Module 4: Trusting, Compassionate, Therapeutic Relationships – Topic G Demonstrate knowledge of change and motivation theories (e.g., self-regulation theory, stages of change, theories of motivation) and of evidence-informed change strategies.

Learning Objectives

By the end of this topic, the student should be able to:

• Describe the role of motivation in behavioural change.
• Identify motivation and change strategies that are supported by evidence.
• Identify stages of behavioural change.
• Describe self-regulation theory.
• Outline debrief interventions including SBIRT (screening, brief intervention, and referral to treatment).
• Discuss how health and social service providers can incorporate motivation and change theories in their practice.

Key Concepts

• The concept of motivation to change behaviour has evolved, and the responsibility for treatment success has shifted from the individual alone to their relationship with health and social service providers.
• Motivation has been described as a prerequisite for treatment, and the therapeutic relationship is a critical component of successful treatment.
• Although change in behaviour is the responsibility of the client, health and social service providers can enhance the individual’s motivation for positive change.
• The stages of change in the transtheoretical model (TTM) developed by Prochaska and DiClemente in 1983 provide a model that explains the change process, including the stage of ambivalence.

Historical View of Motivation

Motivation to change among individuals receiving treatment for substance use disorder has been a focus of concern among service providers.

While motivation is considered to be a prerequisite for treatment, the Center for Substance Abuse Treatment (1999) identified an important shift in how it is understood.

• Historically, motivation was believed to be a static internal trait or disposition that a client either did or did not possess, and that service providers could do little about.
• Lack of motivation was frequently used to explain an individual’s inability to begin treatment, continue treatment, or complete a treatment program successfully.
• Motivation for treatment was viewed as the individual’s willingness to go along with a health and social service provider's particular approach to recovery, and therefore a choice. So, a lack of motivation to change was seen as the client’s fault.
• A client who seemed amenable to clinical advice or accepted the label of "substance use disorder" was considered to be motivated, whereas one who resisted the diagnosis or refused to adhere to a prescribed treatment plan was deemed unmotivated.
• Motivation was seen to be the exclusive responsibility of the client, rather than the responsibility of the health and social service provider.

Evolving Understanding of Motivation

The concept of motivation has evolved, as has the view that the responsibility for treatment success lies solely with the individual.

Motivation to change has come to be understood as intentional and directed to what individuals believe to be in their best interest.

• Motivation affects the probability that a person using substances will seek help, resources, and the support to succeed.
• Motivation is enhanced when health and service providers work with the individual to determine the best strategy for positive change.

Attributes of Motivation

The Center for Substance Abuse Treatment (1999) provided the following characteristics of motivation:

Multidimensional and Intersectional

Motivation integrates an individual’s internal urges and desires with social, cultural, spiritual, and financial factors. In combination, these variables influence the individual’s perception of the risks and benefits their behaviours will have.

Dynamic and Fluctuating

Motivation is fluid and changes in different situations and in different cognitive states. It vacillates and can vary in intensity.

Influenced by Social Interactions

While motivation is an internal and individual process, it is affected by the individual’s experiences with others (Miller, 1995). An individual's motivation to change can, therefore, be influenced positively or negatively by social variables, including relationships with family, friends, and peers, as well as past trauma or violence. Access to health care, employment, public perception of substance abuse, stigma, discrimination, and historical trauma can also significantly affect an individual's motivation.

Modifiable

Motivation is “accessible and can be modified or enhanced at many points in the change process which brings hope and optimism for change.” (Center for Substance Abuse Treatment, 1999, p. 3). Thus, an individual can be actively engaged in change even when they continue to use substances.

Motivation Is Influenced by the Health and Social Service Provider

Health and Social Service Provider Role Related to Motivation

While many people change substance-using behaviour on their own without therapeutic intervention, the health and social service provider can enhance the individual’s motivation for positive change throughout the change process.

Key aspects of a therapeutic relationship include assisting and encouraging individuals to recognize a problem behaviour. An individual may feel tension and discomfort when their values and beliefs are not reflected in their behaviours. This may lead to changes in behaviour, but it often results in changes in beliefs, such as rationalizations regarding behaviour, or denial of its consequences.

Working with cognitive dissonance can be an effective approach when counselling an individual using substances.

A wider or distal approach may be adopted by service providers to enhance motivation in which historical, societal, or cultural factors that impinge on an individual’s ability to change are identified and labelled.

• Such an approach involves awareness of, sensitivity to, and respect for the impact that culture, race, gender, colonization, and both historical and current trauma may engender on the individual’s motivation to change.

Self-regulation and Self-efficacy Theory

• Self-regulation plays an important role in an individual’s abstention from substance use.
• Self-regulation in the context of addiction is linked to the concept of abstinence self-efficacy.

• Self-efficacy affects the amount of energy a person will put into an attempt to change an undesired behaviour, such as opioid use. It has emerged as an important predictor of treatment outcomes related to opioid use (Chavarria et al., p. 2).
• Abstinence self-efficacy is a person’s belief in their ability to abstain from an undesired action, including substance use, especially in situations where they often carrying out this action (Chavarria et al., 2012, p. 2).

