# Motivation and emotion/Book/2023/Treatment motivation in substance use disorder

* Multimedia presentation (3 min)

## Overview

Motivation is the foundation for channelling one's energy towards achieving a goal. It is a prerequisite for change. Imagine it as a conscious, purposeful, and uplifting force that propels you toward self-improvement. It's the fuel that drives your quest for a better self. Motivation takes centre stage when it comes to substance abuse treatment. Belici and colleagues (2014) emphasise motivations' pivotal role in the success of such therapies. It determines if someone is ready to recover, continuously engage with therapeutic interventions, and maintain those crucial strides toward sobriety. A recent article by Health Direct Australia (2023) revealed that about 1 in 20 Australians grapple with addiction or substance abuse. That's a staggering number, making treatment motivation even more vital.
Treatment Motivation refers to an individual's drive to participate in interventions for substance abuse recovery. So, why is treatment motivation so crucial in the context of substance abuse? People battling substance use disorders often find themselves caught in a tug-of-war within themselves. Substance abuse researchers Medalia and Saperstein (2011) point out that treatment motivation enables individuals see the light. It makes them recognise the immense benefits of recovery and helps to align their actions with their deepest goals.
Here's the kicker: When motivation to change is strong, it's a game-changer (see Figure 1). It gets people to engage in treatment and increases the odds of successful outcomes. Plus, it's the key to breaking free from the relentless grip of addiction, reducing the risk of relapse, and setting a new course towards a brighter, healthier future.
* Focus Questions
* What factors motivate people to engage in treatment for substance abuse?
* How might social stigma affect parents who use illicit substances?
* How might poverty influence the decision to try and overcome substance abuse disorder?

## The role of treatment motivation for substance abuse disorder

According to George and Koob (2017), drug addiction is a three-stage process that comprises preoccupation/anticipation, binge/intoxication, and withdrawal/negative affect phases (Figure 2). These stages are interconnected and give rise to an addiction cycle, ultimately leading to a pathological state of addiction. Importantly, these phases act as powerful motivators for compulsive drug-seeking behaviour.
The primary purpose of treatment motivation in addressing substance abuse disorders is to encourage individuals to actively seek, engage in, and complete addiction treatment to break this cycle. This, in turn, helps individuals recover physically and emotionally while reducing harm and mitigating the damage caused by their substance abuse. According to a yearly report for 2021-2022 on drug treatment services [where?], the most frequently sought-after treatment types are counselling, assessment, and withdrawal management. Notably, alcohol is the predominant substance of concern among individuals undergoing substance abuse treatment in Australia, accounting for 42% of cases (Alcohol, Tobacco & Other Drugs in Australia, 2023).
Effective psychological treatment strategies tap into intrinsic and extrinsic motivators, fostering a sense of hope, self-efficacy, and empowerment. By acknowledging individuals' challenges and guiding them towards their reasons for change, treatment providers can help individuals overcome the barriers to seeking help and embracing recovery. Ultimately, treatment motivation paves the way for a transformative journey toward breaking the cycle of substance abuse and achieving lasting well-being.

