“The prevalent clinical focus on denial and motivation as client traits was misguided. Indeed, client motivation clearly was a dynamic process responding to a variety of interpersonal influences including advice, feedback, goal setting, contingencies, and perceived choice among alternatives.”
—Miller & Rollnick, 2013, p. 374
•
Personalized feedback about a client's use of substances relative to others and level of health-related risk can enhance client motivation to change substance use behaviors.
•Counselor focus and motivational counseling strategies should be tailored to the client's stage in the Stage of Change (SOC) model.
•Effective motivational counseling approaches can be brief and include a brief intervention (BI) and brief treatment (BT) or comprehensive and include screening, brief intervention, and referral to treatment (SBIRT).
Chapter 2 examines science-informed elements of motivational approaches that are effective in treating substance use disorders (SUDs). Any clinical strategy that enhances client motivation for change is a motivational intervention. Such interventions can include counseling, assessment, and feedback. They can occur over multiple sessions or during one BI, and they can be used in specialty SUD treatment settings or in other healthcare settings. Chapter 2 also highlights what you should focus on in each stage of the SOC approach and discusses how to adapt motivational interventions to be culturally responsive and suitable for clients with co-occurring substance use and mental disorders (CODs).
Motivational counseling strategies have been used in a wide variety of settings and with diverse client populations to increase motivation to change substance use behaviors. The following elements are important parts of motivational counseling:
•FRAMES approach
•Decisional balancing
•Developing discrepancy between personal goals and current behavior
•Flexible pacing
•Maintaining contact with clients
Miller and Sanchez (1994) identified six common elements of effective motivational counseling, which are summarized by the acronym FRAMES:
•Feedback on personal risk relative to population norms is given to clients after substance use assessment.
•Responsibility for change is placed with the client.
•Advice about changing the client's substance use is given by the counselor nonjudgmentally.
•Menu of options and treatment alternatives is offered to the client.
•Empathetic counseling style (i.e., warmth, respect, an understanding) is demonstrated and emphasized by the counselor.
•Self-efficacy is supported by the counselor to encourage client change.
Since FRAMES was developed, research and clinical experience have expanded and reined elements of this motivational counseling approach. FRAMES is often incorporated into SBIRT interventions. It has also been combined with other interventions and tested in diverse settings and cultural contexts (Aldridge, Linford, & Bray, 2017; Manuel et al., 2015; Satre, Manuel, Larios, Steiger, & Satterfield, 2015).
Give personalized feedback to clients about their substance use; feedback presented in this way is effective in reducing substance misuse and other health-risk behaviors (Davis, Houck, Rowell, Benson, & Smith, 2015; DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017; Field et al., 2014; Kahler et al., 2018; McDevitt-Murphy et al., 2014; Walker et al., 2017). This type of feedback usually compares a client's scores or ratings on standard screening or assessment instruments with normative data from a general population or treatment groups. Feedback should address cultural differences and norms related to substance misuse. For example, a review of the research on adaptations of BI found that providing feedback specifically related to cultural and social aspects of drinking to Latino clients reduced drinking among these clients to a greater degree than standard feedback (Manuel et al., 2015; Satre et al., 2015).
Presenting and discussing assessment results can enhance client motivation to change health-risk behaviors. Providing personalized feedback is sometimes enough to move clients from the Precontemplation stage to Contemplation without additional counseling and guidance.
Structure a feedback session thoughtfully. Establish rapport before giving a client his or her score. Strategies to focus the conversation before offering feedback include the following:
•Express appreciation for the client's efforts in providing the information.
•Ask whether the client had any difficulties with answering questions or filling out forms. Explore specific questions that might need clarification.
•Make clear that you may need the client's help to interpret the findings accurately.
•Encourage questions: “I'll be giving you lots of information. Please stop me if you have a question or don't understand something. We have plenty of time today or in the next session, if needed.”
•Stress that the instruments provides objective data. Give some background, if appropriate, about how the tests are standardized for all populations and how widely they are used.
