Enhancing Motivation

For Change in

Substance Abuse

Treatment

35

Treatment Improvement Protocol (TIP) Series

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration
Blue Lines FPO

(for spine positioning)

Enhancing Motivation For Change in Substance Abuse Treatment CSAT (TIP)

35
Enhancing

Motivation for 

Change in 

Substance

Abuse

Treatment

Treatment Improvement Protocol (TIP) Series 

35

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

1 Choke Cherry Road 

Rockville, MD 20857 
ii

Acknowledgments

This publication was prepared under contract 

number 270-95-0013 for the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and 

Human Services (HHS). Sandra Clunies, M.S., 

ICADC, served as the Contracting Officer’s 

Representative. 

Disclaimer

The opinions expressed herein are the views of 

the consensus panel members and do not 

necessarily reflect the official position of 

SAMHSA or HHS. No official support of or 

endorsement by SAMHSA or HHS for these

opinions or for the instruments or resources 

described are intended or should be inferred. 

The guidelines presented should not be 

considered substitutes for individualized client 

care and treatment decisions.

Public Domain Notice

All materials appearing in this volume except 

those taken directly from copyrighted sources 

are in the public domain and may be 

reproduced or copied without permission from 

SAMHSA or the authors. Citation of the source 

is appreciated. However, this publication may 

not be reproduced or distributed for a fee 

without the specific, written authorization of the 

Office of Communications, SAMHSA, HHS.

Electronic Access and Printed Copies

This publication may be ordered for free from 

SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov. Or, please call 

SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). The document can be 

downloaded from the KAP Web site at 

http://kap.samhsa.gov. 

Recommended Citation

Center for Substance Abuse Treatment.

Enhancing Motivation for Change in Substance 

Abuse Treatment. Treatment Improvement 

Protocol (TIP) Series, No. 35. HHS Publication 

No. (SMA) 12-4212. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, 1999. 

Originating Office

Quality Improvement and Workforce 

Development Branch, Division of Services 

Improvement, Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health 

Services Administration, 1 Choke Cherry Road, 

Rockville, MD 20857.

HHS Publication No. (SMA) 12-4212

First Printed 1999

Revised 2000, 2001, 2002, 2003, 2004, 2006, 2007, 

2008, 2011, and 2012

 
Contents

What Is a TIP?..........................................................................................................................................................vii

Editorial Advisory Board........................................................................................................................................ ix

Consensus Panel ...................................................................................................................................................... xi

Foreword..................................................................................................................................................................xiii

Executive Summary and Recommendations ..................................................................................................... xv

Summary of Recommendations...................................................................................................................... xvi

To Which Clients Does This TIP Apply? ..................................................................................................... xxvi 

Chapter 1—Conceptualizing Motivation and Change........................................................................................1

A New Look at Motivation..................................................................................................................................1

Changing Perspectives on Addiction and Treatment......................................................................................4

Changes in the Addictions Field.......................................................................................................................11

A Transtheoretical Model of the Stages of Change ........................................................................................15

To Whom Does This TIP Apply? ......................................................................................................................19

Summary..............................................................................................................................................................21

Chapter 2—Motivation and Intervention............................................................................................................23

Elements of Effective Motivational Interventions ..........................................................................................23

Motivational Intervention and the Stages of Change ....................................................................................29

Special Applications of Motivational Interventions.......................................................................................30

Brief Interventions ..............................................................................................................................................36

Chapter 3—Motivational Interviewing as a Counseling Style .......................................................................39

Ambivalence ........................................................................................................................................................40

Five Principles of Motivational Interviewing .................................................................................................40

Five Opening Strategies for Early Sessions .....................................................................................................49

Effectiveness of Motivational Interviewing.....................................................................................................

..............................................................................................

..............................................

.................................................................................................................................................

53

Motivational Interviewing and Managed Care 55

Chapter 4—From Precontemplation to Contemplation: Building Readiness 57

Raising the Topic 58

 
Gentle Strategies To Use With the Precontemplator......................................................................................62

Assessment and Feedback Process ...................................................................................................................65

Intervene Through Significant Others .............................................................................................................71

Motivational Enhancement and Coerced Clients: Special Considerations .................................................80

Chapter 5—From Contemplation to Preparation: Increasing Commitment .................................................83

Changing Extrinsic to Intrinsic Motivation .....................................................................................................84

Tipping the Decisional Balance.........................................................................................................................86

Emphasizing Personal Choice and Responsibility .........................................................................................90

The Importance of Self-Efficacy ........................................................................................................................95

Chapter 6—From Preparation to Action: Getting Started ................................................................................97

Recognizing Readiness To Move Into Action .................................................................................................98

Negotiating a Plan for Change..........................................................................................................................98

Initiating the Plan..............................................................................................................................................109

Chapter 7—From Action to Maintenance: Stabilizing Change.....................................................................111

Engaging and Retaining Clients in Treatment..............................................................................................112

Planning for Stabilization ................................................................................................................................118

Developing and Using Reinforcers.................................................................................................................123

Chapter 8—Measuring Components of Client Motivation ...........................................................................135

Self-Efficacy........................................................................................................................................................136

Readiness To Change .......................................................................................................................................137

Decisional Balancing.........................................................................................................................................141

Motivation for Using Substances....................................................................................................................143

Goals and Values...............................................................................................................................................144

Chapter 9—Integrating Motivational Approaches Into Treatment Programs............................................147

The Treatment Continuum and Stepped Care..............................................................................................148

Applications of Motivational Approaches in Specific Treatment Settings ...............................................149

Chapter 10—Directions for Future Research ....................................................................................................159

Conclusion .........................................................................................................................................................162

Appendix A—Bibliography.................................................................................................................................163 

Appendix B—Screening and Assessment Instruments..................................................................................185

Alcohol and Drug Consequences Questionnaire (ADCQ)..........................................................................186

Alcohol (and Illegal Drugs) Decisional Balance Scale..................................................................................189

Alcohol Effects Questionnaire.........................................................................................................................192

Alcohol Expectancy Questionnaire—III (Adult) ..........................................................................................195

Alcohol Use Disorders Identification Test (AUDIT) ....................................................................................202

Brief Situational Confidence Questionnaire (BSCQ)...................................................................................204

Personal Feedback Report................................................................................................................................206

Readiness To Change Questionnaire (Treatment Version) (RCQ-TV) ......................................................214
#ONTENTS

Situational Confidence Questionnaire (SCQ-39) ..........................................................................................

.......................................

.......................................

...............................................................

.........................................................................................................................

..............................................................

................................................................................................................................................

.............................................................................................................................

............................................................................................................................

........................................................................................................................

217

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES 8A) 220

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES 8D) 222

University of Rhode Island Change Assessment Scale (URICA) 226

What I Want From Treatment 230

Appendix C—Ordering Information for Assessment Instruments 235

Other Resources 237

Appendix D—Resource Panel 239

Appendix E—Field Reviewers 241

Figures 

1-1 Examples of Natural Changes 16

1-2 Five Stages of Change ......................................................................................................................................

......................................................................

................................................................

................................................................................................................

...............................................................................................................

............................................................................................................

.....................................................................................................................

............................................................................................................

.......................................................................................

........................................................................

........................................................................................

.......................................................................................

17

2-1 Specific FRAMES Components of 32 Evaluated Brief Trials 24

2-2 Appropriate Motivational Strategies for Each Stage of Change 31

2-3 Ten Effective Catalysts for Change 33

2-4 Catalysts and the Stages of Change 34

3-1 Stage-Specific Motivational Conflicts 40

3-2 Four Types of Client Resistance 47

3-3 How To Ask Open-Ended Questions 51

3-4 How To Recognize Self-Motivational Statements 53

3-5 Sample Questions To Evoke Self-Motivational Statements 54

4-1 Where Does Your Drinking Fit In?: Health Risks 69

4-2 Where Does Your Drinking Fit In?: AUDIT Score 70

5-1 Tips for Moving Clients Through Contemplation to Preparation.............................................................84

5-2 Recapitulation ...................................................................................................................................................

...................................................................................................................................................

.........................................................................................................................................

................................................................................................................................

...................................................................................

............................................................................................................................................

.............................................................................

..............................................................................................

...............................................................................................................

...........................................................................................................

91

5-3 Key Questions 92

5-4 When Goals Collide 93

6-1 Change Plan Worksheet 100

7-1 Options for Responding to a Missed Appointment 117

7-2 Coping Strategies 120

7-3 Case Study 1: Client With Drug-Using Social Support 122

7-4 Case Study 2: Client Lacking Social Support 123

7-5 Case Study 3: Payday as a Trigger 124

7-6 Using Cultural Values as Motivators 128

7-7 Therapeutic Workplaces for Individuals With Substance Abuse Disorders..........................................

.........................................................................................

..............................................................................................................................................

.......................................................................................................................................

130

8-1 20-Item Alcohol Abstinence Self-Efficacy Scale 138

8-2 Readiness Ruler 139

8-3 Deciding To Change 142

V

vii

What Is a TIP?

reatment Improvement Protocols (TIPs) 

are developed by the Substance Abuse 

and Mental Health Services 

Administration (SAMHSA) within the U.S. 

Department of Health and Human Services 

(HHS). Each TIP involves the development of 

topic-specific best-practice guidelines for the 

prevention and treatment of substance use and 

mental disorders. TIPs draw on the experience 

and knowledge of clinical, research, and 

administrative experts of various forms of 

treatment and prevention. TIPs are distributed 

to facilities and individuals across the country. 

Published TIPs can be accessed via the Internet 

at http://kap.samhsa.gov.

Although each consensus-based TIP strives 

to include an evidence base for the practices it 

recommends, SAMHSA recognizes that 

behavioral health is continually evolving, and 

research frequently lags behind the innovations 

pioneered in the field. A major goal of each TIP 

is to convey "front-line" information quickly but 

responsibly. If research supports a particular 

approach, citations are provided.

T

Editorial Advisory Board

Karen Allen, Ph.D., R.N., C.A.R.N. 

Professor and Chair 

Department of Nursing 

Andrews University 

Berrien Springs, Michigan 

Richard L. Brown, M.D., M.P.H. 

Associate Professor 

Department of Family Medicine 

University of Wisconsin School of Medicine 

Madison, Wisconsin 

Dorynne Czechowicz, M.D. 

Associate Director 

Medical/Professional Affairs 

Treatment Research Branch 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Rockville, Maryland 

Linda S. Foley, M.A. 

Former Director 

Project for Addiction Counselor Training 

National Association of State Alcohol and 

Drug Abuse Directors 

Washington, D.C. 

Wayde A. Glover, M.I.S., N.C.A.C. II 

Director

Commonwealth Addictions Consultants and 

Trainers

Richmond, Virginia

Pedro J. Greer, M.D. 

Assistant Dean for Homeless Education 

University of Miami School of Medicine 

Miami, Florida 

Thomas W. Hester, M.D. 

Former State Director 

Substance Abuse Services 

Division of Mental Health, Mental 

Retardation and Substance Abuse 

Georgia Department of Human Resources 

Atlanta, Georgia 

James G. (Gil) Hill, Ph.D. 

Director

Office of Substance Abuse 

American Psychological Association 

Washington, D.C. 

Douglas B. Kamerow, M.D., M.P.H. 

Director

Office of the Forum for Quality and 

Effectiveness in Health Care 

Agency for Health Care Policy and Research 

Rockville, Maryland 

Stephen W. Long 

Director

Office of Policy Analysis 

National Institute on Alcohol Abuse and 

Alcoholism

Rockville, Maryland 

Richard A. Rawson, Ph.D. 

Executive Director 

Matrix Center and Matrix Institute on 

Addiction

Deputy Director, UCLA Addiction Medicine 

Services 

Los Angeles, California 
Ellen A. Renz, Ph.D. 

Former Vice President of Clinical Systems 

MEDCO Behavioral Care Corporation 

Kamuela, Hawaii 

Richard K. Ries, M.D. 

Director and Associate Professor 

Outpatient Mental Health Services and Dual 

Disorder Programs 

Harborview Medical Center 

Seattle, Washington 

Sidney H. Schnoll, M.D., Ph.D. 

Chairman 

Division of Substance Abuse Medicine 

Medical College of Virginia 

Richmond, Virginia 
Consensus Panel 

Chair

William R. Miller, Ph.D. 

Regents Professor of Psychology and 

Psychiatry 

Director of Research 

Center on Alcoholism, Substance Abuse, and 

Addictions

Department of Psychology 

University of New Mexico

Albuquerque, New Mexico

Workgroup Leaders 

Edward Bernstein, M.D., F.A.C.E.P. 

Associate Professor and Academic Affairs 

Vice Chairman 

Boston University School of Medicine 

Boston, Massachusetts

Suzanne M. Colby, Ph.D. 

Assistant Professor of Psychiatry and 

Human Behavior 

Center for Alcohol and Addiction Studies 

Brown University 

Providence, Rhode Island 

Carlo C. DiClemente, Ph.D. 

Department of Psychology 

University of Maryland, Baltimore County 

Baltimore, Maryland 

Robert J. Meyers, M.A. 

Center on Alcoholism, Substance Abuse, and 

Addictions

University of New Mexico

Albuquerque, New Mexico

Maxine L. Stitzer, Ph.D. 

Professor of Psychiatry and Behavioral 

Biology 

Johns Hopkins University School of 

Medicine 

Baltimore, Maryland 

Allen Zweben, D.S.W. 

Director and Associate Professor of Social 

Work

Center for Addiction and Behavioral Health 

Research 

University of Wisconsin at Milwaukee 

Milwaukee, Wisconsin 

Panelists

Ray Daw 

Executive Director 

Northwest New Mexico Fighting Back, Inc. 

Gallup, New Mexico 

Jeffrey M. Georgi, M.Div., C.S.A.C., C.G.P. 

Program Coordinator 

Duke Alcoholism & Addictions Program 

Clinical Associate 

Department of Psychiatry and Behavioral 

Science

Duke University Medical Center 

Durham, North Carolina 

Cheryl Grills, Ph.D. 

Department of Psychology 

Loyola Marymount University 

Los Angeles, California 
Rosalyn Harris-Offutt, B.S., C.R.N.A., L.P.C., 

A.D.S. 

UNA Psychological Associates 

Greensboro, North Carolina 

Don M. Hashimoto, Psy.D. 

Clinical Director 

Ohana Counseling Services, Inc. 

Hilo, Hawaii 

Dwight McCall, Ph.D. 

Evaluation Manager 

Substance Abuse Services 

Virginia Department of Mental Health, 

Mental Retardation and Substance Abuse 

Services 

Richmond, Virginia 

Jeanne Obert, M.F.C.C., M.S.M. 

Director of Clinical Services 

Matrix Center 

Los Angeles, California 

Carole Janis Otero, M.A., L.P.C.C. 

Director

Albuquerque Metropolitan Central Intake 

Albuquerque, New Mexico 

Roger A. Roffman, D.S.W. 

Innovative Programs Research Group 

School of Social Work 

Seattle, Washington 

Linda C. Sobell, Ph.D. 

Professor 

NOVA Southeastern University 

Fort Lauderdale, Florida 
xiii

Foreword

he Treatment Improvement Protocol (TIP) 

series fulfills the Substance Abuse and 

Mental Health Services Administration’s 

(SAMHSA’s) mission to improve prevention and 

treatment of substance use and mental disorders 

by providing best practices guidance to clinicians, 

program administrators, and payers. TIPs are the 

result of careful consideration of all relevant 

clinical and health services research findings, 

demonstration experience, and implementation 

requirements. A panel of non-Federal clinical 

researchers, clinicians, program administrators, 

and patient advocates debates and discusses their 

particular area of expertise until 

they reach a consensus on best practices. This 

panel’s work is then reviewed and critiqued by 

field reviewers.

The talent, dedication, and hard work that TIPs 

panelists and reviewers bring to this highly 

participatory process have helped bridge the gap 

between the promise of research and the needs of 

practicing clinicians and administrators to serve, 

in the most scientifically sound and effective ways, 

people in need of behavioral health services. We 

are grateful to all who have joined with us to 

contribute to advances in the behavioral health

field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Peter J. Delany, Ph.D., LCSW-C RADM, USPHS

Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration

T

Executive Summary and 

Recommendations

This TIP is based on a fundamental 

rethinking of the concept of motivation. 

Motivation is not seen as static but as 

dynamic. It is redefined here as purposeful, 

intentional, and positive—directed toward the 

best interests of the self. Specifically, motivation 

is considered to be related to the probability that 

a person will enter into, continue, and adhere to 

a specific change strategy. This TIP shows how 

substance abuse treatment staff can influence 

change by developing a therapeutic relationship 

that respects and builds on the client’s 

autonomy and, at the same time, makes the 

treatment clinician a partner in the change 

process. The TIP also describes different 

motivational interventions that can be used at all 

stages of the change process, from 

precontemplation and preparation to action and 

maintenance, and informs readers of the 

research, results, tools, and assessment 

instruments related to enhancing motivation. 

 The primary purpose of this TIP is to link

research to practice by providing clear 

applications of motivational approaches in 

clinical practice and treatment programs. This 

TIP also seeks to shift the conception of client 

motivation for change toward a view that 

empowers the treatment provider to elicit 

motivation. These approaches may be especially 

beneficial to particular populations (e.g., courtmandated offenders) with a low motivation for 

change. 

Despite the preponderance of evidence 

supporting the efficacy of motivation-focused 

interventions, their use in the United States has 

occurred primarily in research settings. One 

obstacle to their implementation may be 

ideological: low motivation, denial, and 

resistance are often considered characteristic 

attributes of those diagnosed with substance 

abuse disorders. The cognitive–behavioral 

emphasis of motivational approaches, however, 

requires a different perspective on the nature of 

the problem and the prerequisites for change. 

This approach places greater responsibility on 

the clinician, whose job is now expanded to 

include engendering motivation. Rather than 

dismissing the more challenging clients as 

unmotivated, clinicians are equipped with skills 

to enhance motivation and to establish 

partnerships with their clients. 

The Consensus Panel recommends that 

substance abuse treatment staff view motivation 

in this new light. Motivation for change is a key 

component in addressing substance abuse. The 

results of longitudinal research suggest that an 

individual’s level of motivation is a very strong 

predictor of whether the individual’s substance 

use will change or remain the same. 

Motivation-enhancing techniques are associated 

with increased participation in treatment and 

such positive treatment outcomes as reductions 

in consumption, higher abstinence rates, better 

social adjustment, and successful referrals to 
treatment. In addition, having a positive 

attitude toward change and being committed to 

change are associated with positive treatment 

outcomes. This is not a new insight. However, 

until relatively recently motivation was more 

commonly viewed as a static trait that the client 

either did or did not have. According to this 

view, the clinician has little chance of 

influencing a client’s motivation. If the client is 

not motivated to change, it is the client’s—not 

the clinician’s—problem. 

Recent models of change, however, recognize 

that change itself is influenced by biological, 

psychological, sociological, and spiritual 

variables. The capacity that each individual 

brings to the change process is affected by these 

variables. At the same time, these models 

recognize that although the client is ultimately 

responsible for change, this responsibility is 

shared with the clinician through the 

development of a “therapeutic partnership.” 

Chapter 1 of this TIP presents an overview of 

how the concepts of motivation and change 

have evolved in recent years and describes the 

“stages-of-change” model, developed by 

Prochaska and DiClemente and upon which this 

TIP is based. Chapter 2 presents interventions 

that can enhance clients’ motivation, highlights 

their effective elements, and links them to the 

stages-of-change model. Developed by Miller 

and Rollnick, motivational interviewing is a 

therapeutic style used to interact with 

substance-using clients that can help them 

resolve issues related to their ambivalence; this 

is discussed in Chapter 3. 

Chapters 4 through 7 address the five stages 

of change and provide guidelines for clinicians 

to tailor their treatment to clients’ stages of 

readiness for change. Various tools and 

instruments used to measure components of 

change are summarized in Chapter 8. Chapter 9 

provides examples of integrating motivational 

approaches into existing treatment programs. 

As motivational interventions are still a 

relatively new field, there are many unanswered 

questions; Chapter 10 offers directions for future 

research. 

In order to avoid awkward construction and 

sexism, this TIP alternates between “he” and 

“she” for generic examples. 

Throughout this TIP, the term “substance 

abuse” has been used in a general sense to cover 

both substance abuse disorders and substance 

dependence disorders (as defined by the 

4th Edition [DSM-IV] [American 

Psychiatric Association, 1994]). Because the 

term “substance abuse” is commonly used by 

substance abuse treatment professionals to 

describe any excessive use of addictive 

substances, commencing with this TIP, it will be 

used to denote both substance dependence and 

substance abuse disorders. The term does relate 

to the use of alcohol as well as other substances 

of abuse. Readers should attend to the context 

in which the term occurs in order to determine 

what possible range of meanings it covers; in 

most cases, however, the term will refer to all 

varieties of substance use disorders as described 

by the DSM-IV. 

Summary of 

Recommendations

The Consensus Panel’s recommendations, 

summarized below, are based on both research 

and clinical experience. Those supported by 

scientific evidence are followed by (1); clinically 

based recommendations are marked (2). 

References for the former are cited in the body 

of this document, where the guidelines are 

presented in detail. 

Conceptualizing Motivation 

In the past 15 years, considerable research has 

focused on ways to better motivate substanceusing clients to initiate and continue substance 

abuse treatment. A series of motivational 
approaches has been developed to elicit and 

enhance a substance-using client’s motivation to 

change. These approaches are based on the 

following assumptions about the nature of 

motivation: 

Motivation is a key to change. (2) 

Motivation is multidimensional. (2) 

Motivation is a dynamic and fluctuating 

state. (2) 

Motivation is interactive. (2) 

Motivation can be modified. (2) 

The clinician’s style influences client 

motivation. (2) 

To incorporate these assumptions about 

motivation while encouraging a client to change 

substance-using behavior, the clinician can use 

the following strategies: 

Focus on the client’s strengths rather than his 

weaknesses. (2) 

Respect the client’s autonomy and decisions. 

(2) 

Make treatment individualized and client 

centered. (1) 

Do not depersonalize the client by using 

labels like “addict” or “alcoholic.” (2) 

Develop a therapeutic partnership. (2) 

Use empathy, not authority or power. (1) 

Focus on early interventions. Extend 

motivational approaches into nontraditional 

settings. (2) 

Focus on less intensive treatments. (1) 

Recognize that substance abuse disorders 

exist along a continuum. (2) 

Recognize that many clients have more than

one substance use disorder. (1) 

Recognize that some clients may have other 

coexisting disorders that affect all stages of 

the change process. (1) 

Accept new treatment goals, which involve 

interim, incremental, and even temporary 

steps toward ultimate goals. (2) 

Integrate substance abuse treatment with 

other disciplines. (2) 

Motivational approaches build on these 

ideas. They seek to shift control away from the 

clinician and back to the client. They emphasize 

treating the client as an individual. They also 

recognize that treating substance abuse is a 

cyclical rather than a linear process and that 

recurrence of use does not necessarily signal 

failure.

Transtheoretical Model of Change 

Substantial research has focused on the 

determinants and mechanisms of personal 

change. Theorists have developed various 

models for how behavior change happens. One 

perspective sees external consequences as being 

largely responsible for influencing individuals 

to change. Another model views intrinsic 

motivations as causing substance abuse 

disorders. Others believe that motivation is 

better described as a continuum of readiness 

than as one consisting of separate stages of 

change. 

The transtheoretical stages-of-change model, 

described in Chapter 1, emerged from an 

examination of 18 psychological and behavioral 

theories about how change occurs, including 

components that make up the biopsychosocial 

framework for understanding addiction. This 

model of change provides the foundation for 

this TIP. The five stages of change are 

precontemplation, contemplation, preparation, 

action, and maintenance. These stages can be 

conceptualized as a cycle through which clients 

move back and forth. The stages are not viewed 

as linear, such that clients enter into one stage 

and then directly progress to the next. Framing 

clients’ treatment within the stages of change 

can help the clinician better understand clients’ 

treatment progress. 

This model also takes into account that for 

most people with substance abuse problems, 

recurrence of substance use is the rule, not the 

exception. After a return to substance use, 

clients usually revert to an earlier change 
stage—not always to maintenance or action, but 

many times to some level of contemplation. In 

this model, recurrence is not equivalent to 

failure and does not mean that a client has 

abandoned a commitment to change. Thus, 

recurrence is not considered a stage but an event 

that can occur at any point along the cycle of 

recovery. Based on research and clinical 

experience, the Consensus Panel endorses the 

transtheoretical model as a useful model of 

change (1, 2); however, it is important to note 

that the model’s use has been primarily 

conceptual and that no current technology is 

available to definitively determine an 

individual’s stage of readiness for change. 

Motivational Interventions 

A motivational intervention is any clinical 

strategy designed to enhance client motivation 

for change. It can include counseling, client 

assessment, multiple sessions, or a 30-minute 

brief intervention. To understand what prompts

a person to reduce or eliminate substance use, 

investigators have searched for the critical 

components—the most important and common 

elements that inspire positive change—of 

effective interventions. The Consensus Panel 

considers the following elements of current 

motivational approaches to be important: 

The FRAMES approach (1) 

Decisional balance exercises (1) 

Developing discrepancy (1) 

Flexible pacing (2) 

Personal contact with clients who are not 

actively in treatment (1) 

The FRAMES approach consists of the 

following components: 

F regarding personal risk or 

impairment is given to the individual 

following an assessment of substance use 

patterns and associated problems. This 

feedback usually compares the client’s scores 

or ratings on standard tests with normative 

data from the general population or specified 

treatment groups. 

R for change is placed squarely 

and explicitly with the individual. Clients 

have the choice to either continue their 

substance use behavior or change it. 

A about changing—reducing or 

stopping—substance use is clearly given to 

the individual by the clinician in a 

nonjudgmental manner. It is better to 

than to Asking clients’ permission to 

offer advice can make clients more receptive 

to that advice. 

M of self-directed change options and 

treatment alternatives is offered to the client. 

E counseling, showing warmth, 

respect, and understanding, is emphasized. 

Empathy entails reflective listening. 

S or optimistic empowerment is 

engendered in the person to encourage 

change. 

Research has shown that simple motivationenhancing interventions are effective for 

encouraging clients to return for another clinical 

consultation, return to treatment following a 

missed appointment, stay involved in treatment, 

and be more compliant. 

The simplicity and universality of the 

concepts underlying motivational interventions 

permit broad-scale application in many different 

settings and offer great potential to reach 

individuals with many types of problems and in 

many different cultures. This is important 

because treatment professionals work with a

wide range of clients who differ with regard to 

ethnic and racial background, socioeconomic 

status, education level, gender, age, sexual 

orientation, type and severity of substance abuse 

problems, physical health, and psychological 

health. Although the principles and 

mechanisms of enhancing motivation to change 

seem to be broadly applicable, there may be 

important differences among populations and 

cultural contexts regarding the expression of 
motivation for change and the importance of 

critical life events. Therefore, clinicians should 

be thoroughly familiar with the populations

with whom they expect to establish therapeutic 

relationships. (2) 

Because motivational strategies emphasize 

clients’ responsibilities to voice personal goals 

and values as well as to make choices among 

options for change, clinicians should understand 

and respond in a nonjudgmental way to 

expressions of cultural differences. They should 

identify elements in a population’s values that 

present potential barriers to change. Clinicians 

should learn what personal and material 

resources are available to clients and be sensitive 

to issues of poverty, social isolation, or recent 

losses in offering options for change or probing 

personal values. In particular, it should be 

recognized that access to financial and social 

resources is an important part of the motivation 

for and process of change. (2) 

Motivational Interviewing 

Motivational interviewing is a therapeutic style 

intended to help clinicians work with clients to 

address their ambivalence. While conducting a 

motivational interview, the clinician is directive 

yet client centered, with a clear goal of eliciting 

self-motivational statements and behavioral 

change from the client, and seeking to create 

client discrepancy to enhance motivation for 

positive change. The Consensus Panel 

recommends that motivational interviewing be 

seen not as a set of techniques or tools, but 

rather as a way of interacting with clients. (2) 

The Panel believes that motivational 

interviewing is supported by the following 

principles:

Ambivalence about substance use and 

change is normal and constitutes an 

important motivational obstacle in recovery. 

(2)

Ambivalence can be resolved by working 

with the client’s intrinsic motivations and 

values. (2) 

The alliance between client and clinician is a 

collaborative partnership to which each 

brings important expertise. (2) 

An empathic, supportive, yet directive 

counseling style provides conditions within 

which change can occur. (Direct argument 

and aggressive confrontation tend to increase 

client defensiveness, reducing the likelihood 

of change.) (2) 

The motivational interviewing style 

facilitates an exploration of stage-specific 

motivational conflicts that can potentially hinder 

further progress. (1) However, each dilemma 

also offers an opportunity to use the 

motivational style as a way of helping clients 

explore and resolve opposing attitudes. 

The Consensus Panel recognizes that 

successful motivational interviewing will entail 

being able to 

Express empathy through reflective listening. 

(1) 

Communicate respect for and acceptance of 

clients and their feelings. (2) 

Establish a nonjudgmental, collaborative

relationship. (2) 

Be a supportive and knowledgeable 

consultant. (2) 

Compliment rather than denigrate. (2) 

Listen rather than tell. (2) 

Gently persuade, with the understanding 

that change is up to the client. (2) 

Provide support throughout the process of 

recovery. (2) 

Develop discrepancy between clients’ goals 

or values and current behavior, helping 

clients recognize the discrepancies between 

where they are and where they hope to be. 

(2) 
Avoid argument and direct confrontation, 

which can degenerate into a power struggle. 

(2) 

Adjust to, rather than oppose, client 

resistance. (2) 

Support self-efficacy and optimism: that is, 

focus on clients’ strengths to support the 

hope and optimism needed to make change. 

(2) 

Clinicians who adopt motivational 

interviewing as a preferred style have found 

that the following five strategies are particularly

useful in the early stages of treatment: 

1. Open-ended 

questions cannot be answered with a single 

word or phrase. For example, rather than 

asking, “Do you like to drink?” ask, “What 

are some of the things that you like about 

drinking?” (2) 

2. Demonstrate that you

have heard and understood the client by 

reflecting what the client said. (2) 

3. It is useful to summarize 

periodically what has transpired up to that 

point in a counseling session. (2) 

4. Support and comment on the client’s 

strengths, motivation, intentions, and 

progress. (2) 

5. Have the 

client voice personal concerns and

intentions, rather than try to persuade the 

client that change is necessary. (2) 

Tailoring Motivational 

Interventions to the 

Stages of Change 

Individuals appear to need and use different 

kinds of help, depending on which stage of 

readiness for change they are currently in and to 

which stage they are moving. (2) Clients who 

are in the early stages of readiness need and use 

different kinds of motivational support than do 

clients at later stages of the change cycle. 