## Conceptualising motivation

There has been an enormous body of research into the factors that prevent substance abuse and the rationale for effective psychosocial treatments. In discussing the reasons for substance abuse and the protective factors, Moos (2007) notes some of the predominant theories that protect against and help treat substance abuse and their standard components. These theories include social control theory and social learning theory, which emphasises that solid connections and social bonds are crucial in guiding individuals to behave responsibly and positively, and social learning theory. Social learning theory is similar in asserting that substance abuse is a socially learned attitude and behaviour.
Behavioural economics and behavioural choice theory suggest that when people replace unhealthy activities with healthier ones, the emotional and physical rewards they gain from these alternatives can substantially reduce the desire to use substances. Stress and coping theory outlines how a problematic and stressful life resulting from family problems, neglect or unfortunate circumstances can lead to trauma, isolation, difficulty socialising and impaired mental health and coping skills.
Another significant theory relevant to substance use disorder is the transtheoretical model (TM) of health behaviour change (see Figure 3). The model outlines the six different stages of people's relationship to change. These stages include pre-contemplation, contemplation, preparation, action, maintenance, and termination. By progressing through these stages, individuals can effectively implement and sustain the changes they seek to make (Moos, 2007).
Here two case studies highlight the differences in possible outcomes when different circumstances and motivational factors occur and we can examine these cases through thinking about which psychosocial theories are most applicable to these situations.
* Case Study 1. Indy
* Indy's journey through addiction and recovery is a testament to the resilience of the human spirit. Despite coming from an affluent and loving family, her tumultuous childhood, marked by her mother's emotional instability and alcoholism, set her on a challenging path. She initially sought solace in a rebellious social circle, experimenting with marijuana, acid, and ecstasy. However, it was the introduction to heroin through her boyfriend that ultimately led her down the dark path of addiction.
* Tragedy struck when her boyfriend died in a car accident, leaving Indy to grapple with overwhelming grief. Heroin became her coping mechanism, a numbing balm for her pain. She dropped out of school, trapped in a cycle of addiction.Years later, with the birth of her child, Indy found renewed determination to break free from the clutches of addiction. She tried to get clean, seeking help through rehab, counselling, and various programs.
* Supported by her family, Indy connected with a skilled therapist who forged a relationship of trust. Together, they delved into her childhood trauma and addressed her drug dependency. The turning point came with applying the reframing technique within motivational interviewing. This technique highlighted the disconnect between her aspirations and her current behaviour. It illuminated how her addiction hindered her personal goals and prevented her from providing her child with the life they deserved.
Indy's story showcases the power of resilience, the significance of a strong support system, and the effectiveness of therapeutic techniques like motivational interviewing and strong intrinsic motivation can be critical in the path to recovery. It is an inspiring example of how, even in the darkest times, one can find the strength to overcome addiction and build a brighter future.
* Case Study 2. Harry
* Once a bright and witty kid, Harry faced a neglectful upbringing with little emotional support from his marijuana-using father and narcissistic mother. Their divorces and remarriages left Harry and his siblings feeling unwelcome and frequently unsupervised, leading them to seek refuge on the streets with friends. His story highlights the profound impact of a challenging childhood and the importance of a supportive environment. At eleven, Harry left home and moved in with his older brother, where he was introduced to hard drugs. His life spiralled into addiction, homelessness, and trauma. Struggling to survive, he resorted to desperate measures. Fortunately, a family friend discovered Harry's dire situation and offered him refuge. She provided him with friendship and support, and alongside his sister, they tried to help him overcome his drug addiction through counselling and rehabilitation centres.
* However, Harry's battle with addiction proved overwhelming, and despite numerous attempts to get clean, he tragically decided to end his life. His story serves as a poignant reminder of the devastating consequences of addiction and the critical need for accessible mental health support.
Harry's story is a stark reminder of the severe consequences of substance abuse and demonstrates the urgent need for substance abuse interventions and mental health support. By engaging with behavioural choice theory in the context of this case study, we can understand why Harry felt he had no alternative or rewarding behaviour to turn to instead of substance abuse. His lack of family support, employment prospects, hobbies, and spiritual guidance contributed to his inability to find healthier ways to elevate his mood and reduce anxiety. Furthermore, his strained family relationships weakened his social bonds, in line with social control theory, making him less likely to uphold high moral standards and more susceptible to engaging in undesirable behaviour. Social learning theory also sheds light on how some of Harry's attitudes towards drugs and alcohol were shaped from a young age through observation and imitation. These behaviours were further reinforced by associating with peers who engaged in similar activities. Stress and coping theory demonstrates how Harry's distress and alienation through trauma and homelessness further drove him towards using substances to help him cope.

## Factors that impact treatment motivation

Treatment motivation is a complex interplay of intrinsic and extrinsic elements (Center for Substance Abuse Treatment, 1999). Intrinsic factors primarily influence the initial decision to change, while extrinsic forces such as social dynamics, familial pressures, and external support systems play significant roles in sustaining motivation. Therapists often employ techniques like motivational Interviewing, reframing, and continuous personal support to integrate these intrinsic and extrinsic motivators. Various factors come into play, including the impact of social support networks, past successes and failures, financial and legal consequences, health concerns, peer pressure, stigma and shame, spirituality and values, co-occurring mental health disorders, economic stability, age and life stage, crisis situations, personal goals and aspirations, and access to treatment resources (Milliere et al., 2014).
Recognising the diversity of these motivating factors is essential for treatment providers and support networks. Motivation is a dynamic process that can change over time. Thus, tailoring interventions that resonate with an individual's unique motivational drivers is crucial for sustaining motivation throughout their journey to recovery. Understanding how these factors influence motivation and recognising that motivation can change over time can be pivotal in remaining on the path to recovery.

