CSAT’s 

Knowledge Application Program 

KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in 

Substance Abuse Treatment 

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 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

Introduction 

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" information. 

For more information on the topics in these KAP Keys, readers 

are referred to TIP 35. 

Other Treatment Improvement Protocols (TIPs) 

that are relevant to these KAP Keys: 

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 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

The FRAMES Approach 1 

To understand what prompts a person to reduce or eliminate 

substance use, clinicians have searched for the critical components of effective interventions; the most important and common elements that inspire positive change. The acronym 

FRAMES was coined to summarize the following six key elements: 

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 alternatives are offered to the client. 

Empathic counseling--showing warmth, respect, and understanding--is emphasized. 

Self-efficacy or optimistic empowerment is engendered in the 

client to encourage change. 

Source: Miller and Sanchez 1994. 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

Appropriate Motivational Strategies 

for Each Stage of Change 

2 

Precontemplation: The client is not yet considering change or 

is unwilling or unable to change. Establish rapport, ask permission, 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 considering the possibility of change but is ambivalent and uncertain. Normalize ambivalence. Help the client "tip the decisional 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 selfefficacy for change. 

• Eliciting self-motivational statements of intent and commitment 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. 

Continued on back 
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 functional 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 symptoms 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 learning opportunity. 

• Assist the client in finding alternative coping strategies. 

• Maintain supportive contact. 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

Ten Effective Catalysts for Change 3 

• Consciousness raising is increasing information about the 

problem. Interventions could include observations, interpretations, 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 alternatives for anxiety caused by substance-related behaviors. 

Interventions could include relaxation training, desensitization, 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 environment. 

• Reinforcement management is rewarding oneself or being 

rewarded by others for making changes. Interventions could 

include contingency contracts and overt and covert reinforcement. 

• Helping relationships are created by being open and trusting about problems with people who care. Interventions 

could include self-help groups, social support, or a therapeutic 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 psychodrama. 

• Environmental reevaluation is the process of assessing how 

one's problems affect the personal and physical environment. Interventions could include empathy training and documentaries. 

• Social liberation involves increasing alternatives for nonproblematic behavior. Interventions could include advocating 

for the rights of the oppressed and policy interventions. 

Source: Adapted from DiClemente and Scott 1997. 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

Four Types of Client Resistance 4 

Arguing: The client contests the accuracy, expertise, or integrity 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 talking, 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 problems, 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 exaggerating 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 reluctance 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 nonverbal reply to the clinician's query. 

• Sidetracking. The client changes the direction of the conversation that the clinician has been pursuing. 

Continued on back 
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. 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

Change Plan Worksheet 5 

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. 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 
KAP KEYS Based on TIP 35 

Enhancing Motivation for Change in Substance Abuse 

Treatment 

Deciding To Change 6 

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. 
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 without 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