To encourage change, individuals in the 

precontemplation stage must increase their 

awareness. (2) To resolve their ambivalence, 

clients in the contemplation stage should choose 

positive change over the status quo. (2) Clients 

in the preparation stage must identify potential 

change strategies and choose the most 

appropriate one for their circumstances. Clients 

in the action stage must carry out change 

strategies. This is the stage toward which most 

formal substance abuse treatment is directed. 

During the maintenance stage, clients may have 

to develop new skills that help maintain 

recovery and a healthy lifestyle. Moreover, if 

clients resume their problem substance use, they 

need help to recover as quickly as possible and 

reenter the change process. 

From precontemplation to 

contemplation 

According to the stages-of-change model, 

individuals in the precontemplation stage are 

not concerned about their substance use or are 

not considering changing their behavior. These 

substance users may remain in 

precontemplation or early contemplation for 

years, rarely or never thinking about change. 

Often, a significant other finds the substance 

user’s behavior problematic. Chapter 4 

discusses a variety of proven techniques and 

gentle tactics that clinicians can use to address 

the topic of substance abuse with people who 

are not thinking of change. Use of these 

techniques will serve to (1) create client doubt 

about the commonly held belief that substance 

abuse is “harmless” and (2) lead to client 

conviction that substance abuse is having, or 

will in the future have, significant negative 

results. The chapter suggests that clinicians 

practice the following: 

Commend the client for coming to substance 

abuse treatment. (2) 

Establish rapport, ask permission to address 

the topic of change, and build trust. (2) 
Elicit, listen to, and acknowledge the aspects 

of substance use the client enjoys. (2) 

Evoke doubts or concerns in the client about 

substance use. (2) 

Explore the meaning of the events that 

brought the client to treatment or the results 

of previous treatments. (2) 

Obtain the client’s perceptions of the 

problem. (2) 

Offer factual information about the risks of 

substance use. (2) 

Provide personalized feedback about 

assessment findings. (2) 

Help a significant other intervene. (2) 

Examine discrepancies between the client’s 

and others’ perceptions of the problem 

behavior. (2) 

Express concern and keep the door open. (2) 

The assessment and feedback process can be 

an important part of the motivational strategy 

because it informs clients of how their own 

substance use patterns compare with norms, 

what specific risks are entailed, and what 

damage already exists or is likely to occur if 

changes are not made. 

Giving clients personal results from a broadbased and objective assessment, especially if the 

findings are carefully interpreted and compared 

with norms or expected values, can be not only 

informative but also motivating. (1) Providing 

clients with personalized feedback on the risks 

associated with use of a particular 

substance—especially for their own cultural and 

gender groups—is a powerful way to develop a 

sense of that can motivate change. 

Considerable research shows that involvement 

of family members or significant others (SOs) 

can help move substance-using persons toward 

contemplation of change, entry into treatment, 

involvement and retention in the therapeutic 

process, and successful recovery. (1) Involving 

SOs in the early stages of change can greatly 

enhance a client’s commitment to change by 

addressing the client’s substance use in the 

following ways: 

Providing constructive feedback to the client 

about the costs and benefits associated with 

her substance abuse (2) 

Encouraging the resolve of the client to 

change the negative behavior pattern (2) 

Identifying the client’s concrete and 

emotional obstacles to change (2) 

Alerting the client to social and individual 

coping resources that lead to a substance-free 

lifestyle (2) 

Reinforcing the client for employing these 

social and coping resources to change the 

substance use behavior (2) 

The clinician can engage an SO by asking the 

client to invite the SO to a treatment session. 

Explain that the SO will not be asked to monitor 

the client’s substance use but that the SO can 

perform a valuable role by providing emotional 

support, identifying problems that might 

interfere with treatment goals, and participating 

in activities with the client that do not involve 

substance use. To strengthen the SO’s belief in 

his capacity to help the client, the clinician can 

use the following strategies: 

Positively describe the steps used by the SO 

that have been successful (define 

“successful” generously). (2) 

Reinforce positive comments made by the SO 

about the client’s current change efforts. (2) 

Discuss future ways in which the client 

might benefit from the SO’s efforts to 

facilitate change. (2) 

Clinicians should use caution when 

involving an SO in motivational counseling. 

Although a strong relationship between the SO 

and the client is necessary, it is not wholly 

sufficient. The SO must also support a client’s 

substance-free life, and the client must value 

that support. (1) An SO who is experiencing 

hardships or emotional problems stemming 
from the client’s substance use may not be a 

suitable candidate. (1) Such problems can 

preclude the SO from constructively 

participating in the counseling sessions, and it 

may be better to wait until the problems have 

subsided before including an SO in the client’s 

treatment. (1) 

In general, the SO can play a vital role in 

influencing the client’s willingness to change; 

however, the client must be reminded that the 

responsibility to change substance use behavior 

is hers. (2) 

An increasing number of clients are mandated 

to obtain treatment by an employer or employee 

assistance program, the court system, or 

probation and parole officers. Others are 

influenced to enter treatment because of legal 

pressures. The challenge for clinicians is to 

engage coerced clients in the treatment process. 

A stable recovery cannot be maintained by 

external (legal) pressure only; motivation and 

commitment must come from internal pressure. 

If you provide interventions appropriate to their 

stage, coerced clients may become invested in 

the change process and benefit from the 

opportunity to consider the consequences of use 

and the possibility of change—even though that 

opportunity was not voluntarily chosen. (2) 

From contemplation to preparation 

Extrinsic and intrinsic motivators should be 

considered when trying to increase a client’s 

commitment to change and move the client 

closer to action because these motivators can be 

examined to enhance decisionmaking, thereby 

enhancing the client’s commitment. Many 

clients move through the contemplation stage

acknowledging only the extrinsic motivators 

pushing them to change or that brought them to 

treatment. Help the client discover intrinsic 

motivators, which typically move the client from 

contemplating change to acting. (2) In addition 

to the standard practices for motivational

interviewing (e.g., reflective listening, asking 

open-ended questions), clinicians can help spur 

this process of changing extrinsic motivators to 

intrinsic motivators by doing the following: 

Show curiosity about clients. Because a 

client’s desire to change is seldom limited to 

substance use, he may find it easier to 

discuss changing other behaviors. This will 

help strengthen the therapeutic alliance. (2) 

Reframe a client’s negative statement about

perceived coercion by re-expressing the 

statement with a positive spin. (2) 

Clinicians can use decisional balancing 

strategies to help clients thoughtfully consider 

the positive and negative aspects of their 

substance use. (1) The ultimate purpose, of 

course, is to help clients recognize and weigh 

the negative aspects of substance use so that the

scale tips toward beneficial behavior. 

Techniques to use in decisional balancing 

exercises include the following: 

Summarize the client’s concerns. (2) 

Explore specific pros and cons of substance 

use behavior. (1) 

Normalize the client’s ambivalence. (2) 

Reintroduce feedback from previous 

assessments. (1) 

Examine the client’s understanding of 

change and expectations of treatment. (1) 

Reexplore the client’s values in relation to 

change. (2) 

Throughout this process, emphasize the 

clients’ personal choices and responsibilities for 

change. The clinician’s task is to help clients 

make choices that are in their best interests. This 

can be done by exploring and setting goals. 

Goal-setting is part of the exploring and 

envisioning activities characteristic of the early 

and middle preparation stage. The process of 

talking about and setting goals strengthens

commitment to change. (1) 
During the preparation stage, the clinician’s 

tasks broaden from using motivational 

strategies to increase readiness—the goals of 

precontemplation and contemplation stages—to 

using these strategies to strengthen a client’s 

commitment and help her make a firm decision 

to change. At this stage, helping the client 

develop self-efficacy is important. (2) Selfefficacy is not a global measure, like self-esteem; 

rather, it is behavior specific. In this case, it is 

the client’s optimism that she can take action to 

change substance-use behaviors. 

From preparation to action 

As clients move through the preparation stage, 

clinicians should be alert for signs of clients’ 

readiness to move into action. There appears to 

be a limited period of time during which change 

should be initiated. (2) Clients’ recognition of 

important discrepancies in their lives is too 

uncomfortable a state to remain in for long, and 

unless change is begun they can retreat to using 

defenses such as minimizing or denying to 

decrease the discomfort. (2) The following can 

signal a client’s readiness to act: 

The client’s resistance (i.e., arguing, denying) 

decreases. (2) 

The client asks fewer questions about the 

problem. (2) 

The client shows a certain amount of resolve

and may be more peaceful, calm, relaxed, 

unburdened, or settled. (2) 

The client makes direct self-motivational 

statements reflecting openness to change and 

optimism. (2) 

The client asks more questions about the 

change process. (2) 

The client begins to talk about how life might 

be after a change. (2)

The client may have begun experimenting 

with possible change approaches such as 

going to an Alcoholics Anonymous meeting 

or stopping substance use for a few days. (2) 

Mere vocal fervor about change, however, is 

not necessarily a sign of dogged determination. 

Clients who are most vehement in declaring 

their readiness may be desperately trying to 

convince themselves, as well as the clinician, of 

their commitment. 

When working with clients in the 

preparation stage, clinicians should try to 

Clarify the client’s own goals and strategies 

for change. (2) 

Discuss the range of different treatment 

options and community resources available 

to meet the client’s multiple needs. (2) 

With permission, offer expertise and advice. 

(2) 

Negotiate a change—or treatment—plan and 

a behavior contract (2); take into 

consideration 

♦

♦

♦

♦

♦

 Intensity and amount of help needed 

 Timeframe

 Available social support, identifying who, 

where, and when 

 The sequence of smaller goals or steps 

needed for a successful plan 

 Multiple problems, such as legal,

financial, or health concerns

Consider and lower barriers to change by 

anticipating possible family, health, system, 

and other problems. (2) 

Help the client enlist social support (e.g., 

mentoring groups, churches, recreational 

centers). (2) 

Explore treatment expectancies and client 

role. (2) 

Have clients publicly announce their change 

plans to significant others in their lives. (2) 

From action to maintenance 

A motivational counseling style has most 

frequently been used with clients in the 

precontemplation through preparation stages as 

they move toward initiating behavioral change. 

Some clients and clinicians believe that formal, 

action-oriented substance abuse treatment is a
%XECUTIVE3UMMARYAND2ECOMMENDATIONS

different domain and that motivational 

strategies are no longer required. This is not 

true for two reasons. First, clients may still need 

a surprising amount of support and 

encouragement to stay with a chosen program 

or course of treatment. Even after a successful 

discharge, they may need support and 

encouragement to maintain the gains they have 

achieved and to know how to handle recurring 

crises that may mean a return to problem 

behaviors. (2) Second, many clients remain 

ambivalent in the action stage of change or 

vacillate between some level of contemplation— 

with associated ambivalence—and continuing 

action. (2) Moreover, clients who do take action 

are suddenly faced with the reality of stopping 

or reducing substance use. This is more difficult 

than just contemplating action. The first stages 

of recovery require only thinking about change, 

which is not as threatening as actually 

implementing it. 

Clients’ involvement or participation in 

treatment can be increased when clinicians 

















Develop a nurturing rapport with clients. (2) 

Induct clients into their role in the treatment 

process. (2) 

Explore what clients expect from treatment 

and determine discrepancies. (2) 

Prepare clients so that they know there may 

be some embarrassing, emotionally 

awkward, and uncomfortable moments but 

that such moments are a normal part of the 

recovery process. (2) 

Investigate and resolve barriers to treatment. 

(2) 

Increase congruence between intrinsic and 

extrinsic motivation. (2) 

Examine and interpret noncompliant 

behavior in the context of ambivalence. (2) 

Reach out to demonstrate continuing 

personal concern and interest to encourage 

clients to remain in the program. (2) 

Clients who are in the action stage can be 

most effectively helped when clinicians 













Engage clients in treatment and reinforce the 

importance of remaining in recovery. (2) 

Support a realistic view of change through 

small steps. (2) 

Acknowledge difficulties for clients in early 

stages of change. (2) 

Help the client identify high-risk situations 

through a functional analysis and develop 

appropriate coping strategies to overcome 

these. (2) 

Assist the client in finding new reinforcers of 

positive change. (2) 

Assess whether the client has strong family 

and social support. (2) 

The next challenge that clients and clinicians 

face is maintaining change. With clients in the 

maintenance stage, clinicians will be most 

successful if they can 











Help the client identify and sample 

substance-free sources of pleasure—i.e., new

reinforcers. (1) 

Support lifestyle changes. (2) 

Affirm the client’s resolve and self-efficacy. 

(2) 

Help the client practice and use new coping 

strategies to avoid a return to substance 

use. (2) 

Maintain supportive contact. (2) 

After clients have planned for stabilization 

by identifying risky situations, practicing new 

coping strategies, and finding their sources of 

support, they still have to build a new lifestyle 

that will provide sufficient satisfaction and can 

compete successfully against the lure of 

substance use. A wide range of life changes 

ultimately needs to be made if clients are to 

maintain lasting abstinence. Clinicians can help 

this change process by using competing 

reinforcers. (1) A competing reinforcer is 

anything that clients enjoy that is or can become 

XXIV
a healthy alternative to drugs or alcohol as a 

source of satisfaction. 

The essential principle in establishing new 

sources of positive reinforcement is to get clients 

involved in generating their own ideas. 

Clinicians should explore all areas of clients’ 

lives for new reinforcers. Reinforcers should not 

come from a single source or be of the same 

type. That way, a setback in one area can be 

counterbalanced by the availability of positive 

reinforcement from another area. Since clients

have competing motivations, clinicians can help 

them select reinforcers that will over 

substances over time. 

Following are a number of potential 

competing reinforcers that can help clients:

Doing volunteer work, thus filling time, 

connecting with socially acceptable friends, 

and improving their self-efficacy (2) 

Becoming involved in 12–Step-based 

activities and other self-help groups (2) 

Setting goals to improve their work, 

education, exercise, and nutrition (2) 

Spending more time with their families and 

significant others (2) 

Participating in spiritual or cultural 

activities (2) 

Socializing with nonsubstance-using 

friends (2) 

Learning new skills or improving in such 

areas as sports, art, music, and other 

hobbies (2) 

Contingency reinforcement systems, such as 

voucher programs, have proven to be effective 

when community support and resources are 

available. (1) Research has shown that these 

kinds of reinforcement systems can help to

sustain abstinence in drug abusers. The 

rationale for this type of incentive program is 

that an appealing external motivator can be used 

as an immediate and powerful reinforcer to 

compete with substance use reinforcers. Not all 

contingent incentives have to have a monetary 

value. In many cultures, money is not the most 

powerful reinforcer. 

Measuring Client Motivation 

Because motivation is multidimensional, it 

cannot be easily measured with one instrument 

or scale. Instead, the Consensus Panel 

recommends that substance abuse treatment 

staff use a variety of tools to measure several 

dimensions of motivation, including (2): 

Self-efficacy 

Importance of change 

Readiness to change

Decisional balancing 

Motivations for using substances 

Integrating Motivational 

Approaches Into Treatment 

Programs 

One of the principles of current health care 

management is that the most intensive and 

expensive treatments should be used only with 

those with the most serious problems or with 

those who have not responded to lesser 

interventions. Motivational interventions can 

serve many purposes in treatment settings: 

As a means of rapid engagement in the 

general medical setting to facilitate referral to 

treatment (2) 

As a first session to increase the likelihood 

that a client will return and to deliver a 

useful service if the client does not return (1) 

As an empowering brief consultation when a 

client is placed on a waiting list, rather than 

telling a client to wait for treatment (1) 

As a preparation for treatment to increase 

retention and participation (1) 

To help clients coerced into treatment to 

move beyond initial feelings of anger and 

resentment (2) 

To overcome client defensiveness and 

resistance (2) 

As a stand-alone intervention in settings 

where there is only brief contact (1) 
As a counseling style used throughout the 

process of change (1) 

Need for Future Research 

Motivational interventions are a relatively new, 

but favorably received, approach to encouraging 

positive behavioral change. As indicated earlier, 

motivational interventions have been 

successfully used with a variety of problems, 

client populations, and settings, and the 

methodology appears to be generally applicable, 

although it was developed primarily with heavy 

alcohol drinkers and cigarette smokers. 

Researchers should consider some of the 

following questions when planning and 

developing future research studies (2): 

What are the active ingredients of 

motivational interventions? 

Can motivational interventions be 

standardized and taught? 

What types of clients are most amenable to 

motivational interventions? 

What types of outcomes can be defined and 

measured?

What clinician characteristics affect the 

outcomes of motivational interventions? 

Are stage-matched interventions 

appropriate?

How do motivational interventions compare 

with other substance abuse treatments in 

terms of cost-effectiveness? 

How do culture and context influence the 

effectiveness of motivational interventions? 

What kinds of training and support are

needed to teach motivational interventions? 

How can motivational interventions be 

applied successfully to an even broader 

variety of problems, populations, and 

settings?

To Which Clients Does 

This TIP Apply? 

Motivational interviewing was originally 

developed for problem alcohol drinkers in the 

early stages (precontemplation and 

contemplation) of readiness for change and was 

conceived as a way of initiating treatment. 

However, it soon became apparent that this 

approach constitutes an intervention in itself. 

Benefits have been reported with severely 

substance-dependent populations, polydrugabusing adolescents, and users of heroin and 

marijuana. In Project MATCH, the largest 

clinical trial ever conducted to compare different 

alcohol treatment methods, a four-session 

motivational enhancement therapy yielded 

long-term overall outcomes virtually identical to 

those of longer outpatient methods. Clients 

varied widely in problem severity; the vast 

majority met criteria for alcohol dependence, 

and they represented a range of cultural 

backgrounds, particularly Hispanic. It is 

noteworthy that neither Hispanic nor AfricanAmerican samples responded differentially to 

the motivational enhancement therapy 

approach. In addition, analyses of clinical trials 

of motivational interviewing that had 

substantial representation of Hispanic clients 

found no indication of self-identified ethnicity 

and socioeconomic status as predictors of 

outcome. Evidence strongly suggests that 

motivational interviewing can be applied across 

cultural and economic differences. 

The motivational style of counseling can be 

useful, not only to instill motivation initially, but 

throughout the process of treatment in the 

preparation, action, and maintenance stages as 

well, with a range of client populations. This is 

reflected in the following chapters of this TIP. 
1 Conceptualizing Motivation 

And Change 

-OTIVATIONCANBEUNDERSTOODNOTASSOMETHINGTHATONEHASBUTRATHER

ASSOMETHINGONEDOES)TINVOLVESRECOGNIZINGAPROBLEMSEARCHINGFORA

WAY TO CHANGE AND THEN BEGINNING AND STICKING WITH THAT CHANGE

STRATEGY 4HEREAREITTURNSOUTMANYWAYSTOHELPPEOPLEMOVETOWARD

SUCHRECOGNITIONANDACTION

Miller, 1995 

Why do people change? What is 

motivation? Can individuals’ 

motivation to change their 

substance-using behavior be modified? Do

clinicians have a role in enhancing substanceusing clients’ motivation for recovery? 

Over the past 15 years, considerable research 

and clinical attention have focused on ways to 

better motivate substance users to consider, 

initiate, and continue substance abuse treatment, 

as well as to stop or reduce their excessive use of 

alcohol, cigarettes, and drugs, either on their 

own or with the help of a formal program. A 

related focus has been on sustaining change and 

avoiding a recurrence of problem behavior 

following treatment discharge. This research 

represents a paradigmatic shift in the addiction 

field’s understanding of the nature of client 

motivation and the clinician’s role in shaping it 

to promote and maintain positive behavioral 

change. This shift parallels other recent 

developments in the addiction field, and the 

new motivational strategies incorporate or 

reflect many of these developments. Coupling a 

new therapeutic style—motivational 

interviewing—with a transtheoretical stages-ofchange model offers a fresh perspective on what 

clinical strategies may be effective at various 

points in the recovery process. Motivational 

interventions resulting from this theoretical 

construct are promising clinical tools that can be 

incorporated into all phases of substance abuse 

treatment as well as many other social and 

health services settings. 

A New Look at 

Motivation

In substance abuse treatment, clients’ motivation 

to change has often been the focus of clinical 

interest and frustration. Motivation has been 

described as a prerequisite for treatment, 

without which the clinician can do little 

(Beckman, 1980). Similarly, lack of motivation 

has been used to explain the failure of 

individuals to begin, continue, comply with, and 


succeed in treatment (Appelbaum, 1972; Miller,

1985b). Until recently, motivation was viewed 

as a static trait or disposition that a client either

did or did not have. If a client was not 

motivated for change, this was viewed as the 

client’s fault. In fact, motivation for treatment 

connoted an agreement or willingness to go 

along with a clinician’s or program’s particular

prescription for recovery. A client who seeme

amenable to clinical advice or accepted the labe

of “alcoholic” or “drug addict” was considered

to be motivated, whereas one who resisted a 

diagnosis or refused to adhere to the proffered 

treatment was deemed unmotivated. 

Furthermore, motivation was often viewed as 

the client’s responsibility, not the clinician’s 

(Miller and Rollnick, 1991). Although there are

reasons why this view developed that will be 

discussed later, this guideline views motivatio

from a substantially different perspective. 

d

l

n

A New Definition 

The motivational approaches described in this 

TIP are based on the following assumptions 

about the nature of motivation: 

Motivation is a key to change. 

Motivation is multidimensional. 

Motivation is dynamic and fluctuating. 

Motivation is influenced by social 

interactions. 

Motivation can be modified. 

Motivation is influenced by the clinician’s 

style.

The clinician’s task is to elicit and enhance 

motivation. 

Motivation is a key to change 

The study of motivation is inexorably linked to 

an understanding of personal change—a 

concept that has also been scrutinized by 

modern psychologists and theorists and is the 

focus of substance abuse treatment. The nature 

of change and its causes, like motivation, is a

complex construct with evolving definitions. 

Few of us, for example, take a completely 

deterministic view of change as an inevitable 

result of biological forces, yet most of us accept 

the reality that physical growth and maturation 

do produce change—the baby begins to walk 

and the adolescent seems to be driven by 

hormonal changes. We recognize, too, that 

social norms and roles can change responses, 

influencing behaviors as diverse as selecting 

clothes or joining a gang, although few of us 

want to think of ourselves as simply conforming 

to what others expect. Certainly, we believe that 

reasoning and problem-solving as well as 

emotional commitment can promote change. 

The framework for linking individual change 

to a new view of motivation stems from what 

has been termed a theory of 

psychology, most familiarly expressed in the 

writings of Carl Rogers. In this humanistic 

view, an individual’s experience of the core 

inner is the most important element for 

personal change and growth—a process of 

 that prompts goal-directed behavior 

for enhancing this self (Davidson, 1994). In this 

context, motivation is redefined as purposeful, 

intentional, and positive—directed toward the 

best interests of the self. More specifically, 

motivation is the probability that a person will 

enter into, continue, and adhere to a specific 

change strategy (Miller and Rollnick, 1991). 

Motivation is multidimensional 

Motivation, in this new meaning, has a number 

of complex components that will be discussed in 

subsequent chapters of this TIP. It encompasses 

the internal urges and desires felt by the client, 

external pressures and goals that influence the 

client, perceptions about risks and benefits of 

behaviors to the self, and cognitive appraisals of 

the situation. 

Motivation is dynamic and 

fluctuating

Research and experience suggest that 

motivation is a dynamic state that can fluctuate 
over time and in relation to different situations, 

rather than a static personal attribute. 

Motivation can vacillate between conflicting 

objectives. Motivation also varies in intensity, 

faltering in response to doubts and increasing as 

these are resolved and goals are more clearly 

envisioned. In this sense, motivation can be an 

ambivalent, equivocating state or a resolute 

readiness to act—or not to act. 

Motivation is influenced by 

social interactions 

Motivation belongs to one person, yet it can be 

understood to result from the interactions 

between the individual and other people or 

environmental factors (Miller, 1995b). Although 

internal factors are the basis for change, external 

factors are the conditions of change. An 

individual’s motivation to change can be 

strongly influenced by family, friends, emotions, 

and community support. Lack of community 

support, such as barriers to health care, 

employment, and public perception of substance 

abuse, can also affect an individual’s motivation. 

Motivation can be modified 

Motivation pervades all activities, operating in 

multiple contexts and at all times. 

Consequently, motivation is accessible and can 

be modified or enhanced at many points in the 

change process. Clients may not have to “hit 

bottom” or experience terrible, irreparable 

consequences of their behaviors to become 

aware of the need for change. Clinicians and 

others can access and enhance a person’s 

motivation to change well before extensive 

damage is done to health, relationships, 

reputation, or self-image (Miller, 1985; Miller et 

al., 1993). 

Although there are substantial differences in 

what factors influence people’s motivation, 

several types of experiences may have dramatic 

effects, either increasing or decreasing 

motivation. Experiences such as the following 

often prompt people to begin thinking about 

making changes and to consider what steps are 

needed:

Distress levels may have a role in increasing 

the motivation to change or search for a 

change strategy (Leventhal, 1971; Rogers et 

al., 1978). For example, many individuals are 

prompted to change and seek help during or 

following episodes of severe anxiety or 

depression.

Critical life events often stimulate the 

motivation to change. Milestones that 

prompt change range from spiritual 

inspiration or religious conversion through 

traumatic accidents or severe illnesses to 

deaths of loved ones, being fired, becoming 

pregnant, or getting married (Sobell et al., 

1993b; Tucker et al., 1994). 

Cognitive evaluation or appraisal, in which 

an individual evaluates the impact of 

substances in his life, can lead to change. 

This weighing of the pros and cons of 

substance use accounts for 30 to 60 percent of 

the changes reported in natural recovery 

studies (Sobell et al., 1993b). 

Recognizing negative consequences and the 

harm or hurt one has inflicted on others or 

oneself helps motivate some people to 

change (Varney et al., 1995). Helping clients 

see the connection between substance use 

and adverse consequences to themselves or 

others is an important motivational strategy.

Positive and negative external incentives 

also can influence motivation. Supportive 

and empathic friends, rewards, or coercion of 

various types may stimulate motivation for 

change. 

Motivation is influenced by the 

clinician’s style 

The way you, the clinician, interact with clients 

has a crucial impact on how they respond and 

whether treatment is successful. Researchers 

have found dramatic differences in rates of 

client dropout or completion among counselors 
in the same program who are ostensibly using 

the same techniques (Luborsky et al., 1985). 

Counselor style may be one of the most 

important, and most often ignored, variables for 

predicting client response to an intervention, 

accounting for more of the variance than client 

characteristics (Miller and Baca, 1983; Miller et 

al., 1993). In a review of the literature on 

counselor characteristics associated with 

treatment effectiveness for substance users, 

researchers found that establishing a helping 

alliance and good interpersonal skills were more 

important than professional training or 

experience (Najavits and Weiss, 1994). The most 

desirable attributes for the counselor mirror 

those recommended in the general 

psychological literature and include 

nonpossessive warmth, friendliness, 

genuineness, respect, affirmation, and empathy. 

A direct comparison of counselor styles 

suggested that a confrontational and directive 

approach may precipitate more immediate client 

resistance and, ultimately, poorer outcomes than 

a client-centered, supportive, and empathic style 

that uses reflective listening and gentle 

persuasion (Miller et al., 1993). In this study, the 

more a client was confronted, the more alcohol 

the client drank. Confrontational counseling in 

this study included challenging the client, 

disputing, refuting, and using sarcasm. 

The clinician’s task is to elicit and 

enhance motivation 

Although change is the responsibility of the 

client and many people change their excessive 

substance-using behavior on their own without 

therapeutic intervention (Sobell et al., 1993b), 

you can enhance your client’s motivation for 

beneficial change at each stage of the change 

process. Your task is not, however, one of 

simply teaching, instructing, or dispensing 

advice. Rather, the clinician assists and 

encourages clients to recognize a problem 

behavior (e.g., by encouraging cognitive 

dissonance), to regard positive change to be in 

their best interest, to feel competent to change, 

to develop a plan for change, to begin taking 

action, and to continue using strategies that 

discourage a return to the problem behavior 

(Miller and Rollnick, 1991). Be sensitive to 

influences such as your client’s cultural 

background; knowledge or lack thereof can 

influence your client’s motivation. 

Why Enhance Motivation? 

Research has shown that motivation-enhancing 

approaches are associated with greater 

participation in treatment and positive 

treatment outcomes. Such outcomes include 

reductions in consumption, increased abstinence 

rates, social adjustment, and successful referrals 

to treatment (Landry, 1996; Miller et al., 1995a). 

A positive attitude toward change and a 

commitment to change are also associated with 

positive treatment outcomes (Miller and 

Tonigan, 1996; Prochaska and DiClemente, 

1992).

The benefits of employing motivational 

enhancement techniques include 

Inspiring motivation to change 

Preparing clients to enter treatment 

Engaging and retaining clients in treatment 

Increasing participation and involvement 

Improving treatment outcomes 

Encouraging a rapid return to treatment if 

symptoms recur 

Changing Perspectives on 

Addiction and Treatment 

Americans have often shown ambivalence 

toward excessive drug and alcohol use. They

have vacillated between viewing offenders as 

morally corrupt sinners who are the concern of 

the clergy and the law and seeing them as 

victims of compulsive craving who should 

receive medical treatment. After the passage of 

the Harrison Narcotics Act in 1914, physicians 

were imprisoned for treating addicts. In the 
1920s, compassionate treatment of opiate 

dependence and withdrawal was available in 

medical clinics, yet at the same time, equally 

passionate support of the temperance movement 

and Prohibition was gaining momentum. These 

conflicting views were further manifested in 

public notions of who deserved treatment (e.g., 

Midwestern farm wives addicted to laudanum) 

and who did not (e.g., urban AfricanAmericans). 

Different views about the nature and 

etiology of addiction have more recently 

influenced the development and practice of 

current treatments for substance abuse. 

Differing theoretical perspectives have guided 

the structure and organization of treatment and 

the services delivered (Institute of Medicine, 

1990b). Comparing substance abuse treatment 

to a swinging pendulum, one writer noted, 

Notions of moral turpitude and incurability 

have been linked with problems of drug 

dependence for at least a century. Even now, 

public and professional attitudes toward 

alcoholism are an amalgam of contrasting, 

sometimes seemingly irreconcilable views: The 

alcoholic is both and . The 

attitudes toward those who are dependent on 

opiates are a similar amalgam, with the 

element of moral defect in somewhat greater 

proportion (Jaffee, 1979, p. 9). 