COUNSELOR NOTE: MOTIVATIONAL ENHANCEMENT THERAPY.
When you provide feedback, show the client his or her score on any screening or assessment instrument and explain what the score means. Exhibit 2.1 is a sample feedback handout to share with a client after completing the Alcohol Use Disorders Identification Test (AUDIT). Appendix B presents the U.S AUDIT questionnaire and scoring instructions.
EXHIBIT 2.1. The Drinker's Pyramid Feedback.
Your score indicates ___________________________________
Check here if applicable _______
Your response to AUDIT Question 3 indicates that you have experienced episodes of binge drinking (e.g., 5 drinks for men and 4 drinks for women consumed within 2 hours on a single occasion). The immediate risks of intoxication or binge drinking include:
•Motor crashes or other serious accidents.
•Falls and other physical injuries.
•Intimate partner violence.
•Depressed mood.
•Suicidal or homicidal thoughts or behavior.
•Unintended firearm injuries.
•Alcohol poisoning.
•Assaults and sexual assaults.
•Unprotected sex (leading to sexually transmitted diseases and unintended pregnancy).
•Child abuse and neglect.
Property and other crime.
•Fires.
Check here if applicable _____
Your responses to AUDIT Questions 1 (frequency) and 2 (number of drinks consumed) indicate that you are drinking more than the recommended limits (no more than 3 drinks on a single day and 7 drinks per week for all women and for men older than 65; no more than 4 drinks on a single day and 14 drinks per week for men ages 65 and younger). Long-term risks of alcohol misuse use include:
•Gastric distress.
•Hypertension.
•Cardiovascular disease.
•Permanent liver damage.
•Cancer.
•Pancreatitis.
•Diabetes.
•Chronic depression.
•Neurologic damage.
•Fetal alcohol spectrum disorders in newborns (which include physical, behavioral, and learning disabilities).
Sources: Babor, Higgins-Biddle, & Robaina, 2016; Venner, Sánchez, Garcia, Williams, & Sussman, 2018
Use a motivational style to present the information. Do not pressure clients to accept a diagnosis or offer unsolicited opinions about the meaning of results. Instead, preface explanations with statements like, “I don't know whether this will concern you, but …” or “I don't know what you'll make of this result, but.” Let clients form their own conclusions, but help them by asking, “What do you make of this?” or “What do you think about this?” Focus the conversation on clients' understanding of the feedback.
Strategies for presenting personalized feedback to clients include:
•Asking about the client's initial reaction to the tests (e.g., “Sometimes people learn surprising things when they complete an assessment. What were your reactions to the questionnaire?”).
•Providing a handout or using visual aids that show the client's scores on screening instruments, normative data, and risks and consequences of his or her level of substance use (see Exhibit 2.1 above). Written materials should be provided in the client's first language.
•Offering information in a neutral, nonjudgmental, and respectful way.
•Using easy-to-understand and culturally appropriate language.
•Providing small chunks of information.
•Using open questions to explore the client's understanding of the information.
•Using reflective listening and an empathetic counseling style that emphasizes the client's perspective on feedback and how it may have affected the client's readiness to change.
•Summarizing results, including risks and problems that have emerged, the client's reactions, and any change talk the feedback has prompted, then asking the client to add to or correct the summary.
•Providing a written summary to the client.
Clients' responses to feedback differ. One may be alarmed to find that she drinks much more in a given week than comparable peers but be unconcerned about potential health risks of drinking. Another may be concerned about his potential health risks at this level of drinking. The key to using feedback to enhance motivation is to continue to explore the client's understanding of the information and what it may suggest about possible behavior change. Personalized feedback is applicable to other health-risk behaviors issues, such as tobacco use (Steinberg, Williams, Stahl, Budsock, & Cooperman, 2015).