### Treatment models and motivational principles

Treatment motivation in addiction recovery is influenced by a range of factors, as outlined by various models.
The moral model places responsibility on the individual's willpower and external threats, emphasizing extrinsic motivation. In contrast, the medical model views addiction as a physiological disease treatable with medications, emphasising both intrinsic recognition and external help. The spiritual model, demonstrated by programs like Narcotics Anonymous (NA) (see Figure 5) focuses on intrinsic motivators such as a higher power and introspection. The psychological model links addiction to intrinsic deficits and often employs therapies like cognitive behavioral therapy. The sociocultural model includes the influence of societal norms and legal frameworks as external motivators. Finally, the biopsychosocial-spiritual model recognizes the complexity of addiction and advocates for a holistic approach, acknowledging that motivation can stem from a combination of factors from these different models.
Treatment models for addiction are designed to understand and address the complex factors that influence an individual's motivation to seek and commit to recovery. These models offer different perspectives on addiction, including moral, medical, spiritual, psychological, sociocultural, and holistic approaches. The diversity of treatment models recognises that addiction is multifaceted, and motivation for recovery can be shaped by various intrinsic and extrinsic factors. Each model provides a unique framework for understanding addiction and offers distinct strategies to support individuals in their journey to overcome substance abuse. Ultimately, the goal of these treatment models is to provide effective interventions that cater to the specific needs and circumstances of individuals struggling with addiction (Center for Substance Abuse Treatment, 1999).

### Types of Interventions for Substance Use Disorder

Various theories and therapies play a vital role in dealing with substance use disorders. According to Ghouchani et al. (2023), substance use disorders are multifaceted conditions that require a comprehensive approach to treatment. Different theories and therapies have been developed to address the unique challenges presented by substance use disorders. These treatments are designed to address various aspects of addiction, including ambivalence, cognitive patterns, emotional regulation, motivation, and physical dependence.
[Provide more detail]
* Motivational interviewing (MI): Focuses on resolving ambivalence towards drug use and addresses conflicting motivations for change.
* Cognitive-behavioral therapy (CBT): Targets both cognitive and behavioural aspects of addiction by helping individuals recognise and modify maladaptive thought patterns and behaviors.
* Dialectical behavioral therapy (DBT): Integrates mindfulness and emotional regulation to enhance coping skills and reduce impulsivity in individuals with substance use disorders.
* Motivation enhancement therapy (MET): Strengthens intrinsic motivation and aligns with the transtheoretical model of change, which outlines various stages of change in substance use.
* Self-determination theory: Emphasises the significance of intrinsic motivation in addiction recovery.
* Maintenance therapy (e.g., methadone programs, opiate agonist therapy): Addresses physical dependence and reduces withdrawal symptoms, enabling individuals to focus on other aspects of their recovery journey.
Ultimately, the strength of motivation becomes a foundation for long-term recovery and maintenance. By tapping into this intrinsic motivation, individuals can create and sustain new, healthier habits that replace the destructive patterns associated with substance use disorders. This way, treatment interventions act as a guiding light, helping individuals navigate the challenging path toward lasting change.