Evolving Models of Treatment 

The development of a modern treatment system 

for substance abuse dates only from the late 

1960s, with the decriminalization of public 

drunkenness and the escalation of fears about 

crime associated with increasing heroin 

addiction. Nonetheless, the system has rapidly 

evolved in response to new technologies, 

research, and changing theories of addiction 

with associated therapeutic interventions. The 

six models of addiction described below have 

competed for attention and guided the 

application of treatment strategies over the last 

30 years. 

Moral model 

Addiction is viewed by some as a set of 

behaviors that violate religious, moral, or legal 

codes of conduct. From this perspective, 

addiction results from a freely chosen behavior 

that is immoral, perhaps sinful, and sometimes 

illegal. It assumes that individuals who choose 

to misuse substances create suffering for 

themselves and others and lack self-discipline 

and self-restraint. Substance misuse and abuse 

are irresponsible and intentional actions that 

deserve punishment (Wilbanks, 1989), including 

arrest and incarceration (Thombs, 1994). 

Because excessive substance use is seen as the 

result of a moral choice, change can only come 

about by an exercise of will power (IOM, 1990b), 

external punishment, or incarceration. 

Medical model 

A contrasting view of addiction as a chronic and 

progressive disease inspired what has come to 

be called the medical model of treatment, which 

evolved from earlier forms of disease models 

that stressed the need for humane treatment and 

hypothesized a dichotomy between “normals” 

and “addicts” or “alcoholics.” The latter were 

asserted to differ qualitatively, physiologically, 

and irreversibly from normal individuals. More 

recent medical models take a broader 

“biopsychosocial” view, consonant with a 

modern understanding of chronic diseases as 

multiply determined. 

Nevertheless, emphasis continues to be 

placed on physical causes. In this view, genetic 

factors increase the likelihood for an individual 

to misuse psychoactive substances or to lose 

control when using them. Neurochemical 

changes in the brain resulting from substance 

use then induce continuing consumption, as 

does the development of physiological 

dependence. Treatment in this model is 

typically delivered in a hospital or medical 

setting and includes various pharmacological 

therapies to assist detoxification, symptom 
reduction, aversion, or maintenance on suitable 

alternatives. 

Responsibility for resolving the problem 

does not rest with the client, and change can 

come about only through acknowledging loss of 

control, adhering to medical prescriptions, and 

participating in a self-help group (IOM, 1990b). 

Spiritual model 

The spiritual model of addiction is one of the 

most influential in America, largely because of 

such 12-Step fellowships as Alcoholics 

Anonymous (AA), Cocaine Anonymous, 

Narcotics Anonymous, and Al-Anon. This 

model is often confused with the moral and 

medical models, but its emphasis is quite 

distinct from these (Miller and Kurtz, 1994). In 

the original writings of AA, there is discussion 

of “defects of character” as central to 

understanding alcoholism, with particular 

emphasis on issues such as pride versus 

humility and resentment versus acceptance. In 

this view, substances are used in an attempt to 

fill a spiritual emptiness and meaninglessness. 

Spiritual models give much less weight to 

etiology than to the importance of a spiritual 

path to recovery. Twelve-Step programs 

emphasize recognizing a Higher Power (often 

called God in AA) beyond one’s self, asking for 

healing of character, maintaining 

communication with the Higher Power through 

prayer and meditation, and seeking to conform 

one’s life to its will. Twelve-Step programs are 

not wholly “self-help” programs but rather 

“Higher Power–help” programs. The first of the 

12 steps is to recognize that one literally cannot 

help oneself or find recovery through the power 

of one’s own will. Instead, the path back to 

health is spiritual, involving surrender of the 

will to a Higher Power. Clinicians follow 

various guidelines in supporting their clients’ 

involvement in 12-Step programs (Tonigan et 

al., 1999). 

Twelve-Step programs are rooted in 

American Protestantism, but other distinctly 

spiritual models do not rely on Christian or even 

theistic thought. Transcendental meditation, 

based on Eastern spiritual practice, has been 

widely practiced as a method for preventing and 

recovering from substance abuse problems 

(Marlatt and Kristeller, 1999). Native American 

spirituality has been integrated into treatment 

programs serving Native American populations 

through the use of sweat lodges and other 

traditional rituals, such as singing and healing 

ceremonies. Spiritual models all share a 

recognition of the limitations of the self and a 

desire to achieve health through a connection 

with that which transcends the individual. 

Psychological model 

In the psychological model of addiction, 

problematic substance use results from deficits 

in learning, emotional dysfunction, or 

psychopathology that can be treated by 

behaviorally or psychoanalytically oriented 

dynamic therapies. Sigmund Freud’s 

pioneering work has had a deep and lasting 

effect on substance abuse treatment. He 

originated the notion of defense mechanisms 

(e.g., denial, projection, rationalization), focused 

on the importance of early childhood 

experiences, and developed the idea of the 

unconscious mind. Early psychoanalysis 

viewed substance abuse disorders as originating 

from unconscious death wishes and selfdestructive tendencies of the id (Thombs, 1994). 

Substance dependence was believed to be a slow 

form of suicide (Khantzian, 1980). Other early 

psychoanalytic writers emphasized the role of 

oral fixation in substance dependence. A more 

contemporary psychoanalytic view is that 

substance use is a symptom of impaired ego 

functioning—a part of the personality that 

mediates the demands of the id and the realities 

of the external world. Another view considers 

substance abuse disorders as “both 

developmental and adaptive” (Khantzian et al., 

1990). 
From this perspective, the use of substances 

is an attempt to compensate for vulnerabilities 

in the ego structure. Substance use, then, is 

motivated by an inability to regulate one’s inner 

life and external behavior. Thus, psychoanalytic 

treatment assumes that insight obtained through 

the treatment process results in the 

strengthening of internal mechanisms, which 

becomes evident by the establishment of 

external controls; in other words, the change 

process shifts from internal (intrapsychic) to 

external (behavioral, interpersonal). An

interesting psychoanalytic parallel to modern 

motivational theory is found in the writings of 

Anton Kris, who described the “conflicts of 

ambivalence” seen in clients that 

May cast a paralyzing inertia not only upon 

the patient but upon the treatment method. In 

such instances, patient and analyst, like the 

driver of an automobile stuck in a snowdrift, 

must aim at a rocking motion that eventually 

gathers enough momentum to permit 

movement in one direction or another (Kris, 

1984, p. 224). 

Other practitioners view addiction as a 

symptom of an underlying mental disorder. 

From this perspective, successful treatment of 

the primary psychiatric disorder should result in 

resolution of the substance use problem. 

However, over the past decade, substantial 

research and clinical attention have revealed a 

more complex relationship between psychiatric 

and substance abuse disorders and symptoms. 

Specifically, substance use can cause psychiatric 

symptoms and mimic psychiatric disorders; 

substance use can prompt or worsen the severity 

of psychiatric disorders; substance use can mask 

psychiatric disorders and symptoms; 

withdrawal from severe substance dependence 

can precipitate psychiatric symptoms and mimic 

psychiatric disorders; psychiatric and substance 

abuse disorders can coexist; and psychiatric 

disorders can produce behaviors that mimic 

ones associated with substance use problems 

(CSAT, 1994b; Landry et al., 1991). 

From the perspective of behavioral 

psychology, substance use is a learned behavior 

that is repeated in direct relation to the quality, 

number, and intensity of that follow 

each episode of use (McAuliffe and Gordon, 

1980). Addiction is based on the principle that 

people tend to repeat certain behaviors if they 

are reinforced for engaging in them. Positive 

reinforcers of substance use depend on the 

substance used but include powerful effects on 

the central nervous system. Other social 

variables, such as peer group acceptance, can 

also act as positive reinforcers. Negative 

reinforcers include lessened anxiety and 

elimination of withdrawal symptoms. A 

person’s experiences and expectations in 

relation to the effects of selected substances on 

certain emotions or situations will determine 

substance-using patterns. Change comes about 

if the reinforcers are outweighed or replaced by 

negative consequences, also known as ,

and the client learns to apply strategies for 

coping with situations that lead to substance 

use.

Other psychologists have emphasized the 

role of cognitive processes in addictive behavior. 

Bandura’s concept of self-efficacy—the 

perceived ability to change or control one’s own 

behavior—has been influential in modern 

conceptions of addiction (Bandura, 1997). 

Cognitive therapists have described treatment 

approaches for modifying pathogenic beliefs 

that may underlie substance abuse (Beck et al., 

1993; Ellis and Velten, 1992). 

Sociocultural model 

A related, sociocultural perspective on addiction 

emphasizes the importance of socialization 

processes and the cultural milieu in 

developing—and ameliorating—substance 

abuse disorders. Factors that affect drinking 

behavior include socioeconomic status, cultural 

and ethnic beliefs, availability of substances, 

laws and penalties regulating substance use, the 

norms and rules of families and other social 
groups as well as parental and peer 

expectations, modeling of acceptable behaviors, 

and the presence or absence of reinforcers. 

Because substance-related problems are seen as 

occurring in interactive relations with families, 

groups, and communities, alterations in policies, 

laws, and norms are part of the change process. 

Building new social and family relations, 

developing social competency and skills, and 

working within one’s cultural infrastructure are 

important avenues for change in the 

sociocultural model (IOM, 1990b). From the 

sociocultural perspective, an often neglected 

aspect of positive behavioral change is sorting 

out ethical principles or renewing opportunities 

for spiritual growth that can ameliorate the 

guilt, shame, regret, and sadness about the 

substance-related harm clients may have 

inflicted on themselves and others. 

Composite biopsychosocial– 

spiritual model 

As the conflicts among these competing models 

of addiction have become evident and as 

research has confirmed some truth in each 

model, the addiction field has searched for a 

single construct to integrate these diverse 

perspectives (Wallace, 1990). This has led to an 

emerging biopsychosocial–spiritual framework 

that recognizes the importance of many 

interacting influences. Indeed, the current view 

is that all chronic diseases, whether substance 

use, cancer, diabetes, or coronary artery disease, 

are best treated by collaborative and 

comprehensive approaches that address both 

biopsychosocial and spiritual components 

(Borysenko and Borysenko, 1995; Williams and 

Williams, 1994). This overarching model of 

addiction retains the proven elements and 

techniques of each of the preceding models 

while eliminating some previous—and 

erroneous—assumptions, which are discussed 

below.

Myths About Client Traits and 

Effective Counseling 

Although the field is evolving toward a more 

comprehensive understanding of substance 

misuse and abuse, earlier views of addiction still 

persist in parts of our treatment system. Some 

of these are merely anachronisms; others may 

actually harm clients. Recent research has 

shown that some types of interventions that 

have been historically embedded within 

treatment approaches in the United States may 

paradoxically reduce motivation for beneficial 

change. Other persisting stereotypes also 

interfere with the establishment of a helping 

alliance or partnership between the clinician and 

the client. Among the suppositions about clients 

and techniques that are being questioned and 

discarded are those discussed below. 

Addiction stems from an 

addictive personality 

Although it is commonly believed that 

substance abusers possess similar personality 

traits that make treatment difficult, no 

distinctive personality traits have been found to 

predict that an individual will develop a 

substance abuse disorder. The tendencies of an 

addictive personality most often cited are denial, 

projection, poor insight, and poor self-esteem. 

Research efforts, many of which have focused 

on clients with alcohol dependence, suggest 

there is no characteristic personality among 

substance-dependent individuals (Løberg and 

Miller, 1986; Miller, 1976; Vaillant, 1995). 

Rather, research suggests that people with 

substance abuse problems reflect a broad range 

of personalities. Nonetheless, the existence of an 

addictive personality continues to be a popular 

belief. One reason for this may be that certain 

similarities of behavior, emotion, cognition, and 

family dynamics do tend to emerge along the 

course of a substance abuse disorder. In the 

course of recovery, these similarities diminish, 

and people again become more diverse. 
Resistance and denial are 

attributes of addiction 

Engaging in denial, rationalization, evasion, 

defensiveness, manipulation, and resistance are 

characteristics that are often attributed to 

substance users. Furthermore, because these 

responses can be barriers to successful 

treatment, clinicians and interventions often 

focus on these issues. Research, however, has 

not supported the conclusion that substancedependent persons, as a group, have abnormally 

robust defense mechanisms. 

There are several possible explanations for 

this belief. The first is selective perception—that 

is, in retrospect, exceptionally difficult clients 

are elevated to become of usual 

responses. Moreover, the terms “denial” and 

“resistance” are often used to describe lack of 

compliance or motivation among substance 

users, whereas the term “motivation” is 

reserved for such concepts as acceptance and 

surrender (Kilpatrick et al., 1978; Nir and Cutler, 

1978; Taleff, 1997). Thus, clients who disagree 

with clinicians, who refuse to accept clinicians’ 

diagnoses, and who reject treatment advice are 

often labeled as unmotivated, in denial, and 

resistant (Miller, 1985b; Miller and Rollnick, 

1991). In other words, the term “denial” can be 

misused to describe disagreements, 

misunderstandings, or clinician expectations 

that differ from clients’ personal goals and may 

reflect countertransference issues (Taleff, 1997). 

Another explanation is that behaviors judged 

as normal in ordinary individuals are labeled as 

pathological when observed in substanceaddicted populations (Orford, 1985). Clinicians 

and others expect substance users to exhibit 

pathological—or abnormally strong—defense 

mechanisms. A third explanation is that 

treatment procedures actually set up many 

clients to react defensively. Denial, 

rationalization, resistance, and arguing, as 

assertions of personal freedom, are common 

defense mechanisms that many people use 

instinctively to protect themselves emotionally 

(Brehm and Brehm, 1981). When clients are 

labeled pejoratively as or or

, given no voice in selecting treatment 

goals, or directed authoritatively to do or not to 

do something, the result is a predictable—and 

quite normal—response of defiance. Moreover, 

when clinicians assume that these defenses must 

be confronted and “broken” by adversarial 

tactics, treatment can become counterproductive 

(Taleff, 1997). A strategy of aggressive 

confrontation is likely to evoke strong resistance 

and outright denial. Hence, one reason that 

high levels of denial and resistance are often 

seen as attributes of substance-dependent 

individuals as a group is that their normal 

defense mechanisms are so frequently 

challenged and aroused by clinical strategies of 

confrontation. Essentially, this becomes a selffulfilling prophecy (Jones, 1977). 

Confrontation is an effective 

counseling style 

In contemporary treatment, the term 

“confrontation” has several meanings, referring 

usually to a type of intervention (a planned 

confrontation) or to a counseling style (a 

confrontational session). The term can reflect 

the assumption that denial and other defense 

mechanisms must be aggressively “broken 

through” or “torn down,” using therapeutic 

approaches that can be characterized as 

authoritarian and adversarial (Taleff, 1997). As 

just noted, this type of confrontation may 

promote resistance rather than motivation to 

change or cooperate. Research suggests that the 

more frequently clinicians use adversarial 

confrontational techniques with substance-using 

clients, the less likely clients will change (Miller 

et al., 1993), and controlled clinical trials place 

confrontational approaches among the least 

effective treatment methods (Miller et al., 1998). 

There is, however, a constructive type of 

therapeutic confrontation. If helping clients 

confront and assess the reality of their behaviors 
What About Confrontation? 

For a number of reasons, the treatment field in the United States fell into some rather aggressive, 

argumentative, “denial-busting” methods for confronting people with alcohol and drug problems. 

This was guided in part by the belief that substance abuse is accompanied by a particular personality 

pattern characterized by such rigid defense mechanisms as denial and rationalization. Within this 

perspective, the clinician must take responsibility for impressing reality on clients, who are thought to 

be unable to see it on their own. Such confrontation found its way into the popular Minnesota model 

of treatment and, more particularly, into Synanon (a drug treatment community well known for its 

group encounter sessions in which participants verbally attacked each other) and other similar 

therapeutic community programs. 

After the 1970s, the treatment field began to move away from such methods. The Hazelden 

Foundation officially renounced the “tear them down to build them up” approach in 1985, expressing 

regret that such confrontational approaches had become associated with the Minnesota model. 

Psychological studies have failed to find any consistent pattern of personality or defense mechanisms 

associated with substance abuse disorders, and clinical studies have linked poorer outcomes to more 

confrontational clinicians, groups, and programs (Miller et al., 1995a). Instead, successful outcomes 

generally have been associated with counselors showing high levels of accurate empathy, as defined by 

Carl Rogers and described by Najavits and Weiss (Najavits and Weiss, 1994). The Johnson Institute 

now emphasizes a supportive, compassionate style for conducting family interventions. 

I was at first surprised, therefore, when clinicians attending my workshops on motivational 

interviewing and watching me demonstrate the style, observed, “In a different way, you’re very 

confrontational.” This issue comes up in almost every training now. “Gentle confrontation” some call 

it. This got me thinking about what confrontation really means. 

The linguistic roots of the verb “to confront” mean to come face to face. When you think about it 

that way, confrontation is precisely what we are trying to accomplish: to allow our clients to come face 

to face with a difficult and often threatening reality, to “let it in” rather than “block it out,” and to allow 

this reality to change them. That makes confrontation a of counseling rather than a particular 

or .

Once you see this—that opening to new information, face to face, is a of counseling—then the 

question becomes, “What is the best way to achieve that goal?” Evidence is strong that direct, forceful, 

aggressive approaches are perhaps the effective way to help people consider new information and 

change their perceptions. Such confrontation increases the very phenomenon it is supposed to 

overcome—defensiveness—and decreases the client’s likelihood of change (Miller et al., 1993). It is 

also quite inappropriate in many cultures. Getting in a client’s face may work for some, but for most, it 

is exactly the opposite of what is needed—to come face to face with painful reality and to change. 

William R. Miller, Consensus Panel Chair 

is a prerequisite for intentional change, 

clinicians using motivational strategies focus on 

constructive confrontation as a treatment goal. 

From this perspective, constructive or 

therapeutic confrontation is useful in assisting 

clients to identify and reconnect with their 

personal goals, to recognize discrepancies 

between current behavior and desired ideals 

(Ivey et al., 1997), and to resolve ambivalence 

about making positive changes. 
Changes in the 

Addictions Field 

As the addictions field has matured, it has tried 

to integrate conflicting theories and approaches 

to treatment, as well as to incorporate relevant 

research findings into a single, comprehensive 

model. Many positive changes have emerged, 

and the new view of motivation and the 

associated strategies to enhance client 

motivation fit into and reflect many of these 

changes. Some of the new features of treatment 

that have important implications for applying 

motivational methods are discussed below. 

Focus on Client Competencies 

And Strengths 

Whereas the treatment field has historically 

focused on the deficits and limitations of clients, 

there is a greater emphasis today on identifying, 

enhancing, and using clients’ strengths and 

competencies. This trend parallels the principles 

of motivational counseling, which affirm the 

client, emphasize free choice, support and 

strengthen self-efficacy, and encourage 

optimism that change can be achieved (see 

Chapter 4). As with some aspects of the moral 

model of addiction, the responsibility for 

recovery again rests squarely on the client; 

however, the judgmental tone is eliminated. 

Individualized and ClientCentered Treatment 

In the past, clients frequently received 

standardized treatment, no matter what their 

problems or severity of substance dependence. 

Today, treatment is usually based on a client’s 

individual needs, which are carefully and 

comprehensively assessed at intake. Research 

studies have shown that positive treatment 

outcomes are associated with flexible program 

policies and a focus on individual client needs 

(Inciardi et al., 1993). Furthermore, clients are 

given choices about desirable and suitable 

treatment options, rather than having treatment 

prescribed. As noted, motivational approaches 

emphasize client choice and personal 

responsibility for change—even outside the 

treatment system. Motivational strategies elicit 

personal goals from clients and involve clients 

in selecting the type of treatment needed or 

desired from a menu of options. 

A Shift Away From Labeling 

Historically, a diagnosis or disease defined the 

client and became a dehumanizing attribute of 

the individual. In modern medicine, individuals 

with asthma or a psychosis are seldom referred 

to—at least face to face—as “the asthmatic” or 

“the psychotic.” Similarly, in the substance use 

arena, there is a trend to avoid labeling persons 

with substance abuse disorders as ”addicts” or 

“alcoholics.” Clinicians who use a motivational 

style avoid branding clients with names, 

especially those who may not agree with the 

diagnosis or do not see a particular behavior as 

problematic. 

Therapeutic Partnerships 

For Change 

In the past, especially in the medical model, 

clients passively treatment. Today, 

treatment usually entails a partnership in which 

the client and the clinician agree on treatment 

goals and work together to develop strategies to 

meet those goals. The client is seen as an active 

partner in treatment planning. The clinician 

who uses motivational strategies establishes a 

therapeutic alliance with the client and elicits 

goals and change strategies from the client. The 

client has ultimate responsibility for making 

changes, with or without the clinician’s 

assistance. Although motivational strategies 

elicit statements from the client about intentions 

and plans for change, they also recognize 

biological reality: the heightened risk associated 

with a genetic predisposition to substance abuse 

or dependence and the powerful effect of 
substances on the brain, both of which can make 

change exceedingly difficult. In fact, 

motivational strategies ask the client to consider 

what they like about substances of choice—the 

motivations to use—before focusing on the less 

good or negative consequences, and weighing 

the value of each. 

Use of Empathy, Not 

Authority and Power 

Whereas the traditional treatment provider was 

seen as a disciplinarian and imbued with the 

power to recommend client termination for rule 

infractions, penalties for “dirty” urine, or 

promotion to a higher phase of treatment for 

successfully following direction, research now 

demonstrates that positive treatment outcomes 

are associated with high levels of clinician 

empathy reflected in warm and supportive 

listening (Landry, 1996). Clinician 

characteristics found to increase a client’s 

motivation include good interpersonal skills, 

confidence in the therapeutic process, the 

capacity to meet the client where the client 

happens to be, and optimism that change is 

possible (Najavits and Weiss, 1994). 

Focus on Earlier Interventions 

The formal treatment system, especially in the 

early days of public funding, primarily served a 

chronic, hard-core group of clients with severe 

substance dependence (Pattison et al., 1977). 

This may be one reason why certain 

characteristics such as denial became associated 

with addiction. If these clients did not succeed 

in treatment, or did not cooperate, they were 

viewed as unmotivated and were discharged 

back to the community to “hit bottom”—i.e., 

suffer severe negative consequences that might 

motivate them for change. 

More recently, a variety of treatment 

programs have been established to intervene 

earlier with persons whose drinking or drug use 

is problematic or potentially risky, but not yet 

serious. These early intervention efforts range 

from educational programs (including 

sentencing review or reduction for people 

apprehended for driving while intoxicated who 

participate in such programs) to brief 

interventions in opportunistic settings, such as 

hospital emergency departments, clinics, and 

doctors’ offices, that point out the risks of 

excessive drinking, suggest change, and make 

referrals to formal treatment programs as 

necessary.

Some of the most successful of these early 

intervention programs use motivational 

strategies to intercede with persons who are not 

yet aware they have a substance-related 

problem (see Chapter 2 and the companion 

forthcoming Treatment Improvement Protocol 

(TIP),

[CSAT, in press (a)]). This shift 

in thinking means not only that treatment 

services are provided when clients first develop 

a substance use problem but also that clients 

have not depleted personal resources and can 

more easily muster sufficient energy and 

optimism to initiate change. Brief 

motivationally focused interventions are 

increasingly being offered in acute and primary 

health care settings (D’Onofrio et al., 1998; 

Ockene et al., 1997; Samet et al., 1996). 

Focus on Less Intensive Treatments 

A corollary of the new emphasis on earlier 

intervention and individualized care is the 

provision of less intensive, but equally effective, 

treatments. When care was standardized, most 

programs had not only a routine protocol of 

services but also a fixed length of stay. Twentyeight days was considered the proper length of 

time for successful inpatient (usually hospitalbased) care in the popular Minnesota model of 

alcohol treatment. Residential facilities and 

outpatient clinics also had standard courses of 

treatment. Research has now demonstrated that 

shorter, less intensive forms of intervention can 
be as effective as more intensive therapies (Bien 

et al., 1993b; IOM, 1990b; Project MATCH 

Research Group, 1997a). The issue of treatment 

“intensity” is far too vague, in that it refers to 

the length, amount, and cost of services 

provided without reference to the content of 

those services. The challenge for future research 

is to identify of intervention 

demonstrably improve outcomes in an additive 

fashion. For purposes of this TIP, emphasis has 

been placed on the fact that even when 

therapeutic contact is constrained to a relatively 

brief period, it is still possible to affect client 

motivation and trigger change. 

Impact of Managed Care on 

Treatment

Changes in health care financing (managed care) 

have markedly affected the amount of treatment 

provided, shifting the emphasis from inpatient 

to outpatient settings and capping the duration 

of some treatments. Still unknown is the overall 

impact of these changes on treatment access, 

quality, outcomes, and cost. In this context, it is 

important to remember that even within 

relatively brief treatment contacts, one can be 

helpful to clients in evoking change through 

motivational approaches. Brief motivational 

interventions can also be an effective way for 

intervening earlier in the development of 

substance abuse while severity and complexity 

of problems are lower (Obert et al., 1997). 

Recognition of a Continuum of 

Substance Abuse Problems 

Formerly, substance misuse, particularly the 

 of alcoholism, was viewed as a 

progressive condition that, if left untreated, 

would inevitably lead to full-blown dependence 

and, likely, an early death. Currently, clinicians 

recognize that substance abuse disorders exist 

along a continuum from risky or problematic 

use through varying types of abuse to 

dependence that meets diagnostic criteria in the 

, 4th Edition (DSM –IV) (American 

Psychiatric Association [APA], 1994). Moreover, 

progression toward increasing severity is not 

automatic. Many individuals never progress 

beyond risky consumption, and others cycle 

back and forth through periods of abstinence, 

excessive use, and dependence. Recovery from 

substance dependence is seen as a 

multidimensional process that differs among 

people and changes over time within the same 

person (IOM, 1990a, 1990b). Motivational 

strategies can be effectively applied to persons 

in any stage of substance use through 

dependence. The crucial variable, as will be 

seen, is not the severity of the substance use 

pattern, but the client’s readiness for change. 

Recognition of Multiple 

Substance Abuse 

Practitioners have come to recognize not only 

that substance-related disorders vary in 

intensity but also that most involve more than 

one substance. For example, a recent study 

reported that in the United States, just over 25 

percent of the general adult population smoke 

cigarettes, whereas 80 to 90 percent of adults 

with alcohol use disorders are smokers (Wetter 

et al., 1998). Formerly, alcohol and drug 

treatment programs were completely separated 

by ideology and policy, even though most 

individuals with substance abuse disorders also 

drink heavily and many persons who drink 

excessively also experiment with substances, 

including prescribed medications that can be 

substituted for alcohol or that alleviate 

withdrawal symptoms. Although many 

treatment programs properly specialize in 

serving a particular type of client for whom their 

therapies are appropriate (e.g., methadone 

maintenance programs for opioid-using clients), 

most now also treat secondary substance use 

and psychological problems or at least identify 

these and make referrals as necessary (Brown et 
al., 1995, 1999). Here, too, motivational 

approaches involve clients in choosing goals and 

negotiating priorities. 

Acceptance of New 

Treatment Goals 

In the past, addiction treatment, at least for 

clients having trouble with alcohol, was 

considered successful only if the client became 

abstinent and never returned to substance use 

following discharge—a goal that proved 

difficult to achieve (Brownell et al., 1986; Polich 

et al., 1981). The focus of treatment was almost 

entirely to have the client stop using and to start 

understanding the nature of her addiction. 

Today, treatment goals include a broad range of 

biopsychosocial measures, such as reduction in 

substance use, improvement in health and 

psychosocial functioning, improvement in 

employment stability, and reduction in criminal 

justice activity. Recovery itself is multifaceted, 

and gains made toward recovery can appear in 

one aspect of a client’s life, but not another; 

achieving the goal of abstinence does not 

necessarily translate into improved life 

functioning for the client. Treatment outcomes 

include interim, incremental, and even 

temporary steps toward ultimate goals. 

Motivational strategies incorporate these ideas 

and help clients select and work toward the 

goals of most importance to them, including 

reducing substance use to less harmful levels, 

even though abstinence may become an ultimate 

goal if cutting back does not work. Harm 

reduction (e.g., reducing the intensity of use and 

high-risk behavior, substituting a less risky 

substance) can be an important goal in early 

treatment (APA, 1995). The client is encouraged 

to focus on personal values and goals, including 

spiritual aspirations and repair of marital and 

other important interpersonal relationships. 

Goals are set within a more holistic context, and 

significant others are often included in the 

motivational sessions. 

Integration of Substance Abuse 

Treatment With Other Disciplines 

Historically, the substance abuse treatment 

system was often isolated from mainstream 

health care, partly because medical professionals 

had little training in this area and did not 

recognize or know what to do with substance 

users whom they saw in practice settings. 

Welfare offices, courts, jails, emergency 

departments, and mental health clinics also were 

not prepared to respond appropriately to 

substance misuse. Today there is a strong 

movement to perceive addiction treatment in 

the context of public health and to recognize its 

impact on numerous other service systems. 

Thanks to the cross-training of professionals and 

an increase in jointly administered programs, 

other systems are identifying substance users 

and either making referrals for them or 

providing appropriate treatment services (e.g., 

substance abuse treatment within the criminal 

justice system, special services for clients who 

have both substance abuse disorders and mental 

health disorders). Motivational interventions 

have been tested and found to be effective in 

most of these opportunistic settings. Although 

substance users originally come in for other 

services, they can be identified and often 

motivated to reduce use or become abstinent 

through carefully designed brief interventions 

(see Chapter 2 and the forthcoming TIP, 

[CSAT, in press (a)]). If broadly applied, 

these brief interventions will tie the addiction 

treatment system more closely to other service 

networks through referrals of persons who, after 

a brief intervention, cannot control their harmful 

use of substances either on their own or with the 

limited help of a nonspecialist. 
A Transtheoretical Model 

Of the Stages of Change 

As noted at the beginning of this chapter, 

motivation and personal change are inescapably 

linked. In addition to developing a new 

understanding of motivation, substantial 

addiction research has focused on the 

determinants and mechanisms of personal 

change. By understanding better how people 

change without professional assistance, 

researchers and clinicians have become better 

able to develop and apply interventions to 

facilitate changes in clients’ maladaptive and 

unhealthy behaviors. 

