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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in
Substance Abuse Treatment



        CSATs
Knowledge Application Program


KAP Keys
For Clinicians

Based on TIP 35
Enhancing Motivation for
Change in Substance Abuse
Treatment



U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov

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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment



These KAP Keys were developed to accompany the Treatment
Improvement Protocol (TIP) Series published by the Center for
Substance Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration. These KAP Keys are
based entirely on TIP 35 and are designed to meet the needs
of the busy clinician for concise, easily accessed "how-to" infor
mation.

For more information on the topics in these KAP Keys, readers
are referred to TIP 35.
Introduction



TIP 25, Substance Abuse Treatment and Domestic Violence
(1997 ) BKD139
TIP 26, Substance Abuse Among Older Adults (1998) BKD250
TIP 27, Comprehensive Case Management for Substance
Abuse Treatment (1998) BKD251
TIP 34, Brief Interventions and Brief Therapies for Substance
Abuse (1999) BKD341
Other Treatment Improvement Protocols (TIPs)
that are relevant to these KAP Keys:

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The FRAMES Approach 
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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

To understand what prompts a person to reduce or eliminate
substance use, clinicians have searched for the critical compo
nents of effective interventions; the most important and com
mon elements that inspire positive change. The acronym
FRAMES was coined to summarize the following six key ele
ments:

Feedback regarding personal risk or impairment is given to the
client following assessment of substance use patterns and
associated problems. 

Responsibility for change is placed squarely and explicitly on
the client (and with respect for the client's right to make
choices for himself). 

Advice about changing--reducing or stopping--substance use is
clearly given to the client by the clinician in a nonjudgmental
manner. 

Menus of self-directed change options and treatment alterna
tives are offered to the client. 

Empathic counseling--showing warmth, respect, and under
standing--is emphasized. 

Self-efficacy or optimistic empowerment is engendered in the
client to encourage change. 


Source: Miller and Sanchez 1994.

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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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Appropriate Motivational Strategies 
for Each Stage of Change 
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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment
Precontemplation: The client is not yet considering change or
is unwilling or unable to change. Establish rapport, ask permis
sion, and build trust.  Raise doubts or concerns in the client
about substance-using patterns by
 Exploring the meaning of events that brought the client to
treatment or the results of previous treatments. 
 Eliciting the client's perceptions of the problem. 
 Offering factual information about the risks of substance use.
 Providing personalized feedback about assessment findings. 
 Exploring the pros and cons of substance use. 
 Helping a significant other intervene. 
 Examining discrepancies between the client's and others'
perceptions of the problem behavior.
 Express concern and keep the door open.

Contemplation: The client acknowledges concerns and is con
sidering the possibility of change but is ambivalent and uncer
tain.  Normalize ambivalence.  Help the client "tip the decision
al balance scales" toward change by 
 Eliciting and weighing pros and cons of substance use and
change. 
 Changing extrinsic to intrinsic motivation. 
 Examining the client's personal values in relation to change. 
 Emphasizing the client's free choice, responsibility, and self-
efficacy for change.
 Eliciting self-motivational statements of intent and commit
ment from the client. 
 Eliciting ideas regarding the client's perceived self-efficacy
and expectations regarding treatment. 
 Summarizing self-motivational statements.

Preparation: The client is committed to and planning to make
a change in the near future but is still considering what to do. 
 Clarify the client's own goals and strategies for change. 
 Offer a menu of options for change or treatment. 
 With permission, offer expertise and advice. 
 Negotiate a change--or treatment--plan and behavior contract.
 Consider and lower barriers to change. 
 Help the client enlist social support. 
 Explore treatment expectancies and the client's role. 
 Elicit from the client what has worked in the past either for
him or others whom he knows. 


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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

 Assist the client to negotiate finances, child care, work,
transportation, or other potential barriers. 
 Have the client publicly announce plans to change.

Action: The client is actively taking steps to change but has
not yet reached a stable state. 
 Engage the client in treatment and reinforce the importance
of remaining in recovery. 
 Support a realistic view of change through small steps. 
 Acknowledge difficulties for the client in early stages of
change. 
 Help the client identify high-risk situations through a func
tional analysis and develop appropriate coping strategies to
overcome these. 
 Assist the client in finding new reinforcers of positive change. 
 Help the client assess whether she has strong family and 
social support.

Maintenance: The client has achieved initial goals such as
abstinence and is now working to maintain gains. 
 Help the client identify and sample drug-free sources of
pleasure (i.e., new reinforcers). 
 Support lifestyle changes. 
 Affirm the client's resolve and self-efficacy. 
 Help the client practice and use new coping strategies to
avoid a return to use. 
 Maintain supportive contact (e.g., explain to the client that
you are available to talk between sessions). 
 Develop a "fire escape" plan if the client resumes substance use.
 Review long-term goals with the client.

Recurrence: The client has experienced a recurrence of symp
toms and must now cope with consequences and decide what
to do next. 
 Help the client reenter the change cycle and commend any
willingness to reconsider positive change. 
 Explore the meaning and reality of the recurrence as a learn
ing opportunity. 
 Assist the client in finding alternative coping strategies. 
 Maintain supportive contact.