## Barriers to treatment motivation

Motivating individuals with substance use disorders to seek treatment can be challenging due to ambivalence. A major barrier is that substance abuse negatively affects the brain's reward and stress systems. This leads to a situation where users experience pleasure when using the drug, but extreme distress when they stop (Ali et al., 2014).
Gressler et al. (2019) conducted a study that examined the barriers to treatment motivation of recovering substance abuse patients. The study identified several obstacles, including existing mental health conditions, lack of coping skills, chaotic life circumstances, and association with friends or family members who use illicit substances. The ability to maintain motivation throughout the stages of treatment were also discussed. The study also found that social stigma, health issues and lack of self-belief or self-efficacy were among the other barriers to successful recovery (Gressler et al., 2019). This study suggests that compensatory measures should be taken to help recovering substance abusers find opportunities to access alternative rewards, such as engaging in fulfilling and enjoyable activities (see Figure 5).
Other barriers to treatment motivation include crises or consequences, such as legal issues, health problems, or strained relationships, which can motivate seeking treatment. Breaking down the recovery journey into achievable goals can make the process seem less daunting, and celebrating small victories can boost motivation. Holistic approaches, addressing underlying issues, such as mental health disorders or trauma, can motivate individuals to seek comprehensive treatment that addresses the root causes of their substance abuse. Additionally, goal setting, family and social support, accountability groups like AA and NA, and various pharmacological maintenance programs, including opiate agonist and antagonist treatment programs, have also been successful in helping people quit using illicit substances (Ali et al., 2014; Centre For Substance Abuse Treatment, 1999).

## Strategies for enhancing treatment motivation

Understanding that relapse is not synonymous with failure but rather a part of the recovery continuum is crucial (see Figure 6). Clients should be encouraged to view relapse as a learning opportunity, helping them identify triggers and develop coping strategies. This perspective shift reduces shame and guilt, enabling a more constructive approach to treatment. Involving significant others, such as family and friends, can create a robust support network around clients. This network can provide encouragement, understanding, and accountability throughout recovery (Markland et al., 2005).
George and Koob (2017) highlighted various factors that facilitate the maintenance of treatment. These include the need for trust and validation from the treatment provider. Najavits and Weiss (1994) also identified empathy and unconditional regard as integral. The therapeutic relationship and the counsellor's competency and interpersonal skills are considered critical factors in supporting change, according to Lundahl and colleagues. (2010). They also discussed how motivational interviewing (MI) positively impacts counselling outcomes and its effectiveness compared to other interventions.
To combat the allure of substance use, we must provide alternative sources of happiness and fulfillment. This approach gives people healthier ways to find satisfaction and reduces their reliance on drugs. It's also vital to have contingency plans and support strategies in place to tackle any obstacles that may arise during treatment. Changing how society views addiction and treatment can encourage more people to seek help without worrying about stigma. Recognising and respecting the diverse backgrounds, genders, and ethnicities of clients is crucial. Offering a range of treatment options that cater to this diversity ensures inclusivity and effectiveness. Advocating for a shift toward a health-focused approach to substance abuse, including decriminalisation, can further reduce the stigma around seeking treatment, making it more accessible to those who need it (Ghouchani et al., 2023).

## Conclusion

Motivation is vital in propelling individuals toward self-improvement and achieving their goals. When motivation to change is strong, it increases the odds of successful outcomes, reduces the risk of relapse, and sets individuals on a path towards a brighter future. The primary role of treatment motivation is to encourage individuals to actively seek, engage in, and complete addiction treatment. Counselling, assessment, and withdrawal management are among the most sought-after treatment types. Effective psychological treatment strategies tap into both intrinsic and extrinsic motivators. Recognising relapse as a learning opportunity and changing societal perceptions reduce stigma. Individualised, holistic approaches promote lasting recovery.
Numerous theories and therapeutic approaches have been explored in the context of substance abuse. These include social control theory, social learning theory, behavioural economics, behavioural choice theory, the transtheoretical model of health behaviour change, and stress and coping theory. These theories shed light on the factors that protect against and treat substance abuse.
Two case studies illustrate the influence of circumstances and motivational factors on the outcomes of individuals grappling with substance abuse. Indy's story demonstrates the power of resilience, family support, and therapeutic techniques in overcoming addiction. In contrast, Tim's tale highlights the devastating consequences of addiction when family support and coping mechanisms are lacking, highlighting the critical need for both intrinsic and extrinsic motivation, accessible substance abuse treatment and mental health support.
In summary, motivation is the driving force behind successful substance abuse treatment. It empowers individuals to seek help, engage in interventions, and sustain their journey to recovery. Motivation, you see, is not just a concept; it's a transformative power. It fuels the spirit of those who have faced the abyss of addiction, empowering them to rise like a phoenix, above their circumstances (see Figure 7). It ignites the spark of change, compelling individuals to actively engage in interventions, laying the foundation for a profound transformation. And it is the unrelenting spirit that stands as a steadfast companion throughout the tumultuous journey to recovery.