Natural Change 

The shift in thinking about motivation includes 

the notion that change is more a process than an 

outcome (Sobell et al., 1993b; Tucker et al., 1994). 

Change occurs in the natural environment, 

among all people, in relation to many behaviors, 

and without professional intervention. This is 

also true of positive behavioral changes related 

to substance use, which often occur without 

therapeutic intervention or self-help groups. 

There is well-documented evidence of selfdirected or natural recovery from excessive, 

problematic abuse of alcohol, cigarettes, and 

drugs (Blomqvist, 1996; Chen and Kandel, 1995; 

Orleans et al., 1991; Sobell and Sobell, 1998). 

One of the best-documented studies of this 

natural recovery process is the longitudinal 

followup of returning veterans from the 

Vietnam War (Robins et al., 1974). Although a 

substantial number of these soldiers became 

addicted to heroin during their tours of duty in 

Vietnam, only 5 percent continued to be 

addicted a year after returning home, and only 

12 percent began to use heroin again within the 

first 3 years—most for only a short time. 

Although a few of these veterans benefited from 

short-term detoxification programs, most did 

not enter formal treatment programs and 

apparently recovered on their own. Recovery 

from substance dependence also can occur with 

very limited treatment and, in the longer run, 

through a maturation process (Brecht et al., 

1990; Strang et al., 1997). Recognizing the 

processes involved in natural recovery and selfdirected change helps illuminate how changes 

related to substance use can be precipitated and 

stimulated by enhancing motivation. 

Figure 1-1 illustrates two kinds of natural 

changes: common and substance-related. 

Everyone must make decisions about important 

life changes such as marriage or divorce or

buying a house. Sometimes, individuals consult 

a counselor or other specialist to help with these 

ordinary decisions, but usually people decide on 

such changes without professional assistance. 

Natural change related to substance use also 

entails decisions to increase, decrease, or stop 

substance use. Some of the decisions are 

responses to critical life events, others reflect 

different kinds of external pressures, and still 

others seem to be motivated by an appraisal of 

personal values. 

It is important to note that natural changes 

related to substance use can go in either 

direction. In response to an impending divorce, 

for example, one individual may begin to drink 

heavily whereas another may reduce or stop 

using alcohol. People who use psychoactive 

substances thus can and do make many choices 

regarding consumption patterns without 

professional intervention. 

Stages of Change 

Theorists have developed various models to 

illustrate how behavioral change happens. In 

one perspective, external consequences and 

restrictions are largely responsible for moving 

individuals to change their substance use 

behaviors. In another model, intrinsic 

motivations are responsible for initiating or 

ending substance use behaviors. Some 

researchers believe that motivation is better 
Figure 1-1 

Examples of Natural Changes

Common Natural Changes 

Going to college 

Getting married 

Getting divorced 

Changing jobs 

Joining the Army 

Taking a vacation 

Moving

Buying a home 

Having a baby 

Retiring 

Natural Changes in Substance Use 

Experimenting with substances during high school 

Stopping drinking after an automobile accident 

Reducing alcohol use after college 

Stopping substance use prior to pregnancy 

Increasing alcohol use during a divorce 

Decreasing cigarette use after a price increase 

Quitting marijuana smoking before looking for employment 

Refraining from drinking with some friends

Reducing consumption following a physician’s advice 

described as a continuum of readiness than as 

separate stages of change (Bandura, 1997; 

Sutton, 1996). This hypothesis is also supported 

by motivational research involving serious 

substance abuse of illicit drugs (Simpson and 

Joe, 1993). 

The change process has been conceptualized 

as a sequence of stages through which people 

typically progress as they think about, initiate, 

and maintain new behaviors (Prochaska and 

DiClemente, 1984). This model emerged from 

an examination of 18 psychological and 

behavioral theories about how change occurs,

including components that compose a 

biopsychosocial framework for understanding 

addiction. In this sense, the model is 

“transtheoretical” (IOM, 1990b). 

This model also reflects how change occurs 

outside of therapeutic environments. The 

authors applied this template to individuals 

who modified behaviors related to smoking, 

drinking, eating, exercising, parenting, and 

marital communications on their own, without 

professional intervention. When natural selfchange was compared with therapeutic 

interventions, many similarities were noticed, 

leading these investigators to describe the 

occurrence of change in steps or stages. They

observed that people who make behavioral 

changes on their own or under professional 

guidance first “move from being unaware or 

unwilling to do anything about the problem to 

considering the possibility of change, then to 

becoming determined and prepared to make the

change, and finally to taking action and 

sustaining or maintaining that change over 

time” (DiClemente, 1991, p. 191). 

As a clinician, you can be helpful at any

point in the process of change by using 

appropriate motivational strategies that are 

specific to the change stage of the individual. 

Chapters 4 through 7 of this TIP use the stagesof-change model to organize and conceptualize 

ways in which you can enhance clients’ 

motivation to progress to the next change stage. 

In this context, the stages of change represent a 

series of tasks for both you and your clients 

(Miller and Heather, 1998). 

The stages of change can be visualized as a 

wheel with four to six parts, depending on how 

specifically the process is broken down 

(Prochaska and DiClemente, 1984). For this TIP, 

the wheel (Figure 1-2) has five parts, with a final 

exit to enduring recovery. It is important to note 

that the change process is cyclical, and 

individuals typically move back and forth 
#ONCEPTUALIZING-OTIVATIONAND#HANGE

between the stages and cycle through the stages 

at different rates. In one individual, this 

movement through the stages can vary in 

relation to different behaviors or objectives. 

Individuals can move through stages quickly. 

Sometimes, they move so rapidly that it is 

difficult to pinpoint where they are because 

change is a dynamic process. It is not 

uncommon, however, for individuals to linger 

in the early stages. 

For most substance-using individuals, 

progress through the stages of change is circular 

or spiral in nature, not linear. In this model, 

recurrence is a normal event because many 

clients cycle through the different stages several 

times before achieving stable change. The five 

stages and the issue of recurrence are described 

below.

Precontemplation

During the precontemplation stage, substanceusing persons are not considering change and 

do not intend to change behaviors in the 

foreseeable future. They may be partly or 

completely unaware that a problem exists, that 

they have to make changes, and that they may 

need help in this endeavor. Alternatively, they 

may be unwilling or too discouraged to change 

their behavior. Individuals in this stage usually 

have not experienced adverse consequences or 

crises because of their substance use and often 

are not convinced that their pattern of use is 

problematic or even risky. 

Contemplation 

As these individuals become aware that a 

problem exists, they begin to perceive that there 

may be cause for concern and reasons to change. 

Typically, they are ambivalent, simultaneously 

seeing reasons to change and reasons not to 
change. Individuals in this stage are still using 

substances, but they are considering the 

possibility of stopping or cutting back in the 

near future. At this point, they may seek 

relevant information, reevaluate their substance 

use behavior, or seek help to support the 

possibility of changing behavior. They typically 

weigh the positive and negative aspects of 

making a change. It is not uncommon for 

individuals to remain in this stage for extended 

periods, often for years, vacillating between 

wanting and not wanting to change. 

Preparation 

When an individual perceives that the 

envisioned advantages of change and adverse 

consequences of substance use outweigh any 

positive features of continuing use at the same 

level and maintaining the status quo, the 

decisional balance tips in favor of change. Once 

instigation to change occurs, an individual 

enters the preparation stage, during which 

commitment is strengthened. Preparation 

entails more specific planning for change, such 

as making choices about whether treatment is 

needed and, if so, what kind. Preparation also 

entails an examination of one’s perceived 

capabilities—or self-efficacy—for change. 

Individuals in the preparation stage are still 

using substances, but typically they intend to 

stop using very soon. They may have already 

attempted to reduce or stop use on their own or 

may be experimenting now with ways to quit or 

cut back (DiClemente and Prochaska, 1998). 

They begin to set goals for themselves and make 

commitments to stop using, even telling close 

associates or significant others about their plans. 

Action

Individuals in the action stage choose a strategy 

for change and begin to pursue it. At this stage, 

clients are actively modifying their habits and 

environment. They are making drastic lifestyle 

changes and may be faced with particularly 

challenging situations and the physiological 

effects of withdrawal. Clients may begin to 

reevaluate their own self-image as they move 

from excessive or hazardous use to nonuse or 

safe use. For many, the action stage can last 

from 3 to 6 months following termination or 

reduction of substance use. For some, it is a 

honeymoon period before they face more 

daunting and longstanding challenges. 

Maintenance

During the maintenance stage, efforts are made 

to sustain the gains achieved during the action 

stage. Maintenance is the stage at which people 

work to sustain sobriety and prevent recurrence 

(Marlatt and Gordon, 1985). Extra precautions 

may be necessary to keep from reverting to 

problematic behaviors. Individuals learn how to 

detect and guard against dangerous situations 

and other triggers that may cause them to use 

substances again. In most cases, individuals 

attempting long-term behavior change do return 

to use at least once and revert to an earlier stage 

(Prochaska et al., 1992). Recurrence of 

symptoms can be viewed as part of the learning 

process. Knowledge about the personal cues or 

Decisionmaking

Decisionmaking has been conceptualized as a balance sheet of potential gains and losses (Janis and 

Mann, 1977). These two decisional measures—the pros and the cons—have become critical constructs 

in the transtheoretical model of change stages. The weights given to the pros and cons—or positive 

and negative aspects of continuing use and of change itself—vary according to personal values and 

the individual’s stage of change. During the contemplation stage, the pros and cons tend to balance— 

or cancel each other out. When the preparation stage is reached, the pros for changing the behavior 

outweigh the cons, and the decisional balance tips toward a commitment to change. 
dangerous situations that contribute to 

recurrence is useful information for future 

change attempts. Maintenance requires 

prolonged behavioral change—by remaining 

abstinent or moderating consumption to 

acceptable, targeted levels—and continued 

vigilance for a minimum of 6 months to several 

years, depending on the target behavior 

(Prochaska and DiClemente, 1992). 

Recurrence

Most people do not immediately sustain the 

new changes they are attempting to make, and a 

return to substance use after a period of 

abstinence is the rule rather than the exception 

(Brownell et al., 1986; Prochaska and 

DiClemente, 1992). These experiences 

contribute information that can facilitate or 

hinder subsequent progression through the 

stages of change. Recurrence often referred to 

as relapse, is the event that triggers the 

individual’s return to earlier stages of change 

and recycling through the process. Individuals 

may learn that certain goals are unrealistic, 

certain strategies are ineffective, or certain 

environments are not conducive to successful 

change. Most substance users will require 

several revolutions through the stages of change 

to achieve successful recovery (DiClemente and 

Scott, 1997). After a return to substance use, 

clients usually revert to an earlier change 

stage—not always to maintenance or action, but 

more often to some level of contemplation. 

They may even become precontemplators again, 

temporarily unwilling or unable to try to change 

soon. As will be described in the following 

chapters, resuming substance use and returning 

to a previous stage of change should not be 

considered a failure and need not become a 

disastrous or prolonged recurrence. A 

recurrence of symptoms does not necessarily 

mean that a client has abandoned a commitment 

to change. 

Triggers to Change 

The multidimensional nature of motivation is 

captured, in part, in the popular phrase that a 

person is and to change. This 

expression highlights three critical elements of 

motivation—but in reverse order from that in 

which motivation typically evolves. 

refers to the extent to which the person has the 

necessary skills, resources, and confidence (selfefficacy) to carry out a change. One can be able 

to change, but not willing. The 

component involves the importance a person 

places on changing—how much a change is 

wanted or desired. (Note that it is possible to 

feel willing yet unable to change.) However, 

even willingness and ability are not always 

enough. You probably can think of examples of 

people who are willing and able to change, but 

not yet ready to change. The component 

represents a final step in which the person 

finally decides to change a particular behavior. 

Being willing and able but not ready can often 

be explained by the relative importance of this 

change compared with other priorities in the 

person’s life. To instill motivation for change is 

to help the client become ready, willing, and 

able. As discussed in later chapters, your 

clinical approach can be guided by deciding 

which of these three needs bolstering. 

To Whom Does 

This TIP Apply? 

To which client populations is material covered 

in this TIP applicable? Motivational 

interviewing was originally developed to work 

with problem alcohol drinkers at early stages 

(precontemplation and contemplation) of 

readiness for change and was conceived as a 

way of initiating treatment (Miller, 1983; Miller 

et al., 1988). It soon became apparent, however, 

that this brief counseling approach constitutes 

an intervention in itself. Problem alcohol 

drinkers in the community who were given 
motivational interventions seldom initiated 

treatment but did show large decreases in their 

drinking (Heather et al., 1996b; Marlatt et al., 

1998; Miller et al., 1993; Senft et al., 1997). In the 

largest clinical trial ever conducted to compare 

different alcohol treatment methods, a foursession motivational enhancement therapy 

yielded long-term overall outcomes virtually 

identical to those of longer outpatient methods 

(Project MATCH Research Group, 1998a), and 

the motivational approach was differentially 

beneficial with angry clients (Project MATCH 

Research Group, 1997a). The MATCH 

population consisted of treatment-seeking 

clients who varied widely in problem severity, 

the vast majority of whom met criteria for 

alcohol dependence. Clients represented a 

range of cultural backgrounds, particularly 

Hispanic. It is noteworthy that neither Hispanic 

nor African-American samples responded 

differentially to the motivational enhancement 

therapy approach. 

Moreover, analyses of clinical trials of 

motivational interviewing that have included 

substantial representation of Hispanic clients 

(Brown and Miller, 1993; Miller et al., 1988, 1993) 

have found no indication of self-identified 

ethnicity and socioeconomic status as predictors 

of outcome. A motivational interviewing trial 

addressing weight and diabetes management 

among women, 41 percent of whom were 

African-American, demonstrated positive 

results (Smith et al., 1997). Evidence strongly 

suggests that motivational interviewing can be 

applied across cultural and economic 

differences. 

While motivational counseling appears to be 

sufficient for some clients, for others it can be 

combined with additional therapeutic methods. 

With more severely dependent drinkers, a 

motivational interviewing session at the outset 

of treatment has been found to double the rate 

of abstinence following private inpatient 

treatment (Brown and Miller, 1993) and 

Veterans Affairs outpatient programs for 

substance abuse treatment (Bien et al., 1993a). 

Benefits have been reported with other severely 

dependent populations (e.g., Allsop et al., 1997). 

Polydrug-abusing adolescents stayed in 

outpatient treatment nearly three times longer 

and showed substantially lower substance use 

and consequences after treatment when they 

had received a motivational interview at intake 

(Aubrey, 1998). Similar additive benefits have 

been reported in treating problems with heroin 

(Saunders et al., 1995), marijuana (Stephens et 

al., 1994), weight control and diabetes 

management (Smith et al., 1997; Trigwell et al., 

1997), and cardiovascular rehabilitation (Scales, 

1998). It is clear, therefore, that the motivational 

approach described in this TIP can be combined 

beneficially with other forms of treatment and 

can be applied with problems beyond substance 

abuse alone. 

The motivational style of counseling, 

therefore, can be useful, not only to instill 

motivation initially, but throughout the process 

of treatment in the preparation, action, and 

maintenance stages as well. This is reflected in 

subsequent chapters of this TIP. Whether 

motivational interviewing will be to 

trigger change in a given case is difficult to 

predict. Sometimes motivational counseling 

may be all that is needed. Sometimes it is only a 

beginning. A stepped care approach, described 

in Chapter 9, is one in which the amount of care 

provided is adjusted to the needs of the 

individual. If lasting change follows after 

motivational interviewing alone, who can be 

dissatisfied? Often more is needed. However 

brief or extensive the service provided, the 

evidence indicates that you are most likely to 

help your clients change their substance use by 

maintaining an empathic motivational style. It 

is a matter of staying with and supporting each 

client until together you find what works. 
Summary

Linking the new view of motivation, the 

strategies found to enhance it, and the stages-ofchange model, along with an understanding of 

what causes change, can create an innovative 

approach to helping substance-using clients. 

This approach provokes less resistance and 

encourages clients to progress at their own pace 

toward deciding about, planning, making, and 

sustaining positive behavioral change. 

In this treatment model, described in the next 

chapter, motivation is seen as a dynamic state 

that can be modified or enhanced by the 

clinician. Motivational enhancement has 

evolved, while various myths about clients and 

what constitutes effective counseling have been 

dispelled. The notion of the addictive 

personality has lost credence, and many 

clinicians have discarded the use of a 

confrontational style. Other factors in 

contemporary counseling practices have 

encouraged the development and 

implementation of motivational interventions. 

Increasingly, counseling has become optimistic, 

focusing on clients’ strengths, and client 

centered. Counseling relationships are more 

likely to rely on empathy, rather than authority, 

to involve the client in treatment. Less intensive 

treatments have also become more common in 

the era of managed care. 

Motivation is what propels substance users 

to make changes in their lives. It guides clients 

through several stages of change that are typical 

of people thinking about, initiating, and 

maintaining new behaviors. When applied to 

substance abuse treatment, motivational 

interventions can help clients move from not 

even considering changing their behavior to 

being ready, willing, and able to do so. 

2 Motivation and Intervention 

Noonan and Moyers, 1997 

Motivational intervention is broadly 

defined as any clinical strategy 

designed to enhance client 

motivation for change. It can include 

counseling, client assessment, multiple sessions, 

or a 30-minute brief intervention. This chapter 

examines the elements of effective motivational 

approaches and supporting research. 

Motivational strategies are then correlated with 

the stages-of-change model (a framework that is 

discussed in Chapter 1 and elaborated on in 

later chapters) to highlight approaches that are 

appropriate to specific stages. 

Recommendations are presented for providing 

motivational interventions that are responsive 

and sensitive to differing cultural and diagnostic 

needs, as well as to different settings and 

formats. This chapter concludes with a

description of an increasingly accepted type of 

intervention known as a brief intervention, 

which is useful outside of traditional substance 

abuse treatment settings. For a broader 

discussion of brief interventions and therapies, 

refer to the forthcoming TIP, 

(CSAT, in 

press [a]). 

Elements of 

Effective Motivational 

Interventions

To understand what prompts a person to reduce 

or eliminate substance use, investigators have 

searched for the critical components—the most 

important and common elements that inspire 

positive change—of effective interventions. The 

following are important elements of current 

motivational approaches: 

The FRAMES approach 

Decisional balance exercises 

Discrepancies between personal goals and 

current behavior 

Flexible pacing 

Personal contact with clients not in treatment

These elements are described in the following 

subsections. 
Figure 2-1 

Specific FRAMES Components of 32 Evaluated Brief Trials 

Author(s) Feedback Responsi- Advice Menu Empathy Self-Efficacy Outcome 

bility 

Anderson and Scott, 1992* Yes Yes Yes Yes Yes Yes Brief > No counseling 

Babor and Grant, 1992* Yes Yes Yes Manual Yes Yes Brief > No counseling 

Bien, 1992* Yes Yes Yes No Yes Yes Brief > No counseling 

Brown and Miller, 1992* Yes Yes Yes No Yes Yes Brief > No counseling 

Carpenter et al., 1985* Yes No Yes No No No Brief = Extended cnslg 

Chapman and Huygens, Yes Yes Yes Yes No Yes Brief = IPT = OPT 

1988*

Chick et al., 1985* Yes Yes Yes No Yes Yes Brief > No counseling 

Chick et al., 1988* No Yes Yes No No No Brief < Extended 

motivational cnslg 

Daniels et al., 1992 Yes No Yes Manual No No Advice + Manual = No 

advice

Drummond et al., 1990 Yes No Yes No No No Brief = OPT 

FRAMES Approach 

Six elements have been identified that were 

present in brief clinical trials, and the acronym 

FRAMES was coined to summarize them (Miller 

and Sanchez, 1994). These elements are defined 

as the following: 

F regarding personal risk or 

impairment is given to the client following 

assessment of substance use patterns and 

associated problems. 

R for change is placed squarely 

and explicitly on the client (and with respect 

for the client’s right to make choices for 

himself).

A about changing—reducing or 

stopping—substance use is clearly given to 

the client by the clinician in a nonjudgmental 

manner.

M of self-directed change options and 

treatment alternatives are offered to the 

client. 

E counseling—showing warmth, 

respect, and understanding—is emphasized. 

S or optimistic empowerment is 

engendered in the client to encourage 

change. 

Figure 2-1 lists 32 trials and their FRAME 

components, as reviewed by Bien and colleagues 

(Bien et al., 1993b). Since the FRAMES construct 

was developed, further clinical research and 

experience have expanded on and refined 

elements of this motivational model. These 

components have been combined in different 

ways and tested in diverse settings and cultural 

contexts. Consequently, additional building 

blocks or tools are now available that can be 

tailored to meet your clients’ needs. 

Feedback

The literature describing successful motivational 

interventions confirms the persuasiveness of 

personal, individualized feedback (Bien et al., 

1993b; Edwards et al., 1977; Kristenson et al., 

1983). Providing constructive, 

nonconfrontational feedback about a client’s 

degree and type of impairment based on 

information from structured and objective 

assessments is particularly valuable (Miller et 

al., 1988). This type of feedback usually 

compares a client’s scores or ratings on standard 

tests or instruments with normative data from a 

general population or from groups in treatment 

(for examples, see Figures 4-1 and 4-2). 
Author(s) Feedback Responsi- Advice Menu Empathy Self-Efficacy Outcome 

bility 

Edwards et al., 1977 Yes Yes Yes No Yes Yes Brief = OPT/IPT 

Elvy et al., 1988 Yes No Yes No No No Brief > No counseling 

Harris and Miller, 1990* No Yes Yes Manual Yes Yes Brief = Extended > No 

Rx

Heather et al., 1986* Yes Yes Manual Manual No No Manual > No manual 

Heather et al., 1987* Yes Yes Yes Manual No No Brief = No counseling 

Heather et al., 1990* Yes Yes Yes Manual No No Manual > No manual 

Kristenson et al., 1983 Yes Yes Yes No Yes Yes Brief > No counseling 

Kuchipudl et al., 1990 Yes No Yes Yes No No Brief = No counseling 

Maheswaran et al., 1992 Yes No Yes No No No Brief > No counseling 

Miller and Taylor, 1980* No Yes Yes Manual Yes Yes Brief = Behavioral cnslg 

Miller et al., 1980* No Yes Yes Manual Yes Yes Brief = Behavioral cnslg 

Miller et al., 1981* No Yes Yes Manual Yes Yes Brief = Behavioral cnslg 

Miller et al., 1988* Yes Yes Yes Yes Yes Yes Brief > No counseling 

Miller et al., 1993* Yes Yes Yes Yes Yes Yes Brief > No counseling 

Persson and Magnusson, Yes Yes Yes No Yes Yes Brief > No counseling 

1989*

Robertson et al., 1986* Yes Yes Yes Yes Yes Yes Brief < Behavioral cnslg 

Romelsjo et al., 1989* Yes Yes Yes No Yes Yes Brief = OPT treatment 

Sannibale, 1988* Yes Yes Yes No Yes Yes Brief = OPT treatment 

Scott and Anderson, 1990* Yes Yes Yes Yes Yes Yes Brief = No counseling 

Skutle & Berg, 1987* No Yes Yes Yes+ Yes Yes Brief = Behavioral cnslg 

Manual

Wallace et al., 1988* Yes Yes Yes Manual Yes Yes Brief > No counseling 

Zweben et al., 1988 Yes Yes Yes Yes No Yes Brief = Conjoint 

therapy 

Percentage w/FRAMES 81 81 100 59 63 69

components 

* Additional information obtained from study authors. 

Abbreviations: Manual: manual-guided therapy; IPT: inpatient treatment setting; OPT: outpatient treatment setting; 

cnslg: counseling; > : more effective than; < : not as effective as; = : as effective as. 

Bien et al., 1993b; Miller et al., 1995c. 

Assessments may include measures related to 

substance consumption patterns, substancerelated problems, physical health, risk factors 

including a family history of substance use or 

affective disorders, and various medical tests 

(Miller et al., 1995c). (Assessments and feedback 

are described in more detail in Chapter 4.) A 

respectful manner when delivering feedback to 

your client is crucial. A confrontational or 
judgmental approach may leave the client 

unreceptive.

Do not present feedback as evidence that can 

be used against the client. Rather, offer the 

information in a straightforward, respectful 

way, using easy-to-understand and culturally 

appropriate language. The point is to present 

information in a manner that helps the client 

recognize the existence of a substance use 

problem and the need for change. Reflective 

listening and an empathic style help the client 

understand the feedback, interpret the meaning, 

gain a new perspective about the personal 

impact of substance use, express concern, and 

begin to consider change. 

Not all clients respond in the same way to 

feedback. One person may be alarmed to find 

that she drinks much more in a given week than 

comparable peers but be unconcerned about 

potential health risks. Another may be 

concerned about potential health risks at this 

level of drinking. Still another may not be 

impressed by such aspects of substance use as 

the amount of money spent on substances, 

possible impotence, or the level of impairment— 

especially with regard to driving ability— 

caused by even low blood alcohol 

concentrations (BACs). Personalized feedback 

can be applied to other lifestyle issues as well, 

and can be used throughout treatment. 

Feedback about improvements is especially 

valuable as a method of reinforcing progress. 

Responsibility

Individuals have the choice of continuing their 

behavior or changing. A motivational approach 

allows clients to be active rather than passive by 

insisting that they choose their treatment and 

take responsibility for changing. Do not impose 

views or goals on clients; instead, ask clients for 

permission to talk about substance use and 

invite them to consider information. If clients 

are free to choose, they feel less need to resist or 

dismiss your ideas. Some clinicians begin an 

intervention by stating clearly that they will not 

ask the client to do anything he is unwilling to 

do but will try nevertheless to negotiate a 

common agenda in regard to treatment goals. 

When clients realize they are responsible for the 

change process, they feel empowered and more 

invested in it. This results in better outcomes 

(Deci, 1975, 1980). When clients make their own 

choices, you will be less frustrated and more 

satisfied because the client is doing the work. 

Indeed, clients are the best experts about their 

own needs. 

Advice

The simple act of giving gentle advice can 

promote positive behavioral change. As already 

discussed, research shows that short sessions in 

which you offer suggestions can be effective in 

changing behaviors such as smoking, drinking 

alcohol, and other substance use (Drummond et 

al., 1990; Edwards et al., 1977; Miller and Taylor, 

1980; Sannibale, 1988; Wallace et al., 1988). As 

with feedback, the in which you advise 

A Realistic Model of Change: Advice to Clients 

Throughout the treatment process, it is important to give clients permission to talk about their 

problems with substance use. During these kinds of dialogs, I often point out some of the realities of 

the recovery process: 

Most change does not occur overnight. 

Change is best viewed as a gradual process with occasional setbacks, much like hiking up 

a bumpy hill. 

Difficulties and setbacks can be reframed as learning experiences, not failures. 

Linda C. Sobell, Consensus Panel Member 
The PIES Approach 

In World War I, military psychiatrists first realized that motivational interventions, done at the right 

time, could return a great number of dysfunctionally stressed soldiers to duty. The method could be 

put into an easily remembered acronym: PIES. 

Provide treatment near the place of duty; don’t evacuate to a hospital. 

 Intervene and treat as soon as the problem is noticed. 

 Expect the intervention to be successful and return the person to duty. 

Simply listening, showing empathy, and demonstrating understanding works best. 

Highlight the fact the person is normal while the situation is abnormal and that the person will 

recover with rest and nourishment. No prolonged or complex therapy was needed for the great 

majority of cases. Evacuation to higher echelons of care was reserved for the low percentage of 

individuals who did not respond to this straightforward approach. 

Kenneth J. Hoffman, Field Reviewer 

clients determines how the advice will be used. 

It is better not to people what to do

 yields better results. A motivational 

approach to offering advice may be either 

directive (making a suggestion) or educational 

(explaining information). Educational advice is 

based on credible scientific evidence supported 

in the literature. Facts that relate to the client’s 

conditions, such as BAC levels at the time of an 

accident or safe drinking limits recommended 

by the National Institute on Alcohol Abuse and 

Alcoholism, can be presented in a 

nonthreatening way. Thoughtfully address the 

client’s behavior by saying, “Can I tell you what 

I’ve seen in the past in these situations?” or, “Let 

me explain something to you about tolerance.” 

Such questions provide a nondirective 

opportunity to share your knowledge about 

substance use in a gentle and respectful manner. 

If the client requests direction, redirect her 

questions in order to clarify what is wanted 

rather than giving advice immediately. Any

advice you give should be simple, not 

overwhelming, and matched to the client’s level 

of understanding and readiness, the urgency of 

the situation, and her culture. (In some cultures, 

a more directive approach is required to 

adequately convey the importance of the advice 

or situation; in other cultures, a directive style is 

considered rude and intrusive.) This style of 

giving advice requires patience. The timing of 

any advice is also important, relying on your 

ability to “hear”—in the broad sense—what the 

client is requesting and willing to receive. 

Options

Compliance with change strategies is enhanced 

when clients choose—or perceive that they can 

choose—from a menu of options. Thus, 

motivation for participating in treatment is

heightened by giving clients choices regarding 

treatment goals and types of services needed. 

Offering a menu of options helps decrease 

dropout rates and resistance to treatment and 

increases overall treatment effectiveness 

(Costello, 1975; Parker et al., 1979). As you 

describe alternative approaches to treatment or 

change that are appropriate for your clients, 

provide accurate information about each option 

and a best guess about the implications of 

choosing one particular path. Elicit from your 

clients what they think is effective or what has 

worked for them in the past. Providing a menu 

of options is consistent with the motivational 

principle that clients must choose and take 

responsibility for their choices. Your role is to 

enhance your clients’ ability to make informed 

choices. When clients make independent 
decisions, they are likely to be more committed 

to them. This concept is further discussed in

Chapter 6. 

Empathic counseling 

Empathy is not specific to motivational 

interventions but rather applies to many types 

of therapies (Rogers, 1959; Truax and Carkhuff, 

1967). Empathy during counseling has been 

interpreted in terms of such therapist 

characteristics as warmth, respect, caring, 

commitment, and active interest (Miller and 

Rollnick, 1991). Empathy usually entails 

reflective listening—listening attentively to each 

client statement and reflecting it back in 

different words so that the client knows you 

understand the meaning. 

The client does most of the talking when a 

clinician uses an empathic style. It is your 

responsibility to create a safe environment that 

encourages a free flow of information from the 

client. Your implied message to the client is “I 

see where you are, and I’m not judgmental. 