Use a motivational approach to encourage clients to actively participate in the change process by reinforcing personal autonomy. Individuals have the choice of continuing their behavior or changing it. Remind clients that it is up to them to make choices about whether they will change their substance use behaviors or enter treatment. Reinforcing personal autonomy is aligned with the self-determination theory discussed in Chapter 1 (Deci & Ryan, 2012; Flannery, 2017).
Strategies for emphasizing client responsibility include the following:
•Ask clients' permission to talk about their substance use; invite them to consider the information you are presenting. If clients have choices, they feel less need to oppose or dismiss your ideas.
•State clearly that you will not ask clients to do anything they are unwilling to do. Let them know that it is up to them to make choices about behavior change.
•Determine a common agenda for each session.
•Agree on treatment goals that are acceptable to clients.
When clients realize they are responsible for the change process, they feel empowered and more invested in it. This results in better treatment outcomes (Deci & Ryan, 2012).
Practice the act of giving advice; this simple act can promote positive behavioral change. BI that includes advice delivered in the MET/MI counseling style can be effective in changing substance use behaviors such as drinking, drug use, and tobacco use (DiClemente et al., 2017; Steinberg et al., 2015). As with feedback, the manner in which you advise clients influences how or whether the client will use your advice. It is better not to tell people what to do; suggestions yield better results. A motivational approach to offering advice may be either directive (making a suggestion) or educational (providing information). Educational advice should be based on credible scientific evidence, such as safe drinking limits recommended by the National Institute on Alcohol Abuse and Alcoholism or facts that relate to the client's conditions (e.g., blood alcohol concentration levels at the time of an automobile crash).
EXPERT COMMENT: A REALISTIC MODEL OF CHANGE—ADVICE TO CLIENTS.
Strategies for offering advice include the following:
•Ask permission to offer suggestions or provide information. For example, “Would you like to hear about safe drinking limits?” or “Can I tell you what tolerance to alcohol is?” Such questions provide a nondirective opportunity to share your knowledge about substance use in a respectful manner.
•Ask what the client thinks about your suggestions or information.
•Ask for clarification if the client makes a specific request, rather than give advice immediately.
•Offer simple suggestions that match the client's level of understanding and readiness, the urgency of the situation, and his or her culture. In some cultures, a directive approach is required to convey the importance of advice or situations; in others, a directive style is considered rude and intrusive.
This style of giving advice requires patience. The timing of any advice is important, relying on your ability to hear what clients are requesting and willing to receive. Chapter 3 provides more information about the structured format used in MI for offering clients feedback or giving advice.
EXPERT COMMENT: THE PIES APPROACH.
Offer choices to facilitate treatment initiation and engagement. These choices have been shown to enhance the therapeutic alliance, decrease dropout rates, and improve outcomes
(Van Horn et al., 2015). Clients are more likely to adhere to a specific change strategy if they can choose from a menu of options. Giving clients choices for treatment goals and types of available service increases their motivation to participate in treatment.
Strategies for offering a menu of options include the following:
•Provide accurate information on each option and potential implications for choosing that option.
•Elicit from clients which options they think would work or what has worked for them in the past.
•Brainstorm alternative options if none offered are acceptable to clients.
Providing a menu of options is consistent with the motivational principle of supporting client autonomy and responsibility. Clients feel more empowered when they take responsibility for their choices. Your role is to enhance their ability to make informed choices. When clients make independent decisions, they are likely to be more committed to them. This concept is examined more fully in Chapter 6.
Use an empathic counseling style by showing active interest in understanding clients' perspectives (Miller & Rollnick, 2013). Counselors who show high levels of empathy are curious, spend time exploring clients' ideas about their substance use, show an active interest in what clients are saying, and often encourage clients to elaborate on more than just the content of their story (Miller & Rollnick, 2013). Counselor empathy is a moderately strong predictor of client treatment outcomes (Elliot, Bohart, Watson, & Murphy, 2018).
