente et al., in press).

CONCLUSION

Motivation is critical for making changes in substance-abusing behaviors. In order to overcome the

common difficulties and barriers to the successful modification of problematic patterns of

substance use and to recover from alcohol and drug dependence, individuals must negotiate aPrint: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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multidimensional path of change that requires decision making, choice, commitment, and coping

activities. Motivation is needed to stimulate and negotiate accomplishment of these tasks. A

number of very self-motivated individuals negotiate this path on their own without treatment.

Others seem to benefit from brief motivational interventions to help them to activate the process.

However, many others need treatment and assistance to consider, decide, plan, and commit to

changing their problematic substance-using behaviors. Motivational enhancement approaches could

be very helpful for all health care providers who treat problems that are related to substance abuse

or who treat substance abuse directly.

There are a number of ways that motivational enhancement techniques are being incorporated into

interventions to assist individuals with problematic patterns of alcohol and drug use. Screening and

brief interventions are being used to address problematic use more proactively in a variety of

health care and opportunistic settings. This is particularly true for alcohol abuse; screening and

brief motivational interventions are being offered in primary care offices, emergency departments,

trauma centers, college health and student services, employee assistance programs, and other

venues. At the same time, substance abuse treatment providers are developing pretreatment

motivational enhancement approaches to prepare patients for treatment, increase engagement,

and accelerate movement through the process of change, both in individual and group formats.

Some treatment programs are using MET as one of the options that are given to patients, either as

stand-alone treatment or as part of a more comprehensive, multicomponent treatment delivered as

a package or in a stepped-care manner (offering more extensive treatments to individuals unable

to change with less intensive, motivational approaches). Clearly, there are many ways to

incorporate motivational enhancement and MI approaches into substance abuse interventions

(Wagner and Conners 2007).

It is also important to note that there are two key components of motivational enhancement

approaches. The first represents a style or way of interacting with the patient that is

patient-centered, nonconfrontational, empathic, respectful, and reflective in its advice giving

(Miller et al. 1993). The second component consists of the techniques and strategies that are

designed to influence motivation, resolve ambivalence, and elicit self-motivational statements and

activities. These techniques include complex reflections, use of summaries to frame motivational

messages, techniques to manage and roll with resistance, offering advice with permission,

maximizing opportunities to affirm and build the patient’s sense of efficacy to be able to implement

change, and assisting the patient to create a realistic change plan rather than attempting to control

the patient change process. Although the techniques are focused on the tasks that generally occur

in the earlier stages of change, the style of MI and MET can be integrated into most treatment

approaches and is compatible with use of pharmacotherapy, mutual help, and intensive

psychosocial treatments.

Over the past 15 years, there have been major advances in treatment options for patients with

alcohol and drug abuse problems. Motivational enhancement approaches represent one of these

advances that have extended the reach and effectiveness of existing interventions. The reach and

impact of motivational enhancement approaches are only beginning to make a difference in the

behaviors of substance abuse treatment providers.

KEY POINTS

Motivation is a multidimensional concept that is critical to understanding recovery and providing substance

abuse treatment.

Motivation consists of the patient’s readiness to change and engagement in the multiple tasks needed to

successfully achieve and maintain sobriety, often identified by the stages of change.

Motivational enhancement strategies can include brief interventions in opportunistic settings (e.g.,

emergency department, primary care, substance abuse testing or screening) and more extensive multisession

treatment protocols.Print: Chapter 25. Motivational Enhancement http://www.psychiatryonline.com/popup.aspx?aID=353218&print=yes…

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Motivational interviewing developed by Miller and Rollnick is both a style of interacting and a set of

techniques that addresses patient ambivalence and lack of motivation.

Although more research is needed (especially with more severe cases and in individuals with multiple

diagnoses), studies generally support use of motivational interviewing and motivational enhancement for

individuals with a broad range of substance abuse problems.

More extensive research on motivational enhancement approaches has been done with alcohol problems

followed by studies of nicotine and marijuana and fewer studies involving cocaine and opiates.

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SUGGESTED READING

Arkowitz H, Westra HA, Miller WR, et al: Motivational Interviewing in the Treatment of

Psychological Problems. New York, The Guilford Press, 2007

Miller WR, Rollnick S: Motivational Interviewing: Preparing People for Change, Second Edition. New

York, Guilford, 2002

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research guide for therapists treating individuals with alcohol abuse and dependence. Project

MATCH Monograph Series, 2 (SHHA Publ No ADM-92-1884). Rockville, MD, National Institute on

Alcohol Abuse and Alcoholism, 1992

Rollnick S, Miller WR, Butler CC: Motivational Interviewing in Health Care. New York: Guilford

Press, 2007

Velasquez MM, Maurer GG, Crouch C, et al: Group Treatment for Substance Abuse: A Stage of

Change Manual. New York, Guilford, 2001

Wagner CC, Conners W: Motivational interviewing: resources for clinicians, researchers, and

trainers. 2007. Available at: http://www.motivationalinterviewing.org. Accessed January 2, 2008.

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