Where would you like to go from here?” The 

assumption is that, with empathic support, a 

client will naturally move in a healthy direction. 

Let this process unfold, rather than direct or 

interrupt it. Although an empathic style 

appears easy to adopt, it actually requires 

careful training and significant effort on your 

part. This style can be particularly effective with 

clients who seem angry, resistant, or defensive. 

Self-efficacy 

To succeed in changing, clients must believe 

they are capable of undertaking specific tasks 

and must have the necessary skills and 

confidence (Bandura, 1989; Marlatt and Gordon, 

1985). One of your most important roles is to 

foster hope and optimism by reinforcing your 

clients’ beliefs in their own capacities and 

capabilities (Yahne and Miller, 1999). This role 

is more likely to be successful if you believe in 

your client’s ability to change (Leake and King, 

1977). You can help clients identify how they

have successfully coped with problems in the 

past by asking, “How did you get from where 

you were to where you are now?” Once you 

identify strengths, you can help clients build on 

past successes. It is important to affirm the 

small steps that are taken and reinforce any 

positive changes. The importance of selfefficacy is discussed again in Chapters 3 and 5. 

Decisional Balance Exercises 

The concept of exploring the pros and cons—or 

benefits and disadvantages—of change is not 

new and is well documented in the literature 

(Colten and Janis, 1982; Janis and Mann, 1977). 

Individuals naturally explore the pros and cons 

of any major life choices such as changing jobs 

or getting married. In the context of recovery 

from substance use, the client weighs the pros 

and cons of changing versus not changing 

substance-using behavior. You assist this 

process by asking your client to articulate the 

good and less good aspects of using substances 

and then list them on a sheet of paper. This 

process is usually called and

is further described in Chapters 5 and 8. The 

purpose of exploring the pros and cons of a 

substance use problem is to 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 one. For example, a 20-year-old smoker 

might not put as much weight on getting lung 

cancer as an older man, but he might be very 

concerned that his diminished lung capacity 

interferes with playing tennis or basketball. 

Discrepancies Between Goals and 

Current Behavior 

One way to enhance motivation for change is to 

help clients recognize a or gap 

between their future goals and their current 

behavior. You might clarify this discrepancy by 

asking, “How does your drinking fit in with
having a happy family and a stable job?” When 

an individual sees that present actions conflict 

with important personal goals such as health, 

success, or family happiness, change is more 

likely to occur (Miller and Rollnick, 1991). This 

concept is expanded in Chapters 3 and 5. 

Flexible Pacing 

Every client moves through the stages of change 

at her own pace. Some will cycle back and forth 

numerous times between, for example, 

contemplating change and making a 

commitment to do so. Others seem stuck in an 

ambivalent state for a long time. A few are 

ready to get started and take action 

immediately. Therefore, assess your client’s 

readiness for change. By determining where the 

individual has been and is now within the 

stages of change, you can better facilitate the 

change process. 

The concept of pacing requires that you meet 

your clients at their levels and use as much or as 

little time as is necessary with the essential tasks 

of each stage of change. For example, with some 

clients, you may have to schedule frequent 

sessions at the beginning of treatment and fewer 

later. In other cases, you might suggest a 

“therapeutic vacation” for a client who has to 

take a break before continuing a particularly 

difficult aspect of recovery. If you push clients 

at a faster pace than they are ready to take, the 

therapeutic alliance may break down. 

Personal Contact With Clients 

Not In Treatment 

Motivational interventions can include simple 

activities designed to enhance continuity of 

contact between you and your client and 

strengthen your relationship. Such activities can 

include personal handwritten letters or 

telephone calls from you to your client. 

Research has shown that these simple 

motivation-enhancing interventions are effective 

for encouraging clients to return for another 

clinical consultation, to return to treatment 

following a missed appointment, to stay 

involved in treatment, and to increase adherence 

(Intagliata, 1976; Koumans and Muller, 1965; 

Nirenberg et al., 1980; Panepinto and Higgins, 

1969). This concept is discussed in Chapter 7. 

Motivational Intervention 

And the Stages of Change 

Clients need and use different kinds of 

motivational support according to which stage 

of change they are in and into what stage they 

are moving. If you try to use strategies 

appropriate to a stage other than the one the 

client is in, the result could be treatment 

resistance or noncompliance. For example, if 

your client is at the contemplation stage, 

weighing the pros and cons of change versus 

continued substance use, and you pursue 

change strategies appropriate to the action stage, 

your client will predictably resist. The simple 

reason for this reaction is that you have taken 

the positive (change) side of the argument, 

leaving the client to argue the other (no change) 

side; this results in a standoff. 

To consider change, individuals at the 

precontemplation stage must have their 

awareness raised. To resolve their ambivalence, 

clients in the contemplation stage require help 

choosing positive change over their current 

situation. Clients in the preparation stage need 

help identifying potential change strategies and 

choosing the most appropriate one for their 

circumstances. Clients in the action stage (the 

stage at which most formal treatment occurs) 

need help to carry out and comply with the 

change strategies. During the maintenance 

stage, clients may have to develop new skills for 

maintaining recovery and a lifestyle without 

substance use. Moreover, if clients resume their 

substance use, they can be assisted to recover as 

quickly as possible to resume the change 

process.
Figure 2-2 provides examples of appropriate 

motivational strategies you can use at each stage 

of change. Of course, these are not the only 

ways to enhance motivation for beneficial 

change. Chapter 3 describes some of the 

fundamental principles of motivational 

interviewing that apply to all stages. Chapters 4 

through 7 describe in more detail the 

motivational strategies that are most 

appropriate for encouraging progression to each 

new change stage. Chapters 4 and 8 present 

some tools to help you recognize clients’ 

readiness to change in terms of their current 

stage.

Catalysts for Change 

In the search for common processes—integrative 

models—of personal growth and change across 

psychotherapies and behavioral approaches, 

Prochaska (Prochaska, 1979) initially isolated the 

core approaches of many therapeutic systems 

and further developed these in a factor analytic 

study (Davidson, 1994; Prochaska and 

DiClemente, 1983). These fundamental 

processes represent cognitive, affective, 

behavioral, and environmental factors 

influencing change as they appear in major 

systems of therapy (DiClemente and Scott, 

1997). These change catalysts are derived from 

studies examining smoking cessation, alcohol 

abstinence, general psychotherapeutic problems, 

weight loss, and exercise adoption (Prochaska et 

al., 1992b). For each of the 10 catalysts, several 

different interventions can be used to encourage 

change. Figure 2-3 describes these catalysts for 

change and illustrates a few interventions often 

used for each. 

Typically, cognitive−experiential processes 

are used early in the cycle (i.e., contemplation, 

preparation), and behavioral processes are 

critical for the later stages (i.e., action, 

maintenance) (Prochaska and Goldstein, 1991). 

Figure 2-4 suggests which catalysts are most 

appropriate for each change stage. To avoid 

confusion for both the client and clinician, only 

those catalysts that are best supported or most 

logical are recommended for a particular stage; 

this does not imply, however, that the other 

catalysts are irrelevant. 

Special Applications of 

Motivational

Interventions

The principles underlying motivational 

enhancement have been applied across cultures, 

to different types of problems, in various 

treatment settings, and with many different 

populations. The research literature suggests 

that motivational interventions are associated 

with a variety of successful outcomes, including 

facilitation of referrals for treatment, reduction 

or termination of substance use, and increased 

participation in and compliance with specialized 

treatment (Bien et al., 1993b; Noonan and 

Moyers, 1997). Motivational interventions have 

been tested in at least 15 countries, including 

Canada, England, Scotland, Wales, the 

Netherlands, Australia, Sweden, Bulgaria, Costa 

Rica, Kenya, Zimbabwe, Mexico, Norway, the 

former Soviet Union, and the United States (Bien 

et al., 1993; Miller and Rollnick, 1991). 

Motivational strategies have been used 

primarily with problem alcohol drinkers and 

cigarette smokers, but also have yielded 

encouraging results in marijuana and opiate 

users with serious substance-related problems 

(Bernstein et al., 1997a; Miller and Rollnick, 

1991; Noonan and Moyers, 1997; Sobell et al., 

1995). 

Special applications of motivational 

approaches have been or are currently being 

explored with diabetic patients, for pain 

management, in coronary heart disease 

rehabilitation, for HIV risk reduction, with sex 

offenders, with pregnant alcohol drinkers, with 

severely alcohol-impaired veterans, with 

persons who have eating disorders, and with 
Figure 2-2 

Appropriate Motivational Strategies for Each Stage of Change 

Client’s Stage of Change Appropriate Motivational Strategies for the Clinician 

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 

self-efficacy for change 

Elicit self-motivational statements of intent and commitment 

from the client.

Elicit ideas regarding the client’s perceived self-efficacy and 

expectations regarding treatment. 

Summarize self-motivational statements.

Preparation Clarify the client’s own goals and strategies for change. 

Offer a menu of options for change or treatment. 

The client i

near future but is still considering contract.

what to do. Consider and lower barriers to change. 

Help the client enlist social support. 

Explore treatment expectancies and the client’s role. 

s committed to and With permission, offer expertise and advice. 

planning to make a change in the Negotiate a change—or treatment—plan and behavior 

-OTIVATIONAND)NTERVENTION
32

individuals with coexisting substance use and 

psychiatric disorders (Carey, 1996; Noonan and 

Moyers, 1997; Ziedonis and Fisher, 1996).

Populations that have been responsive to 

motivational interventions include persons 

arrested for driving under the influence and 

other nonviolent offenders, adolescents (Colby 

et al., 1998), older adults, employees, married

Chapter 2 

Figure 2-2 (continued)

Appropriate Motivational Strategies for Each Stage of Change

Client’s Stage of Change Appropriate Motivational Strategies for the Clinician

Preparation (continued) Elicit from the client what has worked in the past either for

him or others whom he knows.

 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.
Figure 2-3 

Ten Effective Catalysts for Change 

1. Consciousness raising is increasing information about the problem. Interventions could include 

observations, interpretations, and bibliotherapy. 

2. 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.

3. 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. 

4. Counterconditioning involves substituting coping alternatives for anxiety caused by substancerelated behaviors. Interventions could include relaxation training, desensitization, assertion, and 

positive self-statements. 

5. 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.

6. Reinforcement management is rewarding oneself or being rewarded by others for making 

changes. Interventions could include contingency contracts and overt and covert reinforcement. 

7. 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. 

8. 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. 

9. Environmental reevaluation is the process of assessing how one’s problems affect the personal 

and physical environment. Interventions could include empathy training and documentaries. 

10. Social liberation involves increasing alternatives for nonproblematic behavior. Interventions 

could include advocating for the rights of the oppressed and policy interventions. 

Adapted from DiClemente and Scott, 1997. 

couples, opioid-dependent clients receiving 

methadone maintenance, and victims and 

perpetrators of domestic violence (Bernstein et 

al., 1997a; Miller and Rollnick, 1991; Noonan 

and Moyers, 1997). The literature also describes 

successful use of these motivational techniques 

in primary care facilities (Daley et al., 1998), 

hospital emergency departments (Bernstein et 

al., 1997a; D’Onofrio et al., 1998), traditional 

inpatient and outpatient substance abuse 

treatment environments, drug courts, and 

community prevention efforts. These 

interventions have been used with individuals, 

couples, groups, and in face-to-face sessions or 

through mailed materials (Miller and Rollnick, 

1991; Sobell and Sobell, 1998). The simplicity 

and universality of the concepts underlying 

motivational interventions permit broad 

application and offer great potential to reach 

clients with many types of problems and in 

many different cultures or settings. 

Responding to Differing Needs 

Clients in treatment for substance abuse differ in 

ethnic and racial backgrounds, socioeconomic 

status, education, gender, age, sexual 

orientation, type and severity of substance use 

problems, and psychological health. As noted 
Figure 2-4 

Catalysts and the Stages of Change 

Stage of Change Catalysts

Precontemplation Consciousness raising 

Environmental reevaluation 

Emotional arousal and dramatic relief 

Contemplation Self-reevaluation 

Emotional arousal and dramatic relief 

Environmental reevaluation 

Preparation Self-liberation 

Counterconditioning

Helping relationships 

Action Counterconditioning

Stimulus control 

Reinforcement management 

Helping relationships 

Self-liberation 

Maintenance Helping relationships 

Environmental reevaluation 

Self-liberation 

Reinforcement management 

above, research and experience suggest that the 

change process is the same or similar across 

different populations. Thus, the principles and 

mechanisms of enhancing motivation to change 

seem to be broadly applicable. Nonetheless, 

there may be important differences among 

populations and cultural contexts regarding the 

expression of motivation for change and the 

importance of critical life events. Hence, be 

familiar with the populations with whom you 

expect to establish therapeutic relationships and 

use your clients as teachers regarding their own 

culture. 

Because motivational strategies emphasize 

the client’s responsibility to voice personal goals 

and values as well as to select among options for 

change, a sensitive clinician will understand 

and, ideally, respond in a nonjudgmental way to 

cultural differences. Cultural differences might 

be reflected in the value of health, the meaning 

of time, the stigma of heavy drinking, 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 

among different populations. Motivationenhancing strategies should be congruent with 

clients’ cultural and social principles, standards, 

and expectations. For example, older adults 

often struggle with loss of status and personal 

identity when they retire, and they may not 

know how to occupy their leisure time. Help 

such retired clients understand their need for 

new activities and how their use of substances is 

a coping mechanism. Similarly, when you try to 

enhance motivation for change in adolescents, 

consider how peers influence their behaviors 

and values and how families may limit their 

emerging autonomy. 
Cultural Appropriateness 

In my practice with persons who have different world views, I’ve made a number of observations on the 

ways in which culture influences the change process. I try to pay attention to cultural effects on a 

person’s style of receiving and processing information, making decisions, pacing, and being ready to act. 

The more clients are assimilated into the surrounding culture, the more likely they are to process 

information, respond, and make choices that are congruent with mainstream beliefs and styles. The 

responsibility for being aware of different cultural value systems lies with the practitioner, not the client 

being treated. 

More specifically, the manner in which a person communicates, verbally and nonverbally, is often 

directly related to culture. One young Native American stated on initial contact that he “might not be 

able to come back because his shoes were too tight.” This was his way of saying he had no money. 

However, ethnicity doesn’t always determine the culture or values one chooses to live by. For 

example, white Americans may adopt Eastern world views and value systems. Further, an advanced 

education doesn’t necessarily indicate the degree of assimilation or acculturation. Asian-Americans or 

African-Americans who are well educated may choose to live according to their traditional cultural value 

system and process information for change accordingly. 

Culture is a powerful contributor to defining one’s identity. Not having a healthy ethnic sense of self 

affects all stages of the change process. As Maslow wrote, to have a strong sense of self, you have to be 

powerful in the areas of being, knowing, doing, and having. Ethnic Americans who have been raised in 

environments that isolate them from their own cultures may not have accurate information about their 

ethnicity and may not develop a healthy ethnic sense of self. 

I believe clinicians who use motivational enhancement therapy need to know different cultural value 

systems and be culturally sensitive. If in doubt of the client’s beliefs, explore them with the client. 

Acknowledging and honoring differing cultural world views greatly influence both motivational style 

and therapeutic outcome. 

Rosalyn Harris-Offutt, Consensus Panel Member 

In addition to understanding and using a 

special population’s values to encourage change, 

identify how those values may present potential 

barriers to change. Some clients will identify 

strongly with cultural or religious traditions and 

work diligently to gain the respect of elders or 

other group leaders; others find membership or 

participation in groups of this type an anathema. 

Some populations are willing to involve family 

members in counseling; others find this 

disrespectful, if not disgraceful. The label 

“alcoholic” is proudly and voluntarily adopted 

by members of AA but viewed as dehumanizing 

by others. The message is simple: Know and be 

sensitive to the concerns and values of your 

clients. 

Another sensitive area is matching the client 

with the clinician. Although the literature 

suggests that warmth, empathy, and genuine 

respect are more important in building a 

therapeutic partnership than professional 

training or experience (Najavits and Weiss, 

1994), nevertheless, programs can identify those 

clinicians who may be optimally suited because 

of cultural identification, language, or other 

similarities of background, to work with clients 

from specific populations. Programs will find it 

useful to develop a network of bilingual 

clinicians or interpreters who can communicate 

with non–English-speaking clients. 

Finally, know what personal and material 

resources are available to your clients and be 
sensitive to issues of poverty, social isolation, 

and recent losses. In particular, recognize that 

access to financial and social resources is an 

important part of the motivation for and process 

of change. Prolonged poverty and lack of 

resources make change more difficult, both 

because many alternatives are not possible and 

because despair can be pervasive. It is a 

challenge to affirm self-efficacy and stimulate 

hope and optimism in clients who lack material 

resources and have suffered the effects of 

discrimination. The facts of the situation should 

be firmly acknowledged. Nevertheless, clients’ 

capacity for endurance and personal growth in 

the face of dire circumstances can be respected 

and affirmed and then drawn on as a strength in 

attempting positive change. 

Brief Interventions 

Over the last two decades, there has been a 

growing trend worldwide to view substancerelated problems in a much broader context than 

diagnosable abuse and dependence syndromes. 

The recognition that persons with substancerelated problems compose a much larger 

group—and pose a serious and costly public 

health threat—than the smaller number of 

persons needing traditional, specialized 

treatment is not always reflected in the 

organization and availability of treatment 

services. As part of a movement toward early 

identification of hazardous drinking patterns 

and the development of effective and low-cost 

methods to ameliorate this widespread problem, 

brief interventions have been initiated and 

evaluated, primarily in the United Kingdom 

(Institute of Medicine, 1990a) and Canada but 

also in many other nations. (For a greater 

discussion of brief intervention and brief 

therapy, refer to the forthcoming TIP, 

[CSAT, in press (a)].) They have been 

tried in the United States and elsewhere with 

great success, although they have not been 

widely adopted outside research settings 

(Drummond, 1997; Kahan et al., 1995). The 

impetus to expand the use of this shorter form of 

treatment is a response to 

The need for a broader base of treatment and 

prevention components to serve all segments 

of the population who have minimal to 

severe substance-related problems and 

consumption patterns 

The need for cost-effective interventions that 

will not further deplete public coffers and 

will also satisfy cost-containment policies in 

an era of managed health care (although 

research indicates that intensive treatment 

for nicotine dependence is more cost effective 

[Agency for Health Care Policy and 

Research, 1996]) 

A growing body of research findings that 

consistently demonstrate the efficacy of brief 

interventions relative to no intervention 

Uses of Brief Interventions 

Brief interventions for substance-using 

individuals are applied most often outside 

traditional treatment settings (in what are often 

referred to as settings), where 

clients are not seeking help for a substance 

abuse disorder but have come, for example, to 

seek medical attention, to pick up a welfare 

check, or to respond to a court summons. These 

settings provide an opportunity to meet and 

engage with individuals with substance abuse 

disorders “where they are at.” In these 

situations, persons seeking services may be 

routinely screened for substance-related 

problems or asked about their consumption 

patterns. (For more on how this can work in one 

such setting, see TIP 24, 

 [CSAT, 

1997].) Those found to have risky or excessive 

patterns of substance use or related problems 

receive a brief intervention of one or more 

sessions, each lasting a few minutes to an hour. 
Brief Intervention in the Emergency Department 

When I apply a motivational interviewing style in my practice of emergency medicine, I experience 

considerable professional satisfaction. Honestly, it’s a struggle to let go of the need to be the expert in 

charge. It helps to recognize that the person I’m talking with in these medical encounters is also an 

expert—an expert in her own lifestyle, needs, and choices. 

After learning about the FRAMES principles in 1987, I tried them once or twice, and they worked, 

so I tried them again and again. This is not to say that I don’t fall back to old ways and sometimes ask 

someone, “Do you want to go to detox?” But more often than not, I try to ask permission to discuss 

each individual’s substance use. I ask patients to help me to understand what they enjoy about using 

substances, and then what they enjoy less about it. Patients often tell me they like to get high because it 

helps them relax and forget their problems and it’s a part of their social life. But they say they don’t 

like getting sick from drugs. They don’t like their family avoiding them or having car accidents or 

having chest pains after using crack. I listen attentively and reflect back what I understood each 

person to have said, summarize, and ask, “Where does this leave you?” I also inquire about how ready 

they are to change their substance use on a scale of 1 to 10. If someone is low on the scale, I inquire 

about what it will take to move forward. If someone is high on the scale, indicating readiness to 

change, I ask what this person thinks would work for him to change his substance use. 

If a patient expresses an interest in treatment, I explore the pros and cons of different choices. An 

emergency department specialist in substance use disorders then works with the person to find 

placement in a program and, if needed, provides a transportation voucher. This systematic approach, 

which incorporates motivational interviewing principles, is helpful to me in our hectic practice setting. 

It’s not only ethically sound, based as it is on respect for the individual’s autonomy, but it’s less time 

consuming and frustrating. Each person does the work for him- or herself by naming the problem and 

identifying possible solutions. My role is to facilitate that process. 

Ed Bernstein, Consensus Panel Member 

Urgent care may involve just one brief 

encounter, with possible referral to other 

services. These brief interventions are usually 

conducted by professionals from the service area 

where the person seeks services, not by 

substance abuse treatment specialists. The 

purpose of a brief intervention is usually to 

counsel individuals about hazardous substance 

use patterns and to advise them to limit or stop 

their consumption altogether, depending on the 

circumstances. If the initial intervention does 

not result in substantial improvement, the 

professional can make a referral for additional 

specialized substance abuse treatment. A brief 

intervention 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. 

Brief interventions have been used effectively 

within substance abuse treatment settings with 

persons seeking assistance but 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 with little additional clinical 

attention. A series of brief interventions can 

constitute brief therapy, a treatment strategy 

that applies therapeutic techniques specifically 

oriented toward a limited length of treatment, 

making it particularly useful for certain 

populations (e.g., older adults, adolescents). 

3 Motivational Interviewing as a 

Counseling Style 

Miller and Rollnick, 1991 

Motivational interviewing is a 

technique in which you become a 

helper in the change process and 

express acceptance of your client. It is a way to 

interact with substance-using clients, not merely 

as an adjunct to other therapeutic approaches, 

and a style of counseling that can help resolve 

the ambivalence that prevents clients from 

realizing personal goals. Motivational 

interviewing builds on Carl Rogers’ optimistic 

and humanistic theories about people’s 

capabilities for exercising free choice and 

changing through a process of self-actualization. 

The therapeutic relationship for both Rogerian 

and motivational interviewers is a democratic 

partnership. Your role in motivational 

interviewing is directive, with a goal of eliciting 

self-motivational statements and behavioral 

change from the client in addition to creating 

client discrepancy to enhance motivation for 

positive change (Davidson, 1994; Miller and

Rollnick, 1991). Essentially, motivational 

interviewing activates the capability for 

beneficial change that everyone possesses 

(Rollnick and Miller, 1995). Although some 

people can continue change on their own, others 

require more formal treatment and support over 

the long journey of recovery. Even for clients 

with low readiness, motivational interviewing 

serves as a vital prelude to later therapeutic 

work.

Motivational interviewing is a counseling 

style based on the following assumptions: 

Ambivalence about substance use (and 

change) is normal and constitutes an 

important motivational obstacle in recovery. 

Ambivalence can be resolved by working 

with your client’s intrinsic motivations and 

values.

The alliance between you and your client is a 

collaborative partnership to which you each 

bring important expertise. 

An empathic, supportive, yet directive, 

counseling style provides conditions under 

which change can occur. (Direct argument 

and aggressive confrontation may tend to 

increase client defensiveness and reduce the 

likelihood of behavioral change.) 

This chapter briefly discusses ambivalence 

and its role in client motivation. Five basic

principles of motivational interviewing are then 

presented to address ambivalence and to 

facilitate the change process. Opening strategies 

to use with clients in the early stages of 
treatment are offered as well. The chapter 

concludes with a summary of a 1997 review by 

Noonan and Moyers that studied the 

effectiveness of motivational interviewing. 

Ambivalence

Individuals with substance abuse disorders are 

usually aware of the dangers of their substanceusing behavior but continue to use substances 

anyway. They may want to stop using 

substances, but at the same time they do not 

want to. They enter treatment programs but 

claim their problems are not all that serious. 

These disparate feelings can be characterized as 

ambivalence, and they are natural, regardless of 

the client’s state of readiness. It is important to 

understand and accept your client’s 

ambivalence because ambivalence is often the 

central problem—and lack of motivation can be 

a manifestation of this ambivalence (Miller and 

Rollnick, 1991). If you interpret ambivalence as 

denial or resistance, friction between you and 

your client tends to occur. 

The motivational interviewing style 

facilitates exploration of stage-specific 

motivational conflicts that can potentially hinder 

further progress. However, each dilemma also 

offers an opportunity to use the motivational 

style to help your client explore and resolve 

opposing attitudes. Examples of how these 

conflicts might be expressed at different stages 

of change are provided in Figure 3-1. 

Five Principles of 

Motivational

Interviewing

In their book, 

, Miller and 

Rollnick wrote, 

[M]otivational interviewing has been 

in focus.... The strategies of motivational 

Figure 3-1 

Stage-Specific Motivational Conflicts 

Stage of Change Client Conflict 

Precontemplation

I don’t see how my cocaine use warrants concern, 

but I hope that by agreeing to talk about it, my 

wife will feel reassured. 

Contemplation 

I can picture how quitting heroin would improve 

my self-esteem, but I can’t imagine never shooting 

up again. 

Preparation I’m feeling good about setting a quit date, but I’m 

wondering if I have the courage to follow through. 

Action

Staying clean for the past 3 weeks really makes me 

feel good, but part of me wants to celebrate by 

getting loaded. 

Maintenance 

These recent months of abstinence have made me 

feel that I’m progressing toward recovery, but I’m 

still wondering whether abstinence is really 

necessary.
interviewing are more persuasive than 

coercive, more supportive than argumentative. 

The motivational interviewer must proceed 

with a strong sense of purpose, clear strategies 

and skills for pursuing that purpose, and a 

sense of timing to intervene in particular ways 

at incisive moments (Miller and Rollnick, 1991, 

pp. 51–52). 

The clinician practices motivational 

interviewing with five general principles in 

mind:

1. Express empathy through reflective 

listening. 

2. Develop discrepancy between clients’ goals 

or values and their current behavior. 

3. Avoid argument and direct confrontation. 

4. Adjust to client resistance rather than

opposing it directly. 

5. Support self-efficacy and optimism. 

Express Empathy 

Empathy “is a specifiable and learnable skill for 

 another’s meaning through the 

use of reflective listening....It requires sharp 

attention to each new client statement, and the 

continual generation of hypotheses as to the

underlying meaning” (Miller and Rollnick, 1991, 

p. 20). An empathic style 

Communicates respect for and acceptance of 

clients and their feelings 

Encourages a nonjudgmental, collaborative 

relationship 

Allows you to be a supportive and 

knowledgeable consultant 

Sincerely compliments rather than denigrates 

Listens rather than tells 

Gently persuades, with the understanding 

that the decision to change is the client’s 

Provides support throughout the recovery 

process

Empathic motivational interviewing 

establishes a safe and open environment that is 

conducive to examining issues and eliciting 

personal reasons and methods for change. A 

fundamental component of motivational 

interviewing is understanding each client’s 

unique perspective, feelings, and values. Your 

attitude should be one of acceptance, but not

necessarily approval or agreement, recognizing 

that ambivalence about change is to be expected. 

Motivational interviewing is most successful 

when a trusting relationship is established 

between you and your client. 

Although empathy is the foundation of a 

motivational counseling style, it “should not be 

confused with the meaning of empathy as 

with the client or the sharing of 

common past experiences. In fact, a recent 

personal history of the same problem area...may 

compromise a counselor’s ability to provide the 

critical conditions of change” (Miller and 

Rollnick, 1991, p. 5). The key component to 

expressing empathy is reflective listening.

If you are not listening reflectively but are 

instead imposing direction and judgment, you 

are creating barriers that impair the therapeutic 

relationship (Miller and Rollnick, 1991). The

client will most likely react by stopping, 

diverting, or changing direction. Twelve 

examples of such nonempathic responses have 

been identified (Gordon, 1970):

Expressing Empathy 

Acceptance facilitates change. 

Skillful reflective listening is fundamental to expressing empathy. 

Ambivalence is normal. 

Miller and Rollnick, 1991. Reprinted with permission.
Expressing Empathy With Native American Clients 

For many traditional Native American groups, expressing empathy begins with the introduction. 

Native Americans generally expect the clinician to be aware of and practice the culturally accepted 

norms for introducing oneself and showing respect. For example, when first meeting a Navajo, the 

person often is expected to say his name, clan relationship or ethnic origin, and place of origin. 

Physical contact is kept to a minimum, except for a brief handshake, which may be no more than a soft 

touch of the palms. 

Ray Daw, Consensus Panel Member 

1. Direction is given with 

a voice of authority. The speaker may be in 

a position of power (e.g., parent, employer) 

or the words may simply be phrased and 

spoken in an authoritarian manner. 

2. These messages are 

similar to ordering but they carry an overt 

or covert threat of impending negative 

consequences if the advice or direction is not 

followed. The threat may be one the 

clinician will carry out or simply a 

prediction of a negative outcome if the client 

doesn’t comply—for example, “If you don’t 

listen to me, you’ll be sorry.” 

3.

The

message recommends a course of action 

based on the clinician’s knowledge and 

personal experience. These 

recommendations often begin with phrases 

such as, “What I would do is....” 

4.

The underlying assumption of these 

messages is that the client has not reasoned 

through the problem adequately and needs 

help to do so. 

5.

These statements contain such words 

as “should” or “ought” to convey moral 

instructions. 

6.

These messages imply that something is 

wrong with the client or with what the client 

has said. Even simple disagreement may be 

interpreted as critical. 

7. Surprisingly, 

praise or approval also can be an obstacle if 

the message sanctions or implies agreement 

with whatever the client has said. 

Unsolicited approval can interrupt the 

communication process and can imply an 

uneven relationship between the speaker 

and the listener. Reflective listening does 

not require agreement. 

8.

These messages express overt disapproval 

and intent to correct a specific behavior or 

attitude. 

9. Clinicians are 

frequently and easily tempted to impose 

their own interpretations on a client’s 

statement and to find some hidden, 

analytical meaning. Interpretive statements 

might imply that the clinician knows what 

the client’s problem is. 

10. 

Clinicians often want to make the client feel 

better by offering consolation. Such 

reassurance can interrupt the flow of 

communication and interfere with careful 

listening. 