As explained in Chapter 3, reflective listening effectively communicates empathy. The client does most of the talking when a counselor uses an empathic style. It is your responsibility to create a safe environment that encourages a free flow of communication with the client. An empathic style appears easy to adopt, but it requires training and significant effort on your part. This counseling style can be particularly effective with clients in the Precontemplation stage.
Help clients build self-efficacy by being supportive, identifying their strengths, reviewing past successes, and expressing optimism and confidence in their ability to change (Kadden & Litt, 2011). To succeed in changing, clients must believe they can undertake specific tasks in a specific situation (Bandura, 1977). In addiction treatment, self-efficacy usually refers to clients' ability to identify high-risk situations that trigger their urge to drink or use drugs and to develop coping skills to manage that urge and not return to substance use. Considerable evidence points to self-efficacy as an important factor in addiction treatment outcomes (Kadden & Litt, 2011; Kuerbis, Armeli, Muench, & Morgenstern, 2013; Litt & Kadden, 2015; Morgenstern et al., 2016).
Ask clients to identify how they have successfully coped with problems in the past: “How did you get from where you were to where you are now?” or “How have you resisted the urge to use in stressful situations?” Once you identify strengths, you can help clients build on past successes. Affirm small steps and reinforce any positive changes. Self-efficacy is discussed again in Chapters 3, 5, and 7.
Explore with the client the benefits and drawbacks of change (Janis & Mann, 1977). Individuals naturally explore the pros and cons of any major life choice, such as changing jobs or getting married. In SUD recovery, the client weighs the pros and cons of changing versus not changing substance use behaviors. You assist this process by asking the client to articulate the positive and negative aspects of using substances. This process is usually called decisional balancing and is further described in Chapter 5.
Exploring the pros and cons of substance use behaviors can tip the scales toward a decision for positive change. The actual number of reasons a client lists on each side of a decisional balance sheet is not as important as the weight—or personal value—of each. For example, a 20-year-old who smokes cigarettes may put less weight on getting lung cancer than an older adult, but he may be very concerned that his diminished lung capacity interferes with playing basketball.
To enhance motivation for change, help clients recognize any discrepancy or gap between their future goals and their current behavior.
You might clarify this discrepancy by asking, “How does drinking fit or not fit with your goal of improving your family relationships?” When individuals see that present actions conflict with important personal goals, such as good health, job success, or close personal relationships, change is more likely to occur (Miller & Rollnick, 2013). This concept is expanded in Chapter 3.
Assess the client's readiness for change; resist your urges to go faster than the client's pace.
Every client moves through the SOC at his or her own pace. Some will cycle back and forth numerous times between stages. Others need time to resolve their ambivalence about current substance use before making a change. A few are ready to get started and take action immediately. Knowing where a client has been and is now in the SOC helps you facilitate the change process at the right pace. Be aware of any discrepancies between where you want the client to be and where he or she actually is in the SOC. For example, if a client is still in the Contemplation stage, your suggestion to take steps that are in the Action stage can create discord.
Flexible pacing requires you to meet clients at their level and allow them as much or as little time as they need to address the essential tasks of each stage in the SOC. For example, with some clients, you may have to schedule frequent sessions at the beginning of treatment and fewer later. In other cases, clients might need a break from the intensity of treatment to focus on specific aspect of recovery. If you push clients at a faster pace than they are ready to take, the treatment alliance may break down.
Employ simple activities to enhance continuity of contact between you and the client. Such activities may include personal handwritten letters, telephone calls, texts, or emails. Use these simple motivation-enhancing interventions to encourage clients to return for another counseling session, return to treatment following a missed appointment, and stay involved in treatment.
Activities that foster consistent, ongoing contact with clients strengthen the therapeutic alliance. The treatment alliance is widely recognized as a significant factor in treatment outcomes in most treatment methods including addiction counseling (Brorson, Arnevik, Rand-Hendriksen, & Duckert, 2013). Low alliance predicts higher risk of clients dropping out of treatment (Brorson et al., 2013).