Sources of Self-efficacy

Bandura’s theory of self-efficacy (1999) outlines four sources of self-efficacy:

Enactive Mastery

Vicarious Experience

Verbal Persuasion

Physiological Arousal

(Bandura et al. 1999)
zmicierkavabata/iStock (template); PeterSnow/iStock (icons)

Self-efficacy and Treatment of Substance Use

In examining research on abstinence self-efficacy, Kadden and Litt (2011) concluded that it is an important predictor of treatment outcomes (p. 3). They noted the following findings in this research:

• People who possess confidence in their ability to abstain from substance use and who have strong coping efficacy are likely to mobilize the effort needed to successfully resist situations of high risk for drug use (p. 2).
• When their ability to abstain from substance use slips, highly self-efficacious persons are likely to identify this as a temporary setback and regain self-control, whereas those with low self-efficacy are more likely to continue the substance use (p. 2).

The Stages of Change

The stages of change in the transtheoretical model (TTM), developed by Prochaska and DiClemente (1983), provide a widely accepted model of the process of change related to substance use. This model identifies six stages in the process that are described below.

Download Accessible Version (PDF)

(Pacheco, 2012)

For most substance-using individuals, progress through the stages of change is circular or spiral in nature, not linear. In this model, relapse is a normal event because many clients cycle through the different stages several times before achieving stable change.

• Movement back and forth, as well as recycling through the stages, represents a successive learning process: the individual continues to redo the tasks of various stages to achieve a level of completion that supports movement toward sustained change of the desired behaviour.
• Motivation is viewed as an important component throughout the entire process of change. The stages of change specify motivational demands by segmenting the change process into specific tasks to be accomplished and goals to be achieved if movement toward successfully sustained change is to occur.

Screening, Brief Intervention and Referral to Treatment (SBIRT)

SBIRT is an acronym that stands for screening, brief intervention, and referral to treatment that is widely used in a variety of non-substance-abuse treatment settings, including schools, social services, primary care setting, and emergency rooms.

• It is a public health approach to delivering early intervention to people with a substance use disorder or who are at risk of developing such a disorder. SBIRT applies motivational interviewing principles to foster behavioural change.

The components of SBIRT are described as follows (Academic ED SBIRT Research Collaborative, 2007):

• Screening clients quickly for problematic behaviours related to substance use disorder, dangerous use of drugs and alcohol, or the risk of developing dependence. The validated screening tools take about 5 to 10 minutes to administer.
• Brief intervention is given to those with problematic behaviours. The interventions focus on increasing awareness and insight related to substance use and on fostering motivation towards behavioural change. It is generally provided in person in one to five sessions lasting five minutes to an hour and may be based on the FRAMES framework (feedback, responsibility, advice, menu of strategies, empathy, self-efficacy):
  • Feedback – Providing constructive feedback on the client’s degree of substance use based on the assessment
  • Responsibility – Enabling the client to take personal responsibility for direction and plans
  • Advice – Informing and advising the client about substance use respectfully
  • Menu of strategies – Collaborating with the client to identify strategies to cut down or stop substance use
  • Empathy – Communicating with respect and empathy
  • Self‐efficacy – Fostering the client’s sense of self-efficacy
• Referral to treatment is done for those identified as needing more extensive treatment and specialty care. Strong coordination and integration of the components of SBIRT is essential to ensure links between early intervention and more specialized treatment services.

To implement SBIRT, it is critical to have service providers who are trained in its core components of screening, brief intervention, and referral.

Screening Tools and SBIRT Resources

There are a number of screening manuals and tools associated with SBIRT.

Motivational Interviewing

Motivational interviewing (MI) was initially used in the substance use field but has been adapted to a variety of contexts. Motivational interviewing is a brief intervention in the SBIRT model. MI is based on four principles:

• expressing empathy and avoiding arguing
• developing discrepancy (i.e., building the person’s awareness of the gap between current behaviour and a desired outcome)
• rolling with resistance (i.e., recognizing that resistance to change occurs and the client is not ready)
• supporting self-efficacy

The goal of MI is not to direct behaviour, teach a skill, or provide a predetermined piece of information, but rather to explore and reinforce an individual’s motivation. A growing body of literature has measured the efficacy of MI. Most evidence supporting MI, however, is in the field of alcohol use, with limited studies directly looking at MI and opioid use (DiClemente et al, 2017).

Summary of Brief Intervention

Questions

Which of the following is a key determinant in predicting the extent of relapse an individual might experience?

a. self-efficacy

b. self-sufficiency

c. self-regulation

d. self-sabotage

Correct! In the event of a slip, highly self-efficacious persons are inclined to regard the slip as a temporary setback and to reinstate control, whereas those who have low self-efficacy are more likely to proceed to a fuller relapse.

Incorrect. The correct answer is a. In the event of a slip, highly self-efficacious persons are inclined to regard the slip as a temporary setback and to reinstate control, whereas those who have low self-efficacy are more likely to proceed to a fuller relapse.

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What style of counselling can promote treatment resistance?

a. motivational Interviewing

b. confrontational counselling

c. empathetic counselling

d. sympathetic counselling

Correct! A confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centred, supportive, and empathic style that uses reflective listening and gentle persuasion.

Incorrect. The correct answer is b. A confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centred, supportive, and empathic style that uses reflective listening and gentle persuasion.

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What are three benefits to using SBIRT? (Select all that apply.)

a. adaptability

b. applicability

c. accessibility

d. cost

e. substance specific

Check

Please select an answer.

Correct! SBIRT can be used by a variety of health and social service professionals (accessibility) in a variety of settings (adaptability) for a range of substance use disorders (applicability).

Incorrect. The correct answers were a, b, and c. SBIRT can be used by a variety of health and social service professionals (accessibility) in a variety of settings (adaptability) for a range of substance use disorders (applicability).

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References