11. Clinicians often 

mistake questioning for good listening. 

Although the clinician may ask questions to 

learn more about the client, the underlying 

message is that the clinician might find the 

right answer to all the client’s problems if 

enough questions are asked. In fact, 

intensive questioning can interfere with the 

spontaneous flow of communication and 
Expressing Empathy With African-American Clients 

One way I empathize with African-American clients is, first and foremost, to be a genuine person (not 

just a counselor or clinician). The client may begin the relationship asking questions about you the 

person, not the professional, in an attempt to locate you in the world. It’s as if the client’s internal 

dialog says, “As you try to understand me, by what pathways, perspectives, life experiences, and 

values are you coming to that understanding of me?” Typical questions my African-American clients 

have asked me are 

Are you Christian? 

Where are you from? 

What part of town do you live in? 

Who are your folks? 

Are you married? 

All of these are reasonable questions that work to establish a real, not contrived, relationship with 

the clinician. As part of a democratic partnership, the client has a right and, in some instances, a 

cultural expectation to know about the helper. 

On another level, African-Americans are a very spiritual people. This spirituality is expressed and 

practiced in ways that supersede religious affiliations. Young people pat their chests and say, “I feel 

you,” as a way to describe this sense of empathy. Understanding and working with this can enhance 

the clinician’s expression of empathy. In other words, the therapeutic alliance between the client and 

clinician can be deepened, permitting another level of empathic connection that some might call an 

intuitive understanding and others a spiritual connection to the client. What emerges is a therapeutic 

alliance—a spiritual connection—that goes beyond what mere words can say. The more clinicians 

express that side of themselves, whether they call it intuition or spirituality, the more intense the 

empathic connection the African-American client will feel. 

Cheryl Grills, Consensus Panel Member 

divert it in directions of interest to the 

clinician rather than the client. 

12.

Although humor may 

represent an attempt to take the client’s 

mind off emotional subjects or threatening 

problems, it also can be a distraction that 

diverts communication and implies that the 

client’s statements are unimportant. 

Ethnic and cultural differences must be 

considered when expressing empathy because 

they influence how both you and your client 

interpret verbal and nonverbal communications. 

Develop Discrepancy 

Motivation for change is enhanced when clients 

perceive discrepancies between their current 

situation and their hopes for the future. Your 

task is to help focus your client’s attention on 

how current behavior differs from ideal or 

desired behavior. Discrepancy is initially 

highlighted by raising your clients’ awareness of 

the negative personal, familial, or community 

consequences of a problem behavior and 

helping them confront the substance use that 

contributed to the consequences. Although 

helping a client perceive discrepancy can be 

difficult, carefully chosen and strategic reflecting 

can underscore incongruities. 
The Columbo Approach 

Sometimes I use what I refer to as the Columbo approach to develop discrepancy with clients. In the 

old “Columbo” TV series, Peter Falk played a detective who had a sense of what had really occurred 

but used a somewhat bumbling, unassuming Socratic style of querying his prime suspect, strategically 

posing questions and making reflections to piece together a picture of what really happened. As the 

pieces began to fall into place, the object of Columbo’s investigation would often reveal the real story. 

Using the Columbo approach, the clinician plays the role of a detective who is trying to solve a 

mystery but is having a difficult time because the clues don’t add up. The “Columbo clinician” 

engages the client in solving the mystery: 

Example #1: “Hmm. Help me figure this out. You’ve told me that keeping custody of your 

daughter and being a good parent are the most important things to you now. How does your heroin 

use fit in with that?” 

Example #2: “So, sometimes when you drink during the week, you can’t get out of bed to get to 

work. Last month, you missed 5 days. But you enjoy your work, and doing well in your job is very 

important to you.“ 

In both cases, the clinician expresses confusion, which allows the client to take over and explain 

how these conflicting desires fit together. 

The value of the Columbo approach is that it forces clients, rather than clinicians, to grapple with 

discrepancies and attempt to resolve them. This approach reinforces the notion that clients are the 

experts on their own behavior and values. They truly are the only ones who can resolve the 

discrepancy. If the clinician attempts to do this instead of the client, however, the clinician risks 

making the wrong interpretation, rushing to her own conclusions rather than listening to the client’s 

perspective, and perhaps most important, making the client a passive rather than an active participant 

in the process. 

Cheryl Grills, Consensus Panel Member 

Separate the behavior from the person and help 

your client explore how important personal 

goals (e.g., good health, marital happiness, 

financial success) are being undermined by 

current substance use patterns. This requires 

you to listen carefully to your client’s statements 

about values and connections to community, 

family, and church. If the client shows concern 

about the effects of personal behavior, highlight 

this concern to heighten the client’s perception 

and acknowledgment of discrepancy. 

Once a client begins to understand how the 

consequences or potential consequences of 

current behavior conflict with significant 

personal values, amplify and focus on this 

discordance until the client can articulate 

consistent concern and commitment to change. 

One useful tactic for helping a client perceive 

discrepancy is sometimes called the “Columbo 

approach” (Kanfer and Schefft, 1988). This 

approach is particularly useful with a client who 

prefers to be in control. Essentially, the clinician 

Developing Discrepancy 

Developing awareness of consequences helps clients examine their behavior. 

A discrepancy between present behavior and important goals motivates change. 

The client should present the arguments for change. 

Miller and Rollnick, 1991. 
expresses understanding and continuously 

seeks clarification of the client’s problems but 

appears unable to perceive any solution. A 

stance of uncertainty or confusion can motivate 

the client to take control of the situation by 

offering a solution to the clinician (Van Bilsen, 

1991).

Tools other than talking can be used to reveal 

discrepancy. For example, show a video and 

then discuss it with the client, allowing the client 

to make the connection to his own situation. 

Juxtaposing different media messages or images 

that are meaningful to a client can also be 

effective. This strategy may be particularly 

effective for adolescents because it provides 

stimulation for discussion and reaction. 

You can help your client perceive 

discrepancy on a number of different levels, 

from physical to spiritual, and in different 

domains, from attitudinal to behavioral. To do 

this, it is useful to understand not only what an 

individual values but also what the community 

values. For example, substance use might 

conflict with the client’s personal identity and 

values; it might conflict with the values of the 

larger community; it might conflict with 

spiritual or religious beliefs; or it might conflict 

with the values of the client’s family members. 

Thus, discrepancy can be made clear by 

contrasting substance-using behavior with the 

importance the clients ascribe to their 

relationships with family, religious groups, and 

the community. 

The client’s cultural background can affect 

perceptions of discrepancy. For example, 

African-Americans may regard addiction as 

“chemical slavery,” which may conflict with 

their ethnic pride and desire to overcome a 

collective history of oppression. Moreover, 

African-Americans may be more strongly 

influenced than white Americans by the 

expressed values of a larger religious or spiritual 

community. In a recent focus group study with 

adolescents, African-American youths were 

much more likely than other youths to view 

cigarette smoking as conflicting with their ethnic 

pride (Luke, 1998). They pointed to this conflict 

as an important reason not to smoke. 

Avoid Argument 

You may occasionally be tempted to argue with 

a client who is unsure about changing or 

unwilling to change, especially if the client is 

hostile, defiant, or provocative. However, trying 

to convince a client that a problem exists or that 

change is needed could precipitate even more 

resistance. If you try to prove a point, the client 

predictably takes the opposite side. Arguments 

with the client can rapidly degenerate into a 

power struggle and do not enhance motivation 

for beneficial change. When it is the client, not 

you, who voices arguments for change, progress 

can be made. The goal is to “walk” with clients 

(i.e., accompany clients through treatment), not 

“drag” them along (i.e., direct clients’ 

treatment). 

A common area of argument is the client’s 

unwillingness to accept a label such as 

“alcoholic” or “drug abuser.” Miller and 

Rollnick stated that 

[T]here is no particular reason why the 

therapist should badger clients to accept a 

label, or exert great persuasive effort in this 

direction. Accusing clients of being or 

Avoiding Arguments 

Arguments are counterproductive. 

Defending breeds defensiveness. 

Resistance is a signal to change strategies. 

Labeling is unnecessary. 

Miller and Rollnick, 1991. Reprinted with permission. 
 or is more likely to increase 

their resistance than to instill motivation for 

change. We advocate starting with clients 

wherever they are, and altering their selfperceptions, not by arguing about labels, but 

through substantially more effective means 

(Miller and Rollnick, 1991, p. 59). 

Although this conflicts with some clinicians’ 

belief that clients must be persuaded to selflabel, the approach advocated in the “Big Book” 

of Alcoholics Anonymous (AA) is that labels are 

not to be imposed (AA, 1976). Rather, it is a 

personal decision of each individual. 

Roll With Resistance 

Resistance is a legitimate concern for the 

clinician because it is predictive of poor 

treatment outcomes and lack of involvement in 

the therapeutic process. One view of resistance 

is that the client is behaving defiantly. 

Another, perhaps more constructive, viewpoint 

is that resistance is a signal that the client views 

the situation differently. This requires you to 

understand your client’s perspective and 

proceed from there. Resistance is a signal to you 

to change direction or listen more carefully. 

Resistance actually offers you an opportunity to 

respond in a new, perhaps surprising, way and 

to take advantage of the situation without being 

confrontational. 

Adjusting to resistance is similar to avoiding 

argument in that it offers another chance to 

express empathy by remaining nonjudgmental 

and respectful, encouraging the client to talk 

and stay involved. Try to avoid evoking 

resistance whenever possible, and divert or 

deflect the energy the client is investing in 

resistance toward positive change. 

How do you recognize resistance? Figure 3-2 

depicts four common behaviors that indicate 

that a client is resisting treatment. How do you 

avoid arguing and, instead, adapt to resistance? 

Miller and colleagues have identified and 

provided examples of at least seven ways to 

react appropriately to client resistance (Miller 

and Rollnick, 1991; Miller et al., 1992). These are 

described below. 

Simple reflection 

The simplest approach to responding to 

resistance is with nonresistance, by repeating 

the client’s statement in a neutral form. This 

acknowledges and validates what the client has 

said and can elicit an opposite response. 

Client: I don’t plan to quit drinking 

anytime soon. 

Clinician: You don’t think that abstinence 

would work for you right now. 

Amplified reflection 

Another strategy is to reflect the client’s 

statement in an exaggerated form—to state it in 

a more extreme way but without sarcasm. This 

can move the client toward positive change 

rather than resistance. 

Client: I don’t know why my wife is 

worried about this. I don’t drink 

any more than any of my friends. 

Clinician: So your wife is worrying needlessly. 

Double-sided reflection 

A third strategy entails acknowledging what the 

client has said but then also stating contrary 

things she has said in the past. This requires the 

use of information that the client has offered 

previously, although perhaps not in the same 

session. 

Client: I know you want me to give up 

drinking completely, but I’m not 

going to do that! 

Clinician: You can see that there are some real 

problems here, but you’re not 

willing to think about quitting 

altogether. 
Figure 3-2 

Four Types of Client Resistance 

Arguing

The client contests the accuracy, expertise, or integrity of the clinician. 

The client directly challenges the accuracy of what the clinician has said. 

The client questions the clinician’s personal authority and expertise. 

The client expresses direct hostility toward the clinician. 

Interrupting 

The client breaks in and interrupts the clinician in a defensive manner. 

The client speaks while the clinician is still talking, without waiting for an appropriate 

pause or silence. 

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. 

The client blames other people for problems. 

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. 

The client makes excuses for his behavior. 

The client claims that she is not in any danger (e.g., from drinking). 

The client suggests that the clinician is exaggerating risks or dangers and that it really 

isn’t so bad. 

The client makes statements about himself or others that are pessimistic, defeatist, or 

negative in tone. 

The client expresses reservations and reluctance about information or advice given. 

 The client expresses a lack of desire or an unwillingness to change. 

Ignoring 

The client shows evidence of ignoring or not following the clinician. 

The client’s response indicates that she has not been paying attention to the clinician. 

In answering a clinician’s query, the client gives a response that is not an answer to the 

question. 

The client gives no audible verbal or clear nonverbal reply to the clinician’s query. 

The client changes the direction of the conversation that the clinician has been 

pursuing.

 Miller and Rollnick, 1991. Adapted from a behavior coding system by Chamberlain et al., 1984. 

Reprinted with permission. 
Shifting focus 

You can defuse resistance by helping the client 

shift focus away from obstacles and barriers. 

This method offers an opportunity to affirm 

your client’s personal choice regarding the 

conduct of his own life. 

Client: I can’t stop smoking reefer when all

my friends are doing it. 

Clinician: You’re way ahead of me. We’re still 

exploring your concerns about 

whether you can get into college. 

We’re not ready yet to decide how 

marijuana fits into your goals. 

Agreement with a twist 

A subtle strategy is to agree with the client, but 

with a slight twist or change of direction that 

propels the discussion forward. 

Client: Why are you and my wife so stuck 

on my drinking? What about all 

problems? You’d drink, too, if your 

family were nagging you all the 

time.

Clinician: You’ve got a good point there, and

that’s important. There is a bigger 

picture here, and maybe I haven’t 

been paying enough attention to 

that. It’s not as simple as one 

person’s drinking. I agree with you 

that we shouldn’t be trying to place 

blame here. Drinking problems like 

these do involve the whole family. 

Reframing

A good strategy to use when a client denies 

personal problems is reframing—offering a new 

and positive interpretation of negative 

information provided by the client. Reframing 

“acknowledges the validity of the client’s raw 

observations, but offers a new meaning...for 

them” (Miller and Rollnick, 1991, p. 107). 

Client: My husband is always nagging me 

about my drinking—always calling 

me an alcoholic. It really bugs me. 

Clinician: It sounds like he really cares about 

you and is concerned, although he

expresses it in a way that makes you 

angry. Maybe we can help him 

learn how to tell you he loves you 

and is worried about you in a more 

positive and acceptable way. 

In another example, the concept of relative 

tolerance to alcohol provides a good 

opportunity for reframing with problem 

drinkers (Miller and Rollnick, 1991). Many 

heavy drinkers believe they are not alcoholics 

because they can “hold their liquor.” When you 

explain that tolerance is a risk factor and a 

warning signal, not a source of pride, you can 

change your client’s perspective about the 

meaning of feeling no effects. Thus, reframing is 

not only educational but sheds new light on the 

client’s experience of alcohol. 

Siding with the negative 

One more strategy for adapting to client 

resistance is to “side with the negative”—to take 

up the negative voice in the discussion. This is 

not “reverse psychology,” nor does it involve 

the ethical quandaries of prescribing more of the 

symptom, as in a “therapeutic paradox.” 

Typically, siding with the negative is stating 

Rolling With Resistance 

Momentum can be used to good advantage. 

Perceptions can be shifted. 

New perspectives are invited but not imposed. 

The client is a valuable resource in finding solutions to problems. 

Miller and Rollnick, 1991. Reprinted with permission. 
what the client has already said while arguing 

against change, perhaps as an amplified 

reflection. If your client is ambivalent, your 

taking the negative side of the argument evokes 

a “Yes, but...” from the client, who then 

expresses the other (positive) side. Be cautious, 

however, in using this too early in treatment or 

with depressed clients. 

Client: Well, I know some people think I 

drink too much, and I may be 

damaging my liver, but I still don’t 

believe I’m an alcoholic or in need 

of treatment. 

Clinician: We’ve spent considerable time now 

going over your positive feelings 

and concerns about your drinking, 

but you still don’t think you are 

ready or want to change your 

drinking patterns. Maybe changing 

would be too difficult for you, 

especially if you really want to stay 

the same. Anyway, I’m not sure 

you believe you could change even 

if you wanted to. 

Support Self-Efficacy 

Many clients do not have a well-developed 

sense of self-efficacy and find it difficult to 

believe that they can begin or maintain 

behavioral change. Improving self-efficacy 

requires eliciting and supporting hope, 

optimism, and the feasibility of accomplishing 

change. This requires you to recognize the 

client’s strengths and bring these to the forefront 

whenever possible. Unless a client believes 

change is possible, the perceived discrepancy 

between the desire for change and feelings of 

hopelessness about accomplishing change is 

likely to result in rationalizations or denial in 

order to reduce discomfort. Because selfefficacy is a critical component of behavior 

change, it is crucial that you as the clinician also 

believe in your clients’ capacity to reach their 

goals.

Discussing treatment or change options that 

might still be attractive to clients is usually 

helpful, even though they may have dropped 

out of other treatment programs or returned to 

substance use after a period of being substance 

free. It is also helpful to talk about how persons 

in similar situations have successfully changed 

their behavior. Other clients can serve as role 

models and offer encouragement. Nonetheless, 

clients must ultimately come to believe that 

change is their responsibility and that long-term 

success begins with a single step forward. The 

AA motto, “one day at a time,” may help clients 

focus and embark on the immediate and small 

changes that they believe are feasible. 

Education can increase clients’ sense of selfefficacy. Credible, understandable, and accurate 

information helps clients understand how 

substance use progresses to abuse or 

dependency. Making the biology of addiction 

and the medical effects of substance use relevant 

to the clients’ experience may alleviate shame 

and guilt and instill hope that recovery can be 

achieved by using appropriate methods and 

tools. A process that initially feels 

overwhelming and hopeless can be broken 

down into achievable small steps toward 

recovery.

Five Opening Strategies 

For Early Sessions 

Clinicians who adopt motivational interviewing 

as a preferred style have found that the five 

strategies discussed below are particularly 

useful in the early stages of treatment. They are 

based on the five principles described in the 

previous section: express empathy, develop 

discrepancy, avoid argument, adjust to rather 

than oppose client resistance, and support selfefficacy. Helping clients address their natural 

ambivalence is a good starting point. These 

opening strategies ensure your support for your 

client and help the client explore ambivalence in 
Self-Efficacy

Belief in the possibility of change is an important motivator. 

The client is responsible for choosing and carrying out personal change. 

There is hope in the range of alternative approaches available. 

Miller and Rollnick, 1991. Reprinted with permission. 

a safe setting. The first four strategies, which are 

derived from client-centered counseling, help 

clients explore their ambivalence and reasons 

for change. The fifth strategy is specific to 

motivational interviewing and integrates and 

guides the other four. 

In early treatment sessions, determine your 

client’s readiness to change or stage of change 

(see Chapters 1, 4, and 8). Be careful to avoid 

focusing prematurely on a particular stage of 

change or assuming the client is at a particular 

stage because of the setting where you meet. As 

already noted, using strategies inappropriate for 

a particular change stage or forming an 

inaccurate perception regarding the client’s 

wants or needs could be harmful. Therefore, try 

not to identify the goals of counseling until you 

have sufficiently explored the client’s readiness. 

Ask Open-Ended Questions 

Asking open-ended questions helps you 

understand your clients’ point of view and

elicits their feelings about a given topic or 

situation. Open-ended questions facilitate

dialog; they cannot be answered with a single 

word or phrase and do not require any 

particular response. They are a means to solicit 

additional information in a neutral way. Openended questions encourage the client to do most 

of the talking, help you avoid making premature 

judgments, and keep communication moving 

forward (see Figure 3-3). 

Listen Reflectively 

Reflective listening, a fundamental component 

of motivational interviewing, is a challenging 

skill in which you demonstrate that you have 

accurately heard and understood a client’s 

communication by restating its meaning. That 

is, you hazard a guess about what the client 

intended to convey and express this in a 

responsive statement, not a question. 

“Reflective listening is a way of checking rather 

than assuming that you what is meant” 

(Miller and Rollnick, 1991, p. 75). 

Reflective listening strengthens the empathic 

relationship between the clinician and the client 

and encourages further exploration of problems 

and feelings. This form of communication is 

particularly appropriate for early stages of

counseling. Reflective listening helps the client 

by providing a synthesis of content and process. 

It reduces the likelihood of resistance, 

encourages the client to keep talking, 

communicates respect, cements the therapeutic 

alliance, clarifies exactly what the client means, 

and reinforces motivation (Miller et al., 1992). 

This process has a tremendous amount of 

flexibility, and you can use reflective listening to 

reinforce your client’s positive ideas (Miller et 

al., 1992). The following dialog gives some 

examples of clinician’s responses that illustrate 

effective reflective listening. Essentially, true 

reflective listening requires continuous alert 

tracking of the client’s verbal and nonverbal 

responses and their possible meanings, 

formulation of reflections at the appropriate 

level of complexity, and ongoing adjustment of 

hypotheses.

Clinician: What else concerns you about your 

drinking?

Client: Well, I’m not sure I’m 

about it, but I do wonder sometimes 

if I’m drinking too much. 
Figure 3-3 

How To Ask Open-Ended Questions 

Closed Question Open Question 

So you are here because you are concerned about 

your use of alcohol, correct? 

Tell me, what is it that brings you here today? 

How many children do you have? Tell me about your family. 

Do you agree that it would be a good idea for you 

to go through detoxification? 

What do you think about the possibility of going 

through detoxification? 

First, I’d like you to tell me some about your 

marijuana use. On a typical day, how much do 

you smoke? 

Tell me about your marijuana use during a typical 

week.

Do you like to smoke? What are some of the things you like about 

smoking?

How has your drug use been this week, compared 

to last: more, less, or about the same? 

What has your drug use been like during the past 

week?

Do you think you use amphetamines too often? In what ways are you concerned about your use of 

amphetamines? 

How long ago did you have your last drink? Tell me about the last time you had a drink. 

Are you sure that your probation officer told you 

that it’s only cocaine he is concerned about in your 

urine screens? 

Now what exactly are the conditions that your 

probation officer wants you to follow? 

When do you plan to quit drinking? So what do you think you want to do about your 

drinking? 

Clinician: Too much for...? 

Client: 

Clinician: 

For my own good, I guess. I mean 

it’s not like it’s really serious, but 

sometimes when I wake up in the 

morning I feel really awful, and I 

can’t think straight most of the 

morning.

It messes up your thinking, your 

concentration. 

Client: Yes, and sometimes I have trouble 

Clinician: 

Client: 

remembering things. 

And you wonder if that might be 

because you’re drinking too much? 

Well, I know it is sometimes. 

Clinician: You’re pretty sure about that. But 

maybe there’s more.... 

Client: Yeah, even when I’m not drinking, 

sometimes I mix things up, and I 

wonder about that. 

Clinician: Wonder if...?

Client: If alcohol’s pickling my brain, I 

guess.

Clinician: You think that can happen to 

people, maybe to you. 

Client: Well, can’t it? I’ve heard that

alcohol kills brain cells.

Clinician: Um-hmm. I can see why that would 

worry you. 

Client: But I don’t think I’m an alcoholic or 

anything.

Clinician: You don’t think you’re that bad off,

but you do wonder if maybe you’re

overdoing it and damaging yourself

in the process. 
Client: Yeah.

Clinician: Kind of a scary thought. What else 

worries you? 

Summarize

Most clinicians find it useful to periodically 

summarize what has occurred in a counseling 

session. Summarizing consists of distilling the 

essence of what a client has expressed and 

communicating it back. “Summaries reinforce 

what has been said, show that you have been

listening carefully, and prepare the client to 

move on” (Miller and Rollnick, 1991, p. 78). A 

summary that links the client’s positive and 

negative feelings about substance use can 

facilitate an understanding of initial 

ambivalence and promote the perception of 

discrepancy. Summarizing is also a good way to 

begin and end each counseling session and to 

provide a natural bridge when the client is 

transitioning between stages of change. 

Summarizing also serves strategic purposes. 

In presenting a summary, you can select what 

information should be included and what can be 

minimized or left out. Correction of a summary 

by the client should be invited, and this often 

leads to further comments and discussion. 

Summarizing helps clients consider their own 

responses and contemplate their own 

experience. It also gives you and your client an 

opportunity to notice what might have been 

overlooked as well as incorrectly stated. 

Affirm

When it is done sincerely, affirming your client 

supports and promotes self-efficacy. More 

broadly, your affirmation acknowledges the 

difficulties the client has experienced. By

affirming, you are saying, “I hear; I

understand,” and validating the client’s 

experiences and feelings. Affirming helps 

clients feel confident about marshaling their 

inner resources to take action and change 

behavior. Emphasizing their past experiences 

that demonstrate strength, success, or power can 

prevent discouragement. For some clients, such 

as many African-Americans, affirmation has a 

spiritual context. Affirming their inner guiding 

spirit and their faith may help resolve their 

ambivalence. Several examples of affirming 

statements (Miller and Rollnick, 1991) follow: 

I appreciate how hard it must have been for 

you to decide to come here. You took a big 

step.

I think it’s great that you want to do 

something about this problem. 

That must have been very difficult for you. 

You’re certainly a resourceful person to have 

been able to live with the problem this long 

and not fall apart. 

That’s a good suggestion. 

It must be difficult for you to accept a day-today life so full of stress. I must say, if I were 

in your position, I would also find that 

difficult. 

Elicit Self-Motivational Statements 

Engaging the client in the process of change is 

the fundamental task of motivational 

interviewing. Rather than identifying the 

problem and promoting ways to solve it, your 

task is to help the client recognize how life 

might be better and choose ways to make it so. 

Remember that your role is to entice the 

client to voice personal concerns and intentions, 

not to convince him that a transformation is 

necessary. Successful motivational interviewing 

requires that clients, not the clinician, ultimately 

argue for change and persuade themselves that 

they want to and can improve. One signal that 

the client’s ambivalence and resistance are 

diminishing is the self-motivational statement. 

Four types of motivational statements can be 

identified (Miller and Rollnick, 1991): 

Cognitive recognition of the problem (e.g., “I 

guess this is more serious than I thought.”)
Affective expression of concern about the 

perceived problem (e.g., “I’m really worried 

about what is happening to me.”) 

A direct or implicit intention to change 

behavior (e.g., “I’ve got to do something 

about this.”) 

Optimism about one’s ability to change (e.g., 

“I know that if I try, I can really do it.”) 

Figure 3-4 illustrates how you can 

differentiate a self-motivational statement from 

a countermotivational assertion. You can 

reinforce your client’s self-motivational

statements by reflecting them, nodding, or 

making approving facial expressions and 

affirming statements. Encourage clients to 

continue exploring the possibility of change. 

This can be done by asking for an elaboration, 

explicit examples, or more details about 

remaining concerns. Questions beginning with 

“What else” are effective ways to invite further 

amplification. Sometimes asking clients to 

identify the extremes of the problem (e.g., 

“What are you most concerned about?”) helps to 

enhance their motivation. Another effective 

approach is to ask clients to envision what they 

would like for the future. From there, clients 

may be able to begin establishing specific goals. 

Figure 3-5 provides a useful list of questions 

you can ask to elicit self-motivational statements 

from the client. 

Effectiveness of 

Motivational

Interviewing

A recent review of 11 clinical trials of 

motivational interviewing concluded that this is 

a “useful clinical intervention...[and] appears to 

be an effective, efficient, and adaptive 

therapeutic style worthy of further 

development, application, and research” 

(Noonan and Moyers, 1997, p. 8). Motivational 

interviewing is a counseling approach that more 

closely reflects the principles of motivational 

enhancement than the variety of brief 

interventions reviewed in Chapter 2, and it also 

Figure 3-4 

How To Recognize Self-Motivational Statements 

Self-Motivational Statements Countermotivational Assertions 

I guess this has been affecting me more than I 

realized.

I don’t have any problem with marijuana. 

Sometimes when I’ve been using, I just can’t think 

or concentrate. 

When I’m high, I’m more relaxed and creative. 

I guess I wonder if I’ve been pickling my brain. I can drink all night and never get drunk. 

I feel terrible about how my drinking has hurt my 

family.

I’m not the one with the problem. 

I don’t know what to do, but something has to 

change.

No way am I giving up coke. 

Tell me what I would need to do if I went into 

treatment.

I’m not going into a hospital. 

I think I could become clean and sober if I decided 

to.

I’ve tried to quit, and I just can’t do it. 

If I really put my mind to something, I can do it. I have so much else going on right now that I 

can’t think about quitting. 
Figure 3-5 

Sample Questions To Evoke Self-Motivational Statements 

Problem Recognition 

What things make you think that this is a problem? 

What difficulties have you had in relation to your drug use? 

In what ways do you think you or other people have been harmed by your drinking? 

In what ways has this been a problem for you? 

How has your use of tranquilizers stopped you from doing what you want to do? 

Concern

What is there about your drinking that you or other people might see as reasons for concern? 

What worries you about your drug use? What can you imagine happening to you? 

How much does this concern you? 

In what ways does this concern you? 

What do you think will happen if you don’t make a change? 

Intention to Change 

The fact that you’re here indicates that at least part of you thinks it’s time to do something. 

What are the reasons you see for making a change? 

What makes you think that you may need to make a change? 

If you were 100 percent successful and things worked out exactly as you would like, what would be 

different?

What things make you think that you should keep on drinking the way you have been? And what 

about the other side? What makes you think it’s time for a change? 

I can see that you’re feeling stuck at the moment. What’s going to have to change?

Optimism

What makes you think that if you decide to make a change, you could do it? 

What encourages you that you can change if you want to? 

What do you think would work for you, if you needed to change? 

: Miller and Rollnick, 1991. Reprinted with permission. 

links these basic precepts to the stages-of-change 

model.

Of the 11 studies reviewed, 9 found 

motivational interviewing more effective than 

no treatment, standard care, extended treatment, 

or being on a waiting list before receiving the 

intervention. Two of the 11 studies did not 

support the effectiveness of motivational 

interviewing, although the reviewers suggested 

that the of this approach may not have 

been followed because the providers delivered 

advice in an authoritarian manner and may not 

have been adequately trained (Noonan and 

Moyers, 1997). Moreover, one study had a high 

dropout rate. Two studies supported the 

efficacy of motivational interviewing as a standalone intervention for self-identified concerned 

drinkers who were provided feedback about 

their drinking patterns but received no 

additional clinical attention. Three trials 

confirmed the usefulness of motivational 

interviewing as an enhancement to traditional 

treatment, five supported the effectiveness of 

motivational interviewing in reducing 
substance-using patterns of patients appearing 

in medical settings for other health-related 

conditions, and one trial compared a brief 

motivational intervention favorably with a more 

extensive alternative treatment for marijuana 

users. 

Motivational

Interviewing and 

Managed Care 

In addition to its effectiveness, motivational 

interviewing is beneficial in that it can easily be 

applied in a managed care setting, where issues 

of cost containment are of great concern. 

Motivational interviewing approaches are 

particularly well suited to managed care in the 

following ways: 

Low cost. Motivational interviewing was 

designed from the outset to be a brief 

intervention and is normally delivered in 

two to four outpatient sessions. 