Make sure you and your clients follow all agency policies and ethical guidelines for making contact outside of sessions or after discharge. For more information on using technology to maintain contact with clients, see Treatment Improvement Protocol (TIP) 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015b).
People considering major changes in their lives, such as adopting an alcohol- or drug-free lifestyle, go through different change processes. Your job as a counselor is to match your treatment focus and counseling strategies with these processes throughout the SOC.
Understand how catalysts for change operate. This will help you use motivational counseling strategies that support and enhance changes clients are contemplating. Prochaska (1979) identified common personal growth processes linked to different behavioral counseling approaches. These processes or catalysts for change have been further developed and applied to the SOC model (Connors, DiClemente, Velasquez, & Donovan, 2013). Catalysts are experiential or behavioral (Exhibit 2.2). Experiential catalysts are linked more frequently with early SOC phases and behavioral catalysts with later SOC phases.
EXHIBIT 2.2. Catalysts for Change.
Use motivational supports that match the client's SOC. If you try to use strategies appropriate to a stage other than the one the client is in, the client might drop out or not follow through on treatment goals. For example, if a client in Contemplation is ambivalent about changing substance use behaviors and you argue for change or jump into the Preparation stage, the client is likely to become reactive.
Examples of how to tailor motivation support to the client's stage in the SOC include helping the client:
•In Precontemplation consider change by increasing awareness of behavior change.
•In Contemplation resolve ambivalence by helping him or her choose positive change over the current situation.
•In Preparation identify potential change strategies and choose the most appropriate one for the circumstances.
•In Action carry out and follow through with the change strategies.
•In Maintenance develop new skills to maintain recovery and a lifestyle without substance misuse. If misuse resumes, help the client recover as fast as possible; support reentering the change cycle.
Exhibit 2.3 depicts the overarching counseling focus in each stage. Chapters 4 through 7 examine specific counseling strategies for each stage.
EXHIBIT 2.3. Counselor Focus in the SOC.
The principles underlying motivational counseling approaches have been applied across cultures, to different types of problems, in various treatment settings, and with many different populations (Miller & Rollnick, 2013). The research literature suggests that motivational interventions (i.e., MI, MET, and BI) are associated with successful outcomes including adherence to and retention in SUD treatment; reduction in or abstinence from alcohol, cannabis, illicit drugs, and tobacco use; and reductions in substance misuse consequences and related problems (DiClemente et al., 2017). Motivational interventions have demonstrated efficacy across ages (i.e., adolescents, young adults, and older adults), genders, and racial and ethnic groups (Lenz et al., 2016).
Special applications of motivational approaches have been successfully employed as stand-alone or add-on interventions for people with diabetes, chronic pain, cardiovascular disease, HIV, CODs, eating disorders, and opioid use disorder, as well as for pregnant women who drink or use illicit drugs (Alperstein & Sharpe, 2016; Barnes & Ivezaj, 2015; Dillard, Zuniga, & Holstad, 2017; Ekong & Kavookjian, 2016; Hunt, Siegfried, Morley, Sitharthan, & Cleary, 2013,: Ingersoll, Ceperich, Hettema, Farrell-Carnahan, & Penberthy, 2013; Lee, Choi, Yum, Yu, & Chair, 2016; Moore, Flamez, & Szirony, 2017; Mumba, Findlay, & Snow, 2018; Osterman, Lewis, & Winhusen, 2017; Soderlund, 2017; Vella-Zarb, Mills, Westra, Carter, & Keating, 2014). The universality of motivational intervention concepts permits broad application and offers great potential to reach diverse clients with many types of problems and in many settings.
Clients in treatment for SUDs differ in ethnic, racial, and cultural backgrounds. Research and experience suggest that the change process is similar across different populations. The principles and mechanisms of enhancing motivation to change seem to be broadly applicable. For example, one study found that MI was one of two evidence-based treatments endorsed as culturally appropriate by a majority of surveyed SUD treatment programs serving American Indian and Alaska Native (AI/AN) clients (Novins, Croy, Moore, & Rieckmann, 2016).