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Ten Effective Catalysts for Change 



 Consciousness raising is increasing information about the
problem. Interventions could include observations, interpre
tations, and bibliotherapy. 
 Self-reevaluation involves assessing how one feels and
thinks about oneself with respect to problem behaviors.
Interventions could include clarifying values and challenging
beliefs or expectations. 
 Self-liberation means choosing and committing to act or
believing in ability to change. Interventions could include
commitment-enhancing techniques, decisionmaking therapy,
and New Year's resolutions. 
 Counterconditioning involves substituting coping alterna
tives for anxiety caused by substance-related behaviors.
Interventions could include relaxation training, desensitiza
tion, assertion, and positive self-statements. 
 Stimulus control means avoiding or countering stimuli that
elicit problem behaviors. Interventions could include avoiding
high-risk cues and removing substances from one's environ
ment. 
 Reinforcement management is rewarding oneself or being
rewarded by others for making changes. Interventions could
include contingency contracts and overt and covert reinforce
ment. 
 Helping relationships are created by being open and trust
ing about problems with people who care. Interventions
could include self-help groups, social support, or a therapeu
tic relationship. 
 Emotional arousal and dramatic relief involve experiencing
and expressing feelings about one's problems and solutions
to them. Interventions could include role-playing and psy
chodrama. 
 Environmental reevaluation is the process of assessing how
one's problems affect the personal and physical environ
ment. Interventions could include empathy training and doc
umentaries. 
 Social liberation involves increasing alternatives for non-
problematic behavior. Interventions could include advocating
for the rights of the oppressed and policy interventions.

Source: Adapted from DiClemente and Scott 1997.
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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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Four Types of Client Resistance 



Arguing: The client contests the accuracy, expertise, or integri
ty of the clinician. 
 Challenging. The client directly challenges the accuracy of
what the clinician has said. 
 Discounting. The client questions the clinician's personal
authority and expertise. 
 Hostility. The client expresses direct hostility toward the clinician.

Interrupting: The client breaks in and interrupts the clinician in
a defensive manner. 
 Talking over. The client speaks while the clinician is still talk
ing, without waiting for an appropriate pause or silence. 
 Cutting off. The client breaks in with words obviously 
intended to cut the clinician off (e.g., "Now wait a minute. I've 
heard about enough").

Denying: The client expresses unwillingness to recognize prob
lems, cooperate, accept responsibility, or take advice. 
 Blaming. The client blames other people for problems. 
 Disagreeing. The client disagrees with a suggestion that the
clinician has made, offering no constructive alternative. This
includes the familiar "Yes, but...," which explains what is
wrong with suggestions that are made. 
 Excusing. The client makes excuses for his behavior. 
 Claiming impunity. The client claims that she is not in any
danger (e.g., from drinking). 
 Minimizing. The client suggests that the clinician is exagger
ating risks or dangers and that it really isn't so bad. 
 Pessimism. The client makes statements about himself or
others that are pessimistic, defeatist, or negative in tone. 
 Reluctance. The client expresses reservations and reluc
tance about information or advice given. 
 Unwillingness to change. The client expresses a lack of 
desire or an unwillingness to change.

Ignoring: The client shows evidence of ignoring or not following
the clinician. 
 Inattention. The client's response indicates that she has not
been paying attention to the clinician. 
 Non-answer. In answering a clinician's query, the client gives
a response that is not an answer to the question. 
 No response. The client gives no audible verbal or clear non-
verbal reply to the clinician's query. 
 Sidetracking. The client changes the direction of the conver
sation that the clinician has been pursuing.

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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

Source: Miller and Rollnick 1991. Adapted from a behavior
coding system by Chamberlain et al. 1984. Reprinted with
permission.

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Change Plan Worksheet 



The changes I want to make are:


The most important reasons I want to make these changes
are:


My main goals for myself in making these changes are: 


I plan to do these things to reach my goals:

Plan of Action


When
The first steps I plan to take in changing are: 


Some things that could interfere with my plan are: 


Other people could help me in changing in these ways: 

Person
Possible ways to help


I hope that my plan will have these positive results: 


I will know that my plan is working if: 



Sources: Miller and Rollnick 1991; Miller et al. 1995.
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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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Deciding To Change

Changing 
Benefits:
 Increased control over my life 
 Support from family and friends 
 Decreased job problems 
 Financial gain 
 Improved health 

Costs:
 Increased stress/anxiety 
 Feel more depressed 
 Increased boredom 
 Sleeping problems

Not Changing

Benefits:
 More relaxed 
 More fun at parties 
 Don't have to think about my problems

Costs:
 Disapproval from friends and family 
 Money problems 
 Could lose my job 
 Damage to close relationships 
 Increased health risks


Source: Sobell et al. 1996.
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KAP KEYS Based on TIP 35
Enhancing Motivation for Change in Substance Abuse
Treatment

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Ordering Information
        TIP 35
Enhancing Motivation for Change 
in Substance Abuse Treatment 



Easy Ways to Obtain Free Copies 
of All TIP Products

1. Call SAMHSA's National Clearinghouse for Alcohol and
Drug Information (NCADI) at 800-729-6686, 
TDD (hearing impaired) 800-487-4889.
2. Visit CSAT's Website at www.csat.samhsa.gov



Do not reproduce or distribute this publication for a fee with
out specific, written authorization from the Office of
Communications, Substance Abuse and Mental Health
Services Administration, U.S. Department of Health and
Human Services.



DHHS Publication No. (SMA) 01-3603
Printed 2001