Efficacy. There is strong evidence that 

motivational interviewing triggers change in

high-risk lifestyle behaviors. 

Effectiveness. Large effects from brief 

motivational counseling have held up across 

a wide variety of real-life clinical settings. 

Mobilizing client resources. Motivational 

interviewing focuses on mobilizing the 

client’s own resources for change. 

Compatibility with health care delivery.

Motivational interviewing does not assume a 

long-term client–therapist relationship. Even 

a single session has been found to invoke 

behavior change, and motivational 

interviewing can be delivered within the 

context of larger health care delivery 

systems.

Emphasizing client motivation. Client 

motivation is a strong predictor of change, 

and this approach puts primary emphasis on 

first building client motivation for change. 

Thus, even if clients do not stay for a long 

course of treatment (as is often the case with 

substance abuse), they have been given 

something that is likely to help them within 

the first few sessions. 

Enhancing adherence. Motivational

interviewing is also a sensible prelude to 

other health care interventions because it has 

been shown to increase adherence, which in 

turn improves treatment outcomes. 

4 From Precontemplation to 

Contemplation: Building 

Readiness

4HERE IS A MYTHxIN DEALING WITH SERIOUS HEALTH
RELATED

ADDICTIVExPROBLEMSTHATMOREISALWAYSBETTER-OREEDUCATIONMORE

INTENSE TREATMENT MORE CONFRONTATION WILL NECESSARILY PRODUCE MORE

CHANGE .OWHERE IS THIS LESS TRUE THAN WITH PRECONTEMPLATORS  -ORE

INTENSITY WILL OFTEN PRODUCE FEWER RESULTS WITH THIS GROUP  3O IT IS

PARTICULARLYIMPORTANTTOUSECAREFULMOTIVATIONALSTRATEGIESRATHERTHAN

TO MOUNT HIGH
INTENSITY PROGRAMSxTHAT WILL BE IGNORED BY THOSE

UNINTERESTED IN CHANGING THExPROBLEM BEHAVIORx 7E CANNOT MAKE

PRECONTEMPLATORS CHANGE BUT WE CAN HELP MOTIVATE THEM TO MOVE TO

CONTEMPLATION

DiClemente, 1991 

Before people enter treatment for related problems are. Moreover, these 

substance use or quit or moderate substance users may remain in a 

substance use on their own, they may precontemplation or early contemplation stage 

have been alerted by a crisis or series of for years, rarely or possibly never thinking 

escalating incidents that their current about change. Epidemiological studies indicate 

consumption pattern is an issue—at least to that only 5 to 10 percent of persons with active 

someone else. If a significant other or a family substance abuse disorders are in treatment or 

member describes their substance-using self-help groups at any one time (Stanton, 1997). 

behavior as problematic, substance users may One study estimated that at least 80 percent of 

react with surprise, hostility, denial, disbelief, persons with substance abuse disorders are 

or—occasionally—with acceptance. According currently in a precontemplation or 

to the stages-of-change model (presented in contemplation stage (DiClemente and 

Chapter 1), those who are not yet concerned Prochaska, 1998). 

about current consumption patterns, or Many scenarios present an opportunity for 

considering change, are in the precontemplation the clinician to help someone who is abusing or 

stage—no matter how much and how frequently dependent on a substance to start on a pathway 

they imbibe or how serious their substance use- toward change—to move from 


precontemplation to contemplation. By 

definition, no one at the precontemplation stage 

willingly walks into a substance abuse treatment 

program without some reservations, but people 

who are at this stage are sent to or bring 

themselves to treatment programs. The 

following situations might result in a call to a 

treatment facility by a substance user or by a 

person making a referral that could involve 

someone at this stage: 

A college coach refers an athlete for 

treatment after he tests positive for cocaine. 

A wife is desperate about her husband’s 

drinking and insists she will file for divorce 

unless he seeks treatment. 

A tenant is displaced from a Federal housing 

project for substance use. 

A driver is referred for treatment by the 

court for driving while intoxicated. 

A woman tests positive for substances 

during a prenatal visit to a public health 

clinic.

An employer sends an employee whose job 

performance has deteriorated to the 

company’s employee assistance program, 

and she is subsequently referred for 

substance abuse treatment. 

A physician in an emergency department 

treats a driver involved in a serious auto 

accident and discovers alcohol in his system. 

A family physician finds physical symptoms 

in a patient that indicate alcohol dependence 

and suggests treatment. 

A mother whose children have been taken 

into custody by a child protective services 

agency because they are neglected is told she 

cannot get them back until she stops using 

substances and seeks treatment. 

In each of these situations, those with an 

important relationship to the substance users 

have stated that the substance use is risky, 

dangerous, aberrant, or harmful to self or others. 

The substance users’ responses depend, in part, 

on their perception of the circumstances as well 

as the manner in which the facts are presented. 

They will be better motivated to moderate their 

substance use or to abstain (either solely 

through their own efforts or with the help of a 

treatment program), if these key persons offer 

relevant information in a supportive and 

empathic manner, rather than being judgmental, 

dismissive, or confrontational. Substance users 

often respond to overt persuasion with some 

form of resistance (Rollnick et al., 1992a). 

This chapter discusses a variety of proven 

techniques and gentle tactics that you, the 

clinician in a treatment facility, can use to raise 

the topic with people not thinking of change, to 

create client doubt about the commonly held 

belief that substance abuse is “harmless” and to 

lead to client conviction that substance-abuse is 

having, or will in the future have, significant 

negative results. An assessment and feedback 

process is an important part of the motivational 

strategy, informing your clients about how their 

personal substance use patterns compare with 

norms, what specific risks are entailed, and what 

damage already exists or is likely to occur if 

changes are not made. Many clinicians have 

succeeded in helping significant others act as 

mediators and use appropriate motivational 

strategies for intervening with close relations 

who are substance users. This chapter also 

discusses the following strategies for helping 

those in the precontemplation stage build their 

readiness to change: unilateral family therapy, 

the community reinforcement approach, and 

community reinforcement approach to family 

training. Constructive means of encouraging 

those clients mandated to enter treatment are 

described in this chapter as well. 

Raising the Topic 

You may find it difficult to believe that some 

persons entering treatment are unaware that 

their substance use is dangerous or causing 
Liver Transplantation: Precontemplation to Contemplation 

The client in precontemplation can appear in surprising medical settings. It is not uncommon for me to 

find myself sitting across from a patient with end-stage liver disease being evaluated for a liver 

transplant. From a medical perspective, the etiology of the patient’s liver disease appears to be 

alcoholic hepatitis, which led to cirrhosis. A variety of other laboratory and collateral information 

further supports a history of years of heavy alcohol consumption. The diagnosis of alcohol 

dependence is not only supported by the medical information but also is given greater clarity when the 

patient’s family indicates years of heavy drinking despite intensely negative consequences, such as 

being charged with driving while intoxicated and marital stress related to the drinking. Yet, despite 

what might seem to be an overwhelming amount of evidence, the patient himself, for a variety of 

dynamic and motivational reasons, cannot see himself as having a problem with alcohol. The patient 

may feel guilty that he caused his liver damage and think he doesn’t deserve this life-saving 

intervention. Or he may be fearful that if he examines his alcohol use too closely and shares his history 

he may not be considered for transplantation at all. He may even have already been told that if he is 

actively drinking he will not be listed for transplantation. 

It is particularly important at this point for me as a clinician not to be surprised or judgmental about 

the patient’s reluctance to see his problematic relationship with alcohol. The simple fact is that he has 

never connected his health problems with his use of alcohol. To confront the patient with the 

overwhelming evidence about his problem drinking only makes him more defensive, reinforces his 

denial, and intensifies his feelings of guilt and shame. 

During the assessment, I will take every opportunity to connect with the patient’s history and 

current situation without excessive self-disclosure. Being particularly sensitive to what the patient 

needs and what he fears, I will help support the therapeutic alliance by asking him to share the positive 

side of his alcohol and drug use thus acknowledging that from his perspective, his use has utility. 

In a situation such as this, it is not uncommon for me, after completing a thorough assessment, to 

provide the patient with a medical perspective on alcohol dependence. I will talk about the variance in 

brain chemistry, reward systems, issues of tolerance, genetic variables, and different enzymatic 

responses to alcohol, as well as other biological processes that support addictive disease, depending on 

the patient’s educational background and medical understanding. I may go into considerable detail. If 

the patient is less sophisticated, I will use analogies to other, more familiar diseases such as diabetes 

mellitus. As the patient asks questions, he begins to paint a new picture of addictive disease that 

allows him to see himself in that picture. By tailoring the presentation to each patient and encouraging 

questions throughout, I provide him and his family, if present, with important information about the 

biological factors supporting alcohol dependence. This knowledge often leads to self-diagnosis. 

This psychoeducational reframing gives the client a different perspective on his relationship with 

alcohol, taking away some of the guilt and shame that was based on a more moralistic understanding 

of the disease. The very act of self-diagnosis is a movement from precontemplation to contemplation. 

It can be accomplished by a simple cognitive reframe within the context of a thorough and caring 

assessment completed in a professional, yet genuinely compassionate manner. 

Jeffrey M. Georgi, Consensus Panel Member 

problems. It is tempting to assume that the 

client with obvious clinical signs of intense and 

long-term alcohol use must be contemplating or 

ready for change. However, such assumptions 

may be wrong. The new client could be at any 

point in the severity continuum (from mild 
problem use to more severe dependence), could 

have few or many associated health or social 

problems, and could be at any stage of readiness 

to change. The strategies you use for beginning 

a therapeutic dialog should be guided by your 

assessment of the client’s motivation and 

readiness. 

In opening sessions it is important to 

Establish rapport and trust 

Explore events that precipitated treatment 

entry

Commend clients for coming 

These recommendations are discussed 

further below. 

Establish Rapport and Trust 

Before you raise the topic of change with people 

who are not thinking about it, establish rapport 

and trust. The challenge is to create a safe and 

supportive environment in which the client can 

feel comfortable about engaging in authentic 

dialog. One way to foster rapport is first to ask 

the client for permission to address the topic of 

change; this shows respect for the client’s 

autonomy.

Next, tell the client something about how 

you or your program operates and how you and 

the client could work together. This is the time 

to state how long the session will last and what 

you expect to accomplish both now and over a 

specified time. Try not to overwhelm the new 

client at this point with all the rules and 

regulations of the program. Do specify what 

assessments or other formal arrangements will 

be needed, if appropriate. If there are 

confidentiality issues (discussed in more detail 

later in this chapter), these should be introduced 

early in the session. It is critical that you inform 

the client which information will be kept 

private, which can be released with permission, 

and which must be sent back to a referring 

agency. 

Because you are using a motivational 

approach, explain that you will not tell the client 

what to do or how and whether to change. 

Rather, you will be asking the client to do most 

of the talking—giving her perspective about 

both what is happening and how she feels about 

it. You can also invite comments about what the 

client expects or hopes to achieve. 

Then ask the client to tell you why she has 

come or mention what you know about the 

reasons, and ask for the client’s version or 

elaboration (Miller and Rollnick, 1991). If the 

client seems particularly hesitant or defensive, 

one strategy is to choose a topic of likely interest 

to the client that can be linked to substance use. 

A clue to such an interest might be provided by 

the referral source or can be ascertained by 

asking if the client has any stresses such as 

illness, marital discord, or overwork. This can 

lead naturally into questions such as “How does 

your use of...fit into this?” or “How does your 

use of...affect your health?” Avoid referring to 

the client’s “problem” or “substance abuse,” 

because this may not reflect her perspective 

about her substance use (Rollnick et al., 1992a). 

You are trying to understand the context in 

which substances are used and this client’s 

readiness to change. Of course, if you discover 

that she is contemplating or committed to

change, you can move immediately to strategies 

more appropriate to later change stages (see 

Chapters 5 and 6). 

An important point to state at the first 

session is whether or not you will work with a 

client who is obviously inebriated or high on 

drugs at the counseling sessions. You are not 

likely to receive accurate and reliable 

information from someone who has recently 

ingested a mind-altering substance (Sobell et al., 

1994). Many programs administer breath tests 

for alcohol or urine tests for drugs and 

reschedule counseling sessions if substances are 

detected at a specified level or if a client appears 

to be under the influence (Miller et al., 1992). 
Explore the Events That Precipitated 

Treatment Entry 

The emotional state in which the client comes to 

treatment is an important part of the or 

context in which counseling begins. Clients 

referred to treatment will exhibit a range of 

emotions associated with the experiences that 

brought them to counseling—an arrest, a 

confrontation with a spouse or employer, or a 

health crisis. People enter treatment shaken, 

angry, withdrawn, ashamed, terrified, or 

relieved—often experiencing a combination of 

feelings. Strong emotions can block change if 

you, the counselor, do not acknowledge them 

through reflective listening. The situation that 

led an individual to treatment can increase 

decrease defensiveness about change. 

It is important that your initial dialog be 

grounded in the client’s recent experience and 

that you take advantage of the opportunities 

provided to increase motivation. For example, 

an athlete is likely to be concerned about his 

continued participation in sports, as well as 

athletic performance; the employee may want to 

keep her job; and the driver is probably worried 

about the possibility of losing his driving 

license, going to jail, or injuring someone. The 

pregnant woman wants a healthy child; the 

neglectful mother probably wants to regain 

custody of her children; and the concerned 

husband needs specific guidance on convincing 

his wife to enter treatment. 

However, clients sometimes blame the 

referring source or someone else for coercing 

them into counseling. The implication is often 

that this individual or agency does not view the 

situation accurately. To find ways to motivate 

change, ascertain what the client sees and 

believes is true. For example, if the client’s wife 

has insisted he come and the client denies any 

problem, you might ask, “What kind of things 

seem to bother her?” Or, “What do you think 

makes her believe there is a problem associated 

with your drinking?” If the wife’s perceptions 

are inconsistent with the client’s, you may 

suggest that the wife come to treatment so that 

differences can be better understood. Similarly, 

you may have to review and confirm a referring 

agency’s account or the physical evidence 

forwarded by a physician to help you to 

introduce alternative viewpoints to the client in 

nonthreatening ways. If the client thinks a 

probation officer is the problem, you can ask, 

“Why do you think your probation officer 

believes you have a problem?” This enables the 

client to express the problem from the 

perspective of the referring party. It also 

provides you with an opportunity to encourage 

the client to acknowledge any truth in the other 

party’s account (Rollnick et al., 1992a). 

In opening sessions, remember to use all the 

strategies described in Chapter 3: Ask openended questions, listen reflectively, affirm, 

summarize, and elicit self-motivational 

statements (Miller and Rollnick, 1991). 

Commend Clients for Coming 

Clients referred for treatment may feel they have 

little control in the process. Some will expect to 

be criticized or blamed; some will expect you 

can cure them. Others will hope that counseling 

can solve all their problems without too much 

effort. Whatever their expectations, affirm their 

courage in coming by saying, “I’m impressed 

you made the effort to get here.” Praising their 

demonstration of responsibility increases their 

confidence that change is possible. You also can 

intimate that coming to counseling shows that 

they have some investment in the topic and an 

interest in change. For example, you can 

commend a client’s decision to come to 

treatment rather than risk losing custody of her 

child by saying, “You must care very much 

about your child.” Such affirmations subtly 

indicate to clients that they are capable of 

making good choices in their own best interest. 
Gentle Strategies To Use 

With the Precontemplator 

Once you have found a way to engage the client, 

the following strategies are useful for increasing 

the client’s readiness to change and encouraging 

contemplation. 

Agree on Direction 

In helping the client who is not yet thinking 

seriously of change, it is important to plan your 

strategies carefully and negotiate a pathway that 

is acceptable to the client. Some are agreeable to 

one option but not another. You honor your 

role as a clinician by being straightforward 

about the fact that you are promoting positive 

change. It also may be appropriate to give 

advice based on your own experience and 

concern. However, do ask whether the client 

wants to hear what you have to say. For 

example, “I’d like to tell you about what we 

could do here. Would that be all right?” 

Whenever you express a different viewpoint 

from that of the client, make clear that you 

intend to be supportive—not authoritative or 

confrontational. The client still has the choice 

about whether to heed your advice or agree to a 

plan. It is not necessary at this early stage in the 

process to agree on treatment goals. 

Types of precontemplators 

Persons with addictive behaviors who are not 

yet contemplating change can be grouped into 

four categories (DiClemente, 1991). Each 

category offers you guidance about appropriate 

strategies for moving clients forward: 

 lack sufficient 

knowledge about the dimensions of the 

problem, or the personal impact it can have, 

to think change is necessary. They often 

respond to sensitive feedback about how 

substance use is actually affecting their lives. 

are afraid of losing 

control over their lives and have a large 

investment in their substance of choice. Your 

challenge is to help them shift this energy 

into making more positive choices for 

themselves rather than rebelling against 

what they perceive as coercion. Emphasizing 

personal control can work well with this type 

of client. 

 feel hopeless about 

change and overwhelmed by the energy 

required. They probably have been in 

treatment many times before or have tried 

repeatedly to quit on their own to no avail. 

This group must regain hope and optimism 

about their capacity for change. This can 

sometimes be accomplished by exploring 

specific barriers that impede new beginnings. 

 have all the 

answers. Substance use may be a problem 

for others but not for them, because the odds 

are against their being at risk. Double-sided 

reflection, rather than reasoned argument, 

seems the most effective strategy for this type 

of client. Acknowledge what the client says, 

but add any qualms the client may have 

expressed earlier (see Chapter 3). 

Assess Readiness To Change 

When you meet the client for the first time, 

ascertain her readiness to change. This will 

determine what intervention strategies are likely 

to be successful. There are several ways to 

assess a client’s readiness to change. Two 

common methods are described below (see 

Chapter 8 for other instruments to assess 

readiness to change). 

Readiness Ruler 

The simplest way to assess the client’s 

willingness to change is to use a Readiness Ruler 

(see Chapter 8 and Figure 8-2) or a 1 to 10 scale, 

on which the lower numbers represent no 

thoughts about change and the higher numbers 

represent specific plans or attempts to change. 

Ask the client to indicate a best answer on the 

ruler to the question, “How important is it for 
you to change?” or, “How confident are you that 

you could change if you decided to?” 

Precontemplators will be at the lower end of the 

scale, generally between 0 and 3. You can then 

ask, “What would it take for you to move from 

an (lower number) to a (higher number)?” 

Keep in mind that these numerical 

assessments are not fixed, nor are they always 

linear. The client moves forward or backward 

across stages or jumps from one part of the 

continuum to another, in either direction and at 

various times. Your role is to facilitate 

movement in a positive direction. 

Description of a typical day 

Another, less direct, way to assess readiness for 

change, as well as to build rapport and 

encourage clients to talk about substance use 

patterns in a nonpathological framework, is to 

ask them to describe a typical day (Rollnick et 

al., 1992a). This approach also helps you 

understand the context of the client’s substance 

use. For example, it may reveal how much of 

each day is spent trying to earn a living and how 

little is left to spend with loved ones. By 

eliciting information about both behaviors and 

feelings, you can learn much about what 

substance use means to the client and how 

difficult—or simple—it may be to give it up. 

Substance use is the most cohesive element in 

some clients’ lives, literally providing an 

identity. For others it is powerful biological and 

chemical changes in the body that drive 

continued use. Alcohol and drugs mask deep 

emotional wounds for some, lubricate 

friendships for others, and offer excitement to 

still others. 

Start by telling the client, “Let’s spend the 

next few minutes going through a typical day or 

session of...use, from beginning to end. Let’s 

start at the beginning.” Clinicians experienced 

in using this strategy suggest avoiding any 

reference to “problems” or “concerns” as the 

exercise is introduced. Follow the client through 

the sequence of events for an entire day, 

focusing on both behaviors and feelings. Keep 

asking, “What happens?” Pace your questions 

carefully, and do not interject your own 

hypotheses about problems or why certain 

events transpired. Let clients use their own 

words and ask for clarification only when you 

do not understand particular jargon or if 

something is missing. 

Provide Information About the 

Effects and Risks of Substance Use 

Provide basic information about substance use 

early in the treatment process if clients have not 

been exposed to drug and alcohol education 

before and seem interested. Tell clients directly, 

“Let me tell you a little bit about the effects 

of...” or ask them to explain what they know 

about the effects or risks of the substance of 

choice. To stay on neutral ground, illustrate 

what happens to any user of the substance, 

rather than referring just to the client. Also, 

state what have found, not what

think happens. As you provide information, 

ask, “What do you make of all this?” (Rollnick et 

al., 1992a). 

It is sometimes helpful to describe the 

addiction process in biological terms to persons 

who are substance dependent and worried that 

they are crazy. Understanding facts about 

addiction can increase hope as well as readiness 

to change. For example, “When you first start 

using substances, it provides a pleasurable 

sensation. As you keep using substances, your 

mind begins to believe that you need these 

substances in the same way you need lifesustaining things like food—that you need them 

to survive. You’re not stronger than this 

process, but you can be smarter, and you can 

regain your independence from substances.” 

Similarly, people who have driven under the 

influence of alcohol may be surprised to learn 

how few drinks constitute legal intoxication and 

how drinking at these levels affects their 

responses. A young woman hoping to have 
children may not understand how substances 

can diminish fertility and potentially harm the 

fetus even before she knows she is pregnant. A 

client may not realize how alcohol interacts with 

other medications he is taking for depression or 

hypertension.

Use Motivational Language in 

Written Materials 

Remember that the effective strategies for 

increasing motivation in face-to-face contacts 

also apply to written language. Brochures, 

flyers, educational materials, and 

advertisements can influence a client to think 

about change. However, judgmental language 

is just as off-putting in these contexts as it is in 

therapy. For example, such words as “abuse” or 

“denial” may be turnoffs. All literature on the 

counseling services you provide should be 

written with motivation in mind. If your 

brochure starts with a long list of rules, the 

client may be scared away rather than 

encouraged to come in for treatment. Review 

written materials from the viewpoint of the 

prospective client and keep in mind your role as 

a partner in a change process for which the 

client must take ultimate responsibility. 

Create Doubt and Evoke Concern 

As clients move beyond a precontemplation 

stage and become aware of or acknowledge 

some problems in relation to their substance use, 

change becomes an increased possibility. Such 

clients become more aware of conflict and feel 

greater ambivalence (Miller and Rollnick, 1991). 

The major strategy for moving clients from a 

precontemplation to a contemplation stage is to 

raise doubts in them about the harmlessness of 

their substance use patterns and to evoke 

concerns that after all. 

One way to foster concern in the client is to 

explore the and aspects of 

substance use. Start with the client’s 

perceptions about the possible “benefits” of 

alcohol or drugs and move on a continuum to 

less beneficial aspects rather than setting up a 

dichotomy of or associated 

with substance use. If you limit the discussion 

to negative aspects of substance use, the client 

could end up defending the substance use while 

you become the advocate for unwanted change. 

In addition, the client may not be ready to 

perceive any harmful effects of substance use. 

By showing that you understand why the client 

values alcohol or drugs, you set the stage for a 

more open acknowledgment of emerging 

problems. For example, you might ask, “Help 

me to understand what you like about your 

drinking. What do you enjoy about it?” Then 

move on to ask, “What do you like less about 

drinking?” The client who cannot recognize any 

of the less good things related to substance use 

is probably not ready to consider change and 

may need more information. After this 

exploration, summarize the interchange in 

personal language so that the client can clearly 

hear any ambivalence that is developing: “So, 

using...helps you relax, you enjoy doing...with 

friends, and...also helps when you are really 

angry. On the other hand, you say you 

sometimes resent all the money you are 

spending, and it’s hard for you to get to work on 

Mondays” (Rollnick et al., 1992a). Chapter 5 

provides additional guidance on working with 

ambivalence. 

You can also move clients toward the 

contemplation stage by having them consider 

the many ways in which substance use can 

affect life experiences. For example, you might 

ask, “How is your substance use affecting your 

studies? How is your drinking affecting your 

family life?” As you explore the effects of 

substance use in the individual’s life, use 

balanced reflective listening: “Help me 

understand. You’ve been saying you see no 

need to change, and you also are concerned 

about losing your family. I don’t see how this 

fits together. It must be confusing for you.” 
Assessment and 

Feedback Process

Most treatment programs require that clients 

complete assessment questionnaires and 

interviews as part of the intake process. 

Sometimes these are administered all at once, 

which places a significant burden on the client 

and poses an obstacle to entering treatment. The 

program may request that the client go to one or 

more locations to complete the assessment, 

requiring the investment of considerable time 

and energy. Although the treatment counselor 

may conduct intake evaluations, assessments 

often are administered by someone the client 

does not know and may not see or be involved 

with again. Too often, programs do not use the 

results of intake evaluations for treatment 

planning but, rather, to confirm a diagnosis or to 

rule out physical or emotional problems that it 

cannot treat. 

More and more programs, however, now 

emphasize comprehensive evaluations along a 

number of dimensions that will help clinicians 

tailor care to individual needs and set priorities 

for treatment. The domains assessed usually 

depend on the types of clients treated and the 

kinds of services offered. For example, an innercity substance abuse treatment program will 

probably have more interest in an applicant’s 

criminal history, employment skills, housing 

arrangements, and HIV test results than an 

outpatient evening program for alcohol-abusing 

middle class professionals. 

Clinicians also have discovered that giving 

clients personal results from a broad-based and 

objective assessment, especially if the findings 

are carefully interpreted and compared with 

norms or expected values, can be not only 

informative but also motivating (Miller and 

Rollnick, 1991; Miller and Sovereign, 1989; 

Miller et al., 1992; Sobell et al., 1996b). This is 

particularly true for clients who misuse or abuse 

alcohol because there are social norms for 

alcohol use, and numerous research studies 

show levels beyond which consumption is risky 

in terms of specific health problems or physical 

reactions. The data are not so extensive for 

illegal drugs, although a similar approach has 

been used with marijuana users (Stephens et al., 

1994). Providing clients with personalized 

feedback on the risks associated with their

use of a particular substance and how their 

consumption pattern compares to norms— 

especially for their own cultural and gender 

groups—is a powerful way to develop a sense of 

discrepancy that can motivate change. When 

clients hear about their evaluation results and 

understand the risks and consequences, many 

come face to face with the considerable gap 

between where they are and where their values 

lie. 

Preparation for an Assessment 

Findings from an assessment can most readily 

become part of the therapeutic process if the 

client understands the practical value of 

objective information and believes the results 

will be helpful. Hence, you would most 

appropriately schedule formal assessments after 

the client has had at least one session with you 

so that you can lay the groundwork and 

determine the client’s readiness for change and 

potential responsiveness to personalized 

feedback. You then can explain what types of 

tests or questionnaires will be administered and 

what information these will reveal. You can also 

estimate how long this usually takes and give 

any other necessary instructions. If the client is 

not considering change and has not 

acknowledged any concerns or problems with 

substance use, you can agree that there might 

not be a problem but that the evaluation is 

designed to ascertain exactly what is happening. 

Just like a medical examination, the assessment 

can pinpoint places where there are—or may 

be—concerns and where some change might be 

considered. 
Content of an Assessment 

A variety of instruments and procedures may be 

used to evaluate clients. Eight major domains 

considered comprehensive in scope for 

assessing clients with primarily alcohol-related 

problems have been suggested (Miller and 

Rollnick, 1991). These eight domains are 

highlighted below. 

Substance use patterns 

The primary domain for assessment is drug and 

alcohol use, including the typical quantity 

currently consumed; frequency of use; mode of 

use (e.g., injection); and history of initiation, 

escalation, previous treatment, and last use. The 

questions should cover all legal substances 

(including prescription medications and 

nicotine) and illegal drugs. The Consensus 

Panel strongly recommends that you assess 

smoking patterns because of the welldocumented link between alcohol and nicotine 

use (Hurt et al., 1996). It is estimated that 80 to 

90 percent of all people with alcohol problems in 

the United States smoke cigarettes, compared 

with around 25 percent of the general adult 

population (Wetter et al., 1998). Furthermore, 

tobacco-related diseases have been found to be 

the leading cause of death in patients who have 

been treated for substance use (Hurt et al., 1996). 

Examining your client’s total pattern of 

substance use is essential to avoid substituting 

one harmful dependence for another. Since 

alcohol and drugs often are used in 

combination, it is important that you gain full 

information about which drugs are used, how 

they are used, and how they may interact. 

This information can be gathered by a variety 

of methods, including questionnaires, structured 

interviews that calculate averages by 

constructing a typical week of substance use and 

variations from this, day-by-day reconstructions 

guided by a calendar and prompted memory, or 

client self-monitoring with a daily diary or 

Alcohol Timeline Followback for a selected 

period of time (Miller et al., 1992; Sobell and 

Sobell, 1995a). TIP 24, 

 (CSAT, 

1997), provides more screening and assessment 

instruments. 

Dependence syndrome 

A related dimension for assessment is substance 

dependence, using criteria specified in the 

4th Edition (DSM-IV) (American 

Psychiatric Association, 1994). The usual 

elements probed are the development of 

tolerance demonstrated by the need for 

increased amounts of the substance to achieve 

the same effects; manifestation of characteristic 

withdrawal symptoms if the substance is 

stopped abruptly (e.g., amnesic events— 

blackouts, alcohol withdrawal, and delirium 

tremens); pursuing the substance at the expense 

of usual daily activities and despite serious 

consequences to health and safety; consumption 

of more of the substance and over a more 

prolonged time than intended; devoting 

excessive time to pursuit of the substance or 

recovery from use; and persistent and 

unsuccessful attempts to cut down or stop use. 

It is important that you know the severity of 

your client’s dependence to plan possible 

medical treatment and as an important indicator 

of outcome (Miller and Rollnick, 1991). 

Structured interview questions, such as those 

from the Structured Clinical Interview for DSMIV, may yield a more reliable and defensible 

diagnosis.

Life functioning problems 

Identification of problems occurring in an 

individual’s life, whether related to substance 

use or not, can point to other difficulties that 

require direct and immediate intervention. 

These could range from marital problems to 

domestic violence, unemployment, criminal 

charges, and financial crises. Screening 

instruments such as the Michigan Alcohol 
Screening Test (MAST), and CAGE are not good 

measures of current life problems, in part 

because they mix together a variety of 

dimensions (e.g., help seeking, pathological use, 

dependence, and negative consequences). 

Instruments specifically designed to assess 

substance-related problems are preferable. (For 

a review, see Allen and Columbus, 1995; Miller 

et al., 1995b.) 