“Processes for engaging do differ across cultures, but listening lies at the heart of nearly all of them. Good listening crosses cultures as well. It stretches the imagination to think of people who don't appreciate being welcomed, heard, understood, affirmed, and recognized as autonomous human beings. In our experience these are universally valued.”
—Miller & Rollnick, 2013, p. 349
There may be important differences among populations and cultural contexts regarding expression of motivation for change and the importance of critical life events. Get familiar with the populations with whom you expect to establish treatment relationships, be open to listening to and learning from clients about their cultures and their own theories of change, and adapt motivational counseling approaches in consideration of specific cultural norms (Ewing, Wray, Mead, & Adams, 2012). For example, a manual for adapting MI for use in treating AI/AN populations includes a spiritual component that uses a prayer to describe MI and several spiritual ceremonies to explain MI (Venner, Feldstein, & Tafoya, 2006).
MI's core elements, including its emphasis on collaboration, evoking clients' perspectives, and honoring clients' autonomy, align well culturally with African Americans (Harley, 2017; Montgomery, Robinson, Seaman, & Haeny, 2017). However, some African American women may be less comfortable with a purely client-centered approach (Ewing et al., 2012). Viable approaches to adapting MI for African Americans include training peers to deliver MI, incorporating moderate amounts of advice, and implementing MI approaches in community settings such as a local church (Harley, 2017).
Because motivational strategies emphasize the client's responsibility to voice personal goals and values as well as to select among options for change, you should respond in a nonjudgmental way to cultural differences. Cultural differences might be reflected in the value of health, the meaning of time, the meaning of alcohol or drug use, or responsibilities to community and family. Try to understand the client's perspective rather than impose mainstream values or make quick judgments. This requires knowledge of the influences that promote or sustain substance use and enhance motivation to change among different populations. Motivation-enhancing strategies should be congruent with a client's cultural and social principles, standards, and expectations. Exhibit 2.4 provides a mnemonic to help you remember the basic principles of cultural responsiveness.
EXHIBIT 2.4. RESPECT: A Mnemonic for Cultural Responsiveness.
EXPERT COMMENT: CULTURAL RESPONSIVENESS.
Understand not just how a client's cultural values encourage change, but how they may present barriers to change. Some clients identify strongly with cultural or religious traditions and work hard to gain respect from elders or group leaders. Others find membership or participation in such groups unhelpful. Some cultures support involvement of family members in counseling; others find this disrespectful.
Know what personal and material resources are available to clients, and be sensitive to issues of poverty, social isolation, historical trauma, and recent losses. Recognize that access to financial and social resources is an important part of the motivation for and process of change. Poverty and lack of resources make change more difficult. It is hard to affirm self-efficacy and stimulate hope and optimism in clients who lack material resources and have experienced discrimination. You can firmly acknowledge the facts of the situation yet still enhance hope and motivation to change by affirming clients' strengths and capacity for endurance and growth despite difficult circumstances. For more information on cultural issues in treatment, see TIP 59: Improving Cultural Competence (SAMHSA, 2014a).
Substance use and mental disorders often co-occur. According to 2017 data from the National Survey on Drug Use and Health (SAMHSA, 2018), 46.6 million adults ages 18 and older (19 percent of all U.S. adults) had any mental illness during the previous year, including 11.2 million (4.5 percent of all adults) with serious mental illness (SMI). Of this 46.6 million, 18 percent also had an SUD versus only 5 percent of adults without any mental illness in the past year. Of the 11.2 million adults with an SMI in the previous year, almost 28 percent also had a co-occurring SUD.
Even low levels of substance misuse can have a serious impact on the functioning of people with SMI (Hunt et al., 2013). For example, AUD often co-occurs with major depressive disorder (MDD), which results in greater disease burdens than either disorder separately (Riper et al., 2014). MI and MI combined with cognitive-behavioral therapy produce positive treatment outcomes, such as reductions in alcohol consumption, cannabis use, alcohol misuse, and depression and other psychiatric symptoms like anxiety (Baker et al., 2014; Baker, Thornton, Hiles, Hides, & Lubman, 2012; Riper et al., 2014; Satre, Delucchi, Lichtmacher, Sterling, & Weisner, 2013; Satre, Leibowitz, et al., 2016).
Having any mental disorder increases the risk of substance misuse. As indicated in TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (SAMHSA, 2013), clients with mental illness or COD may find it harder to engage and remain in treatment. Motivational interventions that engage and retain clients in treatment, increase motivation to adhere to treatment interventions, and reduce substance use are a good fit for these clients. A meta-analysis of randomized controlled treatment studies of people with SMI and substance misuse found that, although MI was not any more effective, in general, than other psychosocial treatments, clients who participated in an MI group reported to their first aftercare appointment significantly more often than clients in other treatment interventions and these clients had greater alcohol abstinence rates (Hunt et al., 2013). Another meta-analysis found that MI-based interventions emphasizing adherence to treatment significantly improved adherence and psychiatric symptoms (Wong-Anuchit, Chantamit-O-Pas, Schneider, & Mills, 2018). Dual Diagnosis MI (DDMI), a modified version of MI for adults with CODs, can effectively increase task-specific motivation and adherence to cognitive training interventions (Fiszdon, Kurtz, Choi, Bell, & Martino, 2015).
COUNSELOR NOTE: DUAL DIAGNOSIS MOTIVATIONAL INTERVIEWING.
Motivational interventions for SMI and co-occurring SUDs should be modified to take into account potential cognitive impairment and focused on specific tasks that lead to the accomplishment of treatment goals, as defined by each client. For more information, see TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (SAMHSA, 2013).
EXPERT COMMENT: MI FOR ADULTS WITH COD.
A growing trend worldwide is to view substance misuse in a much broader context than diagnosable SUDs. The recognition that people who misuse substances make up a much larger group—and pose a serious and costly public health threat—than the smaller number of people needing specialized addiction treatment is not always reflected in the organization and availability of treatment services. As part of a movement toward early identification of alcohol misuse and the development of effective and low-cost methods to ameliorate this widespread problem, BI strategies, which include motivational components, are widely disseminated in the United States and other countries (Joseph & Basu, 2016).
The impetus to expand the use of BI is a response to:
•The need for a broader base of treatment and prevention components to serve all segments of the population that have minimal to severe use and misuse patterns.
•The need for cost-effective interventions that satisfy cost-containment policies in an era of managed health care (Babor, Del Boca, & Bray, 2017).
•A growing body of research findings that consistently demonstrate the efficacy of BI relative to no intervention (DiClemente et al., 2017).
BI is a structured, person-centered counseling approach that can be delivered by trained health and behavioral health professionals in one to four sessions and typically lasts from 5 to 30 minutes (Mattoo, Prasad, & Gosh, 2018). Even single-session interventions incorporating MET/MI modalities have demonstrated effectiveness in reducing substance use behaviors (Samson & Tanner-Smith, 2015). BI for individuals who use substances are applied most often outside specialty addiction treatment settings (in what are often referred to as opportunistic settings), where clients are not seeking help for an SUD but have come, for example, to seek medical attention or treatment for a mental disorder (Mattoo et al., 2018). In these situations, people seeking services are routinely screened for substance misuse or asked about their substance use patterns. Those found to be misusing substances or who have related problems receive a specific BI.
EXPERT COMMENT: BI IN THE EMERGENCY DEPARTMENT.
The purpose of a BI is usually to counsel individuals, using a motivational approach, about substance misuse patterns; increase awareness about the negative effects of substance misuse; and advise them to limit or stop their use altogether, depending on the circumstances (Nunes, Richmond, Marzano, Swenson, & Lockhart, 2017). If the initial intervention does not result in substantial improvement, the provider can make a referral for specialized SUD treatment. A BI also can explore the pros and cons of entering treatment and present a menu of options for treatment, as well as facilitate contact with the treatment system. There are several BI models, but FRAMES is the dominant BI method for substance misuse (Mattoo et al., 2018).
BI strategies have been used effectively in SUD treatment settings where people seek assistance but are placed on waiting lists, as a motivational prelude to engagement and participation in more intensive treatment, and as a first attempt to facilitate behavior change. A series of BI can constitute BT, an approach that applies motivational and other treatment methods (e.g., cognitive-behavioral therapy) for a limited timeframe, making the modality particularly effective for clients who want to abstain from, instead of reduce, alcohol or drug use (Barbosa et al., 2017). Research has found that BT may be more effective than BI in reducing illicit drug use patterns (Aldridge, Dowd, & Bray, 2017).
A specific BI called SBIRT, which adds screening and referral components, has been implemented widely in the United States in diverse settings, including EDs, primary care offices, and community-based health clinics, through a SAMHSA multisite initiative (Babor et al., 2017). It is the largest SBIRT dissemination effort in the United States (Aldridge, Linford, & Bray, 2017). SBIRT was specifically developed for nonspecialized treatment settings. It has demonstrated effectiveness in primary care offices, EDs, and general inpatient medical units in reducing substance use and misuse among adolescents, young adults, and adults, as well as in increasing participation in follow-up care (Barata et al., 2017; DiClemente et al., 2017; Kohler & Hoffman, 2015; McQueen, Howe, Allan, Mains, & Hardy, 2015; Merchant, Romanoff, Zhang, Liu, & Baird, 2017; Timko, Kong, Vittorio, & Cucciare, 2016; Woolard et al., 2013).
People often seek treatment for medical concerns that may be related to or impacted by substance misuse but are not specifically seeking help for substance use problems. Screening has become an integral component of BI in these opportunistic settings (Mattoo et al., 2018). The results of the screening determine whether the person seeking services is offered a BI such as FRAMES or is referred to specialized addiction treatment when the person meets the criteria for moderate or severe SUD. From a public health perspective, SBIRT is seen as both a prevention and a treatment strategy. Although, research results about the effectiveness of SBIRT for illicit drug use are mixed (Hingson & Compton, 2014), recent outcome data from a SAMHSA initiative demonstrate its effectiveness to lower alcohol consumption, alcohol misuse, and illicit drug use (Aldridge, Linford, & Bray, 2017). Other studies found that initiation of buprenorphine treatment in the ED significantly increased clients' engagement in specialty addiction treatment and decreased illicit drug use (Bernstein & D'Onofrio, 2017) and that motivational interventions in ED and public health settings reduced overdose risk behaviors and nonmedical use of opioids (Bohnert et al., 2016; Coffin et al., 2017).
In addition, a growing body of evidence supports the use of SBIRT with adolescents, young adults, adults, and older adults, as well as ethnically and culturally diverse populations, particularly with careful selection of screening tools and tailoring the BI and referrals to each client's needs (Appiah-Brempong, Okyere, Owusu-Addo, & Cross, 2014; Gelberg et al., 2017; Manuel et al., 2015; Satre et al., 2015; Schonfeld et al., 2010; Tanner-Smith & Lipsey, 2015). For information about an SBIRT initiative for older adults (the BRITE Project), see the upcoming TIP on Treating Addiction in Older Adults (SAMHSA, planned).
Motivational interventions can be used in BI, in BT, and throughout the SOC process. Some strategies, like screening and FRAMES, are more applicable to BI methods whereas others, like developing discrepancy and decisional balancing, are more useful in specialized addiction counseling settings where clients receive longer and more intensive treatment. What is common in all motivational interventions, no matter the treatment setting or the client population, is the focus on engaging clients, building trust through empathetic listening, and demonstrating respect for clients' autonomy and cultural customs and perspectives.