Functional analysis 

A functional analysis probes the situations 

surrounding drug and alcohol use. Specifically, 

it examines the relationships among stimuli that 

trigger use and consequences that follow. This 

type of analysis provides important clues 

regarding the meaning of the behavior to the 

client, as well as possible motivators and 

barriers to change. See Chapter 7 for more 

information on functional analysis. 

Biomedical effects 

Unfortunately, drug and alcohol use do not have 

predictable effects on physical health because of 

the wide variability of individual response. 

Although there are a variety of biomedical 

measures of the impact of alcohol, such as blood 

chemistries and blood pressure screening, no 

conclusive diagnostic test or set of tests can 

verify a substance abuse disorder (Eastwood 

and Avunduk, 1994). However, certain 

indicators can lead you to become suspicious of 

excessive drug or alcohol use. Elevations in 

blood pressure or in certain enzymes, such a 

gamma-glutamyltransferase, aspartate 

aminotransferase, and alanine aminotransferase, 

are examples (Eastwood and Avunduk, 1994). 

A host of physiological concerns is associated 

with abusive use of alcohol and drugs. Almost 

all systems within the body can be affected. 

Neuropsychological effects 

Impaired memory and other cognitive effects 

may be either temporary or permanent 

consequences of alcohol and drug use. 

Although tests in this domain can be expensive 

and are not routinely ordered, feedback about 

impairment on such measures can provide a 

potent motivational boost because such 

information is novel and not available to the 

person from ordinary daily experience (Miller 

and Rollnick, 1991). However, because the 

impairment detected by the assessment may 

have preceded the substance use, use caution 

when providing feedback. (For reviews of 

appropriate tests, see Miller, 1985a, and Miller 

and Saucedo, 1983.) More information on how 

to screen and assess both physical and cognitive 

disabilities that might be mistaken for the results 

of substance use can be found in TIP 29, 

(CSAT, 1998). 

Family history 

Because risk for substance abuse and 

dependence is, in part, influenced by genetic 

factors, a complete family history of relatives on 

both sides who have experienced substancerelated problems or affective disorders, 

antisocial personality disorder, or attention 

deficit/hyperactivity disorder can be 

illuminating. Predisposition toward substancerelated problems does not predict a consequence 

of a substance abuse disorder, but risk can be an 

important warning signal and a motivator for 

clients to choose consciously to be free from 

addictive substances. 

Other psychological problems 

Abuse of alcohol and drugs is frequently 

associated with additional psychological 

problems, including depression, anxiety 

disorders, antisocial personality, sexual 

problems, and social skills deficits (Miller and 

Rollnick, 1991). Because symptoms of 

intoxication or withdrawal from some drugs 

and alcohol can mimic or mask symptoms of 

some psychological problems, it is important 

that a client remain abstinent for some time 

before psychological testing is conducted. Some 

psychological disorders respond well to 
different types of prescription medications, and 

it should be determined whether your client has 

a coexisting disorder and can benefit from 

simultaneous treatment of both disabilities. If 

you are not trained to assess clients for 

coexisting psychological disorders, and if your 

program is not staffed to handle such 

assessments or treatment, you should refer your 

clients to appropriate mental health programs or 

clinicians for assessment. For more information 

on assessing clients who have both a substance 

abuse disorder and an additional psychological 

problem, see TIP 9, 

(CSAT, 1994b). 

Personalize and Interpret Feedback 

About Assessment Results 

The presentation and discussion of assessment 

results can be pivotal for enhancing motivation; 

thus, structure this session thoughtfully and 

establish rapport before providing your clients 

with individual scores from the tests and 

questionnaires that were administered. First, 

express appreciation for clients’ efforts in 

providing the information. Ask if there were 

any difficulties. Inasmuch as answering 

questions or filling out forms can be revealing in 

itself, clients may already have a new perception 

about the role of substances in their lives. You 

can raise this point by asking, “Sometimes 

people learn surprising things as they complete 

an assessment. What were your reactions to the 

testing?” Make clear that you may need their 

help to interpret the findings accurately. 

Encourage them to ask questions: “I’m going to 

be giving you a lot of information. Please stop 

me if you don’t understand something or want 

more explanation. We have plenty of time 

today or in another session, if need be.” You 

may also want to stress the objectivity of the 

instruments used and give a bit of background, 

if appropriate, about how they are standardized 

and how widely they are used. It is also helpful 

to provide a written summary so that clients can 

have a copy. 

It is helpful in providing feedback to 

compare clients’ personal scores with normative 

data or other interpretive information. Clients 

must understand, for example, that their usual 

drinking level is above the normal range and 

that this is predictive of long-term risk for such 

negative consequences as stroke, liver cirrhosis, 

breast cancer for women, and all cancers for 

men (see Figure 4-1). Both the score and the 

interpretive explanation are important; neither is 

interesting or motivational in itself. The 

realization that, for instance, a high score of 23 

on the Alcohol Use Disorders Identification Test 

(AUDIT) indicates heavy—and problematic— 

drinking can raise questions for clients about 

what they previously thought was normal 

behavior (see Figure 4-2). The AUDIT is 

reproduced in Appendix B. 

Although clients are often already given 

handouts that contain extensive information, 

even minimal data should be presented in 

written form with accompanying explanations. 

Also, use a motivational style in presenting the 

information. Do not pressure clients to accept a 

diagnosis or offer unsolicited opinions about 

what a result might mean. Instead, preface 

explanations with such statements as, “I don’t 

know whether this will concern you, but...” or 

“I don’t know what you will make of this result, 

but....” Let them form their own conclusions, 

but help them along by asking, “What do you 

make of this?” or, “How do you feel about this?” 

When soliciting clients’ reactions, watch for 

nonverbal cues such as scowls, frowns, or even 

tears. Reflect these in statements such as, “I 

guess this must be difficult for you to accept 

because it confirms what your wife has been 

saying” or, “This must be scary” or, “I can see 

you are having a hard time believing all this” 

(Miller and Rollnick, 1991). 

Finally, summarize the results, including 

risks and problems that have emerged, clients’ 
&ROM0RECONTEMPLATIONTO#ONTEMPLATION


#HAPTER


reactions, and any self-motivational statements 

that the feedback has prompted. Then ask 

clients to add to or correct your summary. 

When presented in a motivational style, 

assessment data alone can move clients toward a 

new way of thinking about substance use and its 

consequences. If they still have difficulty 

accepting assessment results and maintain that 

consumption levels are not unusual, you can try 

the “Columbo approach” (see Chapter 3): “I’m 

confused. When we were talking earlier, there 

didn’t seem to be a problem. But these results 

suggest there is a problem, and these are usually 

considered pretty reliable tests. What do you 

make of this?” 

One good example of a format and 

description of the feedback process can be found 

in the Personal Feedback Report developed for 

Project MATCH (Miller et al., 1995c), 

reproduced in Appendix B. Another is the 

summary report, 

 (Sobell et al., 1996b) (parts of which are 

given in Figures 4-1 and 4-2), given to 

individuals who participate in Guided SelfChange—an assessment and feedback program 

developed for excessive drinkers who do not 

view their alcohol consumption as serious 

enough to warrant formal treatment but do 

agree to a checkup. The materials are intended 

to foster self-change by encouraging drinkers to 

view their alcohol use from a new perspective 

(Sobell and Sobell, 1998). 

For practitioners working in situations that 

do not allow an extensive drinking assessment, 

a free, personalized alcohol feedback program is 

available for use on the Internet. Three 

researchers (Drs. Cunningham, Humphries, and 

Koski-Jannes) have developed a program based 

on the materials used in the 

(Miller et al., 1995c) and 

the report 

(Sobell et al., 1996b). This program was formerly

accessible on the Web site of the Addiction 

Research Foundation, a division of the Centre 

for Addiction and Mental Health in Toronto, 

Canada (no longer available as of 2012 TIP update).

The respondent fills out a brief, 21-question survey 

about her drinking and submits the data. A personalized feedback report is returned that compares 

the respondent’s drinking to others of the same age, 

gender, and country of origin (for people living in

the United States or Canada). While brief, the

feedback program is a useful tool for practitioners

to use.

 Providing feedback—on clients’ level of 

alcohol or drug use compared with norms, 

health hazards associated with their level of use, 

costs of use at the current level, and similar 

facts—is sometimes sufficient to move 

precontemplators through a fairly rapid change 

process without further need for counseling and 

guidance. Feedback provided in a motivational 

style also enhances commitment to change and 

improves treatment outcomes. For example, one 

study in which persons admitted to a residential 

treatment center received assessment feedback 

and a motivational interview found these clients 

to be more involved in treatment, as perceived 

by clinicians, than a control group and to have 

twice the normal rate of abstinence at followup 

(Brown and Miller, 1993). 

Intervene Through 

Significant Others 

Considerable research shows that involvement 

of significant others (SOs) can help move 

substance users to contemplation of change, 

entry into treatment, retention and involvement 

in the therapeutic process, and successful 

recovery. An SO can play a vital role in 

enhancing an individual’s commitment to 

change by addressing a client’s substance use in 

the following ways: 

Providing constructive feedback to the client

about the costs and benefits associated with 

his substance use behavior 
Involving a Significant Other in the Change Process 

I have found that actively involving an SO such as a spouse, relative, or friend in motivational 

counseling can really help facilitate a client’s commitment to change. The SO can provide constructive 

input while the client is struggling with ambivalence about changing the addictive behavior. Feedback 

from the SO can help raise the client’s awareness of the negative consequences of substance use. At the 

same time, the SO can provide the requisite support in sustaining the client’s commitment to change. 

Before involving the SO, I routinely determine whether the SO has a positive relationship with the 

client and a genuine investment in contributing to the change process. SOs with strong ties to the client 

and an interest in helping the client change the substance-using behavior can make a valuable 

contribution toward change; those who lack these qualities can interfere with this process. Therefore, 

before involving the SO, I assess the interactions between the client and the SO. I am particularly 

interested in determining whether motivational statements made by the client are supported by the SO. 

Following this brief assessment, I employ a variety of commitment-enhancing strategies with the SO 

to help him facilitate the motivational process. I try to ask questions that will promote optimism on the 

part of the SO with regard to the client’s ability to change. For example, I may ask the SO the following 

questions: 

Have you noticed what efforts Jack has made to change his drinking? 

What has been most helpful to you in helping Jack deal with the drinking? 

What is different now that leads you to feel better about Jack’s ability to change? 

By using techniques such as eliciting self-motivational statements from the client, the SO can become 

a cofacilitator in the change process. 

Allen Zweben, Consensus Panel Member 

Encouraging the resolve of the client to 

change the negative behavior pattern 

Identifying the concrete and emotional 

obstacles to change 

Alerting the client to social and individual 

coping resources that lead to a substance-free 

lifestyle

Reinforcing the client for using these social 

and coping resources to change the substance 

use behavior 

Several recognized methods of involving SOs 

in motivational interventions are discussed in 

this section: involving them in counseling, in a 

face-to-face intervention, in family therapy, or as

part of a community reinforcement approach. 

Significant Others and 

Motivational Counseling 

In general, the SO helps to mobilize the client’s 

inner resources to generate, implement, and 

sustain actions that subsequently lead to a 

lifestyle that does not involve substance use. 

The SO is expected to move the client toward 

generating her own solutions for change. 

Nevertheless, it is important to remember that 

the ultimate responsibility for change lies with 

the client. 

An SO is typically a spouse, live-in partner, 

or other family member but can be any person 

who has maintained a close personal 

relationship with the client. Although a strong 

relationship is necessary, it is not sufficient for 

involving an SO in motivational counseling. 

Evidence indicates that a suitable candidate for 
SO-involved treatment is an individual who 

supports a client’s substance-free life and whose 

support is highly valued by the client 

(Longabaugh et al., 1993). 

Orient the client to SO-involved 

treatment

Ask a client about inviting an SO to a treatment 

session. Inform him that an SO can play a 

crucial role in addressing his substance use by 

providing emotional support, identifying 

problems that might interfere with treatment 

goals, and participating in activities that do not 

involve substances, such as attending church 

together. Explain that the SO is not asked to 

monitor the client’s substance use since the 

ultimate responsibility for change is the client’s. 

The SO’s role is entirely supportive, and the 

decisions and choices belong entirely to the 

client. Review confidentiality issues and tell the 

client that information shared between the 

partners should not be discussed with others 

outside of the sessions unless agreed on by both 

parties. Some settings may require a written 

statement giving permission for the SO to 

participate. 

Create a comfortable, supportive, 

and optimistic treatment 

environment

In the initial SO-involved session, compliment 

the SO and client for their willingness to work 

collaboratively and constructively on changing 

the client’s substance use pattern. Reiterate the 

rationale for asking the SO to participate and 

explain the roles and responsibilities of each of 

the partners, reminding them that the client is 

ultimately responsible for changing. Also, it is 

essential to instill a sense of optimism in the SO 

about her own ability to effect change in the 

client. Often, SOs enter treatment feeling

frustrated or disappointed; many do not 

understand the chronicity of the problem or the 

phases of recurrence and recovery, leading to 

increased frustration. As a result, the SO may 

feel helpless about her ability to influence the 

change process. To strengthen the SO’s belief 

about her capacity to help, you can use the 

following strategies: 

Positively connote the steps used by the SO 

which have been successful, and define 

successful generously. 

Reinforce positive comments made by the SO 

about the client’s current change efforts. 

Discuss future ways in which the client 

might benefit the SO’s efforts to facilitate 

change.

The overall goal at this point is to empower the 

SO in helping the client change. 

Provide constructive feedback 

In motivational counseling sessions, a positive 

movement toward change often occurs after the 

SO has had an opportunity to point out that 

continuing a current pattern of substance use 

could potentially interfere with sustaining a 

highly valued relationship. A client is 

particularly susceptible to an SO’s input because 

it can potentially lead to loss of or harm to 

important relationships. Explain to the client 

that the benefits of substance use cannot be 

obtained without increasing the social costs. 

The benefits might include enhancing 

pleasurable activities or coping resources; the 

costs entail loss of or harm to highly valued 

relationships. Consequently, the client may feel 

a state of disequilibrium over his continued 

substance use. To reduce the dissonance, the 

client must make a decision about stopping his 

substance use. In this context, the SO’s 

feedback becomes a major vehicle for activating 

the change process. 

For this reason, ask the SO to be more 

involved in the counseling; for example, by 

sharing relevant information about precipitants 

and consequences of the client’s substance use 

problem and working collaboratively with the 

client to find strategies for change. Such 

information must be communicated in a 
constructive manner. This is accomplished by 

focusing the discussion on the consequences or 

harm resulting from the drinking or drug use 

(e.g., family disruption) rather than on the client 

herself (e.g., “She is a bad person because of her 

drinking”). The feedback from the SO can cause 

a shift in the client’s decisional balance. 

Maintain a therapeutic alliance 

Special efforts should be made to strengthen ties 

between the SO and client, especially if the SO is 

a spouse. Having strong family ties is 

considered an active ingredient in sustaining a 

client’s commitment to change (Zweben, 1991).

Explore with the couple various activities that 

can contribute to improving the quality of the 

marital relationship, such as vacationing and 

dining out without the children. For some SOs, 

carrying out these tasks might become a cause of 

concern, especially if the client has a history of 

disrupting the household while using 

substances. The SO may be afraid that the client 

will once again destabilize the family situation if 

he is given major responsibilities in the home. 

(Such a concern may be realistic if the client has 

had an unstable pattern of recovery.) The 

counselor must acknowledge these concerns, 

normalize them, and develop an incremental 

plan for handling these new arrangements. A 

step-by-step approach should be introduced, 

including a procedure for handling recurrence if 

it occurs. This may prevent family members 

from feeling overwhelmed by the magnitude of 

the tasks involved in reintegrating the client into 

the household. 

Problematic SOs 

Despite proper screening, some SOs 

demonstrate little or no commitment to change. 

These SOs repeatedly miss treatment sessions, 

cancel appointments without rebooking, arrive 

late, and in general, display a negative attitude 

toward the client. Some interact negatively with 

the client, offering few constructive remarks 

without excessive prompting by the counselor. 

Others refuse to participate in substance-free 

activities. It is important to deal with these SOs 

before they pose serious problems in treatment. 

In such circumstances, consider the following: 

Gently remind the SO about the purposes of 

SO-involved treatment—namely, to offer 

emotional support, to provide constructive 

feedback, to reinforce incentives for change, 

and in general, to work collaboratively with 

the client to change the substance using 

behavior. 

Some SOs may be unaware of the anxiety 

they are feeling about the client’s ability and 

willingness to change, which in turn could 

account for the negative feelings being 

expressed to the client. In such 

circumstances, address these underlying 

concerns of the SO. Using such techniques as 

reflective listening, normalizing, clarifying, 

and summarizing, you can help the SO 

explore the underlying reasons for her 

negative reactions to the client. This strategy 

gives the SO an opportunity to vent her 

anxieties about the client. Otherwise the SO 

may continue to respond negatively (i.e., “act 

out” the anxiety) to the client in the sessions. 

These issues are usually addressed in an 

individual session with the SO. 

If the above approaches do not work, 

consider limiting the SO’s role to mainly 

information sharing. Inform the SO only 

about the proposed treatment plan for the 

client, such as attending self-help groups, 

taking medications, and completing specific 

tasks such as finding new employment. 

These matters could be covered in a single 

session with the option of adding another 

appointment if warranted. No attempt is 

made to involve the SO in reinforcing or 

decisionmaking activities related to changing 

the substance use behavior. For SOs 

requiring or requesting additional help, a

referral to individual counseling or a 

community support group such as Al-Anon 
may be in order. This can help the SO 

distance herself from the client’s problems 

and prevent her from undermining the 

therapeutic process. 

Research support 

Studies of brief motivational counseling have 

suggested that SO participation (mainly the 

spouse’s) can be an important factor 

contributing to the effectiveness of the 

intervention (Longabaugh et al., 1993; Sisson 

and Azrin, 1986; Zweben et al., 1988). Beginning 

with the work of Edwards, SO-involved brief 

motivational counseling has been found to be 

just as effective or more effective than more 

extensive conventional treatment approaches 

across a number of outcome measures, such as 

drinking and related problems (Edwards et al., 

1977; Holder et al., 1991; Zweben and Barrett, 

1993). All the studies were conducted with 

individuals having alcohol-related problems. 

Nonetheless, given the favorable outcomes 

found in the above studies and positive 

experiences reported by practitioners who have 

used the model with clients using other 

substances, consideration should be given to 

adding an SO-involved component to 

motivational counseling approaches with 

individuals having a variety of substance abuse 

problems. This can help augment the potency of 

the intervention with certain clients, namely 

those individuals who have strong positive ties 

with their families. 

However, the relative contributions of 

different components of brief motivational 

counseling (such as therapist empathy, feedback 

and advice, and bibliotherapy) to enhancing 

client motivation have not yet been determined 

(Zweben and Fleming, in press); it may be that 

such factors as therapist empathy could play a 

more salient role than SO involvement in 

effecting motivational change. Future research 

will have to further explore the relative 

contribution of the SO involvement component 

compared to the other treatment components 

(e.g., therapist empathy) in facilitating change. 

The Johnson Intervention 

Since its introduction in the 1960s, the approach 

developed by the Johnson Institute has been 

modified from a confrontational technique to a 

much less harsh strategy with numerous 

permutations (Stanton, 1997). The Johnson 

Intervention is a well-known technique in which 

family members and others from the user’s 

social network, after considerable formal 

training and rehearsal, confront the substance 

user in a clinician’s presence. They take turns 

telling the user how substance use has affected 

them, urge the user to seek help, and specify 

what consequences will occur if change— 

usually treatment entry—does not happen. An 

element of surprise is usually part of the plan. 

The basic assumptions outlined by the 

originator of this method are as follows 

(Johnson, 1973): 

Meaningful, influential persons present the 

user with facts or personal information. 

The data presented must be specific and 

descriptive of actual events or conditions, not 

opinions.

The tone of the confrontation should not be 

judgmental but reflect concern. 

The evidence presented should be tied 

directly to drinking or other substance use 

and given in some detail. 

The goal is that the substance user will see 

and accept enough facts to acknowledge the 

need for help. 

The user should be offered appropriate and 

available choices of treatment so that dignity 

is retained and decisionmaking capabilities 

are respected. 

Although the approach was originally 

applied to referrals for inpatient care (e.g., 28-

day, Minnesota model programs), it has 

subsequently been used by outpatient facilities. 
However, it has not been extensively evaluated, 

and the little research reflects a small number of 

participants. A recent study of people seeking 

help from a treatment center found that those 

who had experienced a Johnson Intervention 

were more likely to enter treatment than were 

those who were there as a result of coercion 

(e.g., by judge, employer, public assistance) or 

voluntary referral (Loneck et al., 1996a, 1996b). 

A major problem, however, is that as many as 75 

percent of families who begin counseling for a 

Johnson Intervention find it unacceptable or, for 

other reasons, fail to go through with the family 

confrontation meeting (Liepman et al., 1989). 

Families who complete a confrontation thus 

represent a minority, and it is among these 

families that 80 percent or more of drinkers 

enter treatment. It also has been reported that 

those who enter treatment after a Johnson

Intervention are more likely to have a recurrence 

of drinking and symptoms, relative to those 

entering treatment through other referral 

sources (Loneck et al., 1996b). 

Unilateral Family Therapy 

In unilateral family therapy (UFT), a counselor 

helps a cooperative, nonusing spouse identify 

and capitalize on opportunities to encourage the 

substance-using partner to change. This 

approach assumes the user’s spouse is “a vital 

and potentially crucial point of leverage who 

may be the main or only rehabilitative influence 

accessible to the therapist” (Thomas and Ager, 

1993). Different forms of unilateral family 

therapy are currently being used by clinicians, 

as described below. 

The Thomas and Ager 

Approach to UFT 

This approach includes descriptions of three foci 

of intervention for UFT for alcohol use 

disorders: 

 increases the coping skills 

of the nonusing spouse and helps him find 

specific ways to address the drinking 

problem.

 helps the spouse improve 

marital and family functioning by reducing 

both ineffective tactics of interaction with the 

substance-using partner (such as nagging or 

pouring out liquor) and enabling behaviors 

(such as buying alcohol). 

 entails preparing the 

spouse and other family members to conduct 

interventions that may motivate the person 

who drinks to seek treatment, stop drinking, 

or both (Thomas and Ager, 1993). 

As practiced by Thomas and associates, UFT 

has three phases. The first phase, requiring 

three to eight weekly sessions, prepares the 

spouse to assume a role in rehabilitation. The 

spouse is educated on the effects of alcohol; 

monitors the extent and timing of the partner’s 

drinking; learns how to enhance the marital 

relationship by trying out reinforcing, enjoyable 

behaviors when the person is not drinking; 

eliminates or modifies old and ineffective 

drinking control behaviors; and reduces 

enabling behaviors. 

The second phase, lasting 5 to 18 weeks, 

involves assessing the suitability and feasibility 

of different types of user-directed interventions 

that are tailored to the special characteristics of 

the resistant drinker, then conducting either 

nonconfrontational interventions (e.g., sobriety 

support or examination by a physician for 

alcohol abuse) or more systematic, wellrehearsed confrontations or requests in the 

presence of the clinician. The interventions are 

marked by their firm and compassionate tone. 

Followup interventions can occur if the drinker 

does not follow through on her commitment. 

The third phase, which entails three to six 

weekly sessions, focuses on maintaining spouse 

and partner gains. The nondrinking spouse 

receives help in adjusting to the partner’s 

sobriety—or reduced drinking—and learns to 

play a positive and appropriate role in deterring 
renewed or increased drinking (Thomas and 

Ager, 1993). 

Two studies of this approach to UFT indicate 

that the coping skills of participating spouses 

were improved, as indicated by reductions in 

associated life distress and psychopathology; the 

marital relationship was enriched, as indicated 

by measures of spousal happiness and 

adjustment; and the drinking persons who had 

mediating spouses also entered treatment and 

moderated drinking or became abstinent more 

frequently than did members of the control 

groups (Thomas and Ager, 1993). 

Orford’s Approach to UFT 

The World Health Organization has used 

Orford’s work to guide clinicians responding to 

the needs and pleas of family and friends of 

alcohol and drug users. This approach stresses 

that family and friends are at risk for stressrelated physical and psychological disorders 

(Orford, 1994). To understand how to empower 

them to deal effectively with their situation, as 

well as to help them bring the substance user 

into treatment, Orford studied coping strategies 

commonly used by families, each of which has 

advantages and disadvantages. The eight 

common strategies he identified are as follows: 

1. express emotion about 

use.

2. support use. 

3. neither support nor 

discourage use. 

4. put distance between 

oneself and the user. 

5. attempt to control use 

directly.

6. communicate openly 

about one’s own needs and the effects of

use.

7. help the person who

drinks or takes drugs achieve alternative 

goals such as family involvement.

8. show a lack of

dependence on the drinker or drug user. 

Orford concluded that “some of the ways in 

which relatives cope are better than others for 

reducing the risks of ill health for themselves” 

and for “influencing drinking or drug use” by 

the loved one (Orford, 1994, p. 428). Which 

strategies work best depends on a relative’s 

circumstances. Orford believes the clinician’s 

most important role is to help relatives find 

effective ways of coping that reduce the risk to 

their own health and help reduce the substanceusing person’s excessive use. To do this, 

clinicians should 

Listen nonjudgmentally and provide 

reassurance. 

Provide useful information. 

Counsel nondirectively about ways of 

coping.

Help strengthen social support and joint 

problem solving in the family. 

Community Reinforcement 

Approach

The Community Reinforcement Approach 

(CRA) is a comprehensive therapeutic system

originally developed in the 1960s to address a 

broad spectrum of areas affected by alcohol use, 

including unemployment, marital problems, 

social isolation, poorly developed social 

networks, and a lack of positive recreational 

activities (Hunt and Azrin, 1973). See also the 

forthcoming TIP, 

(CSAT, in press [a]). 

The CRA seeks to reduce or stop drinking by 

working through legitimate employment, family 

support, and social activities. In this behavioral 

treatment program, the clinician teaches a 

nondrinking family member—usually the 

spouse—the following skills: 

 by recognizing signs of 

possible violence and taking self-protective 

action.
 by reinforcing periods of 

sobriety through rewarding behavior and by 

allowing the drinker to experience negative 

consequences of drinking—as long as they 

are not life-threatening. The clinician 

counsels the family member on how to 

behave when drinking is occurring and 

provides suggestions about appealing 

outside activities that do not involve alcohol. 

 by 

identifying the best times to suggest seeking 

professional help (e.g., after occasions when 

the alcohol use was especially severe and the 

individual is keenly aware of the negative 

consequences of drinking). When the person 

who drinks agrees to come in, the clinician is 

available to meet with the marital couple 

immediately.

 by participating with the 

drinker in couples counseling and helping 

him find work and discover alcohol-free 

activities. The drinker also receives a 

medical exam and disulfiram (Antabuse). 

In a study of its effectiveness, this CRA 

required an average of 7.2 sessions compared 

with 3.5 for a more traditional program in which 

the clinician provided a spouse with supportive 

counseling and a referral to local Al-Anon selfhelp groups. Although requiring a greater time 

commitment, the CRA approach resulted in six 

of seven drinking persons entering treatment, 

whereas none entered treatment in the 

traditional approach (Sisson and Azrin, 1986). 

See Chapter 7 for discussion on the use of CRA 

during the maintenance stage. 

Community Reinforcement Approach 

to Family Training 

CRA has been modified by enhancing its proven 

features (Meyers and Smith, 1997). Referred to 

as the Community Reinforcement Approach to 

Family Training (CRAFT), this approach 

contends that a concerned SO can have an 

impact on a loved one’s drinking or drug use 

and can influence that person to enter treatment, 

if appropriate. See also the forthcoming TIP, 

(CSAT, in press [a]). Using this approach, 

the clinician’s tasks are to 

Encourage the SO to express frustration 

about the loved one’s substance use and also 

assure the participant that the responsibility 

for the situation lies with the person who 

drinks or takes drugs. 

Work with the SO to identify the triggers for 

and consequences of the loved one’s 

substance use and analyze these for ways in 

which the SO can modify coping responses. 

Identify positive reinforcers the SO can use 

when the user is sober or working toward 

change and negative consequences of 

substance use that the SO may have 

unknowingly supported. 

Teach the SO to recognize the potential for 

domestic violence in response to behavioral 

changes in the home and to take appropriate 

precautions that reduce the risk of harm. 

Train the SO in seven communication rules 

that have been found effective for interacting 

with persons who misuse alcohol and drugs: 

1. Be brief 

2. Be positive 

3. Be specific and clear 

4. Label your feelings 

5. Offer an understanding statement once an 

issue has been viewed from the drinker’s 

perspective

6. Accept partial responsibility, when 

appropriate

7. Offer to help 

Encourage the SO to find meaningful and 

rewarding activities that reduce stress and 

build a better quality of life regardless of 

whether the substance-using person changes. 

Coach the SO on nonthreatening ways to 

approach the loved one and suggest 

treatment through role-playing, rehearsing 

the language and voice tone to provide the 
best chance of success, and developing a 

“road map” of the best times to talk with the 

substance-using person. 

Make certain that treatment is available 

when a decision is made to begin treatment 

and also help the SO to support the client in 

treatment. 

A clinical trial of CRAFT found this approach 

to be substantially more effective than either AlAnon or the Johnson Intervention for engaging 

unmotivated problem drinkers and drug users 

in treatment (Miller and Meyers, in press). The 

combination of behavioral skills enhancement, 

well-chosen moments for bringing up the topic 

of change, techniques that the SO can use for 

positively reinforcing appropriate behavior by 

the drinking or drug-using loved one, and rapid 

intake into counseling are promising ways of 

moving precontemplators toward serious 

contemplation of change (Meyers and Smith, 

1997).

Albany-Rochester Interventional 

Sequence for Engagement 

The Albany-Rochester Interventional Sequence 

for Engagement (ARISE) was developed at a 

large outpatient treatment facility in Albany, 

New York. Following this approach, the 

clinician intervenes through family members 

with persons who abuse either drugs or alcohol, 

using a slower, less distressing way of 

introducing change rather than confrontation. 

The developers of this strategy were responding 

to three limitations of similar, currently 

available techniques: the expenditure of 

considerable time and effort in preparing for 

and rehearsing encounters with the substanceusing person; the ultimatums in full-blown, 

traditional interventions that frighten some 

family members away; and a recent study in 

which clients who participated in formal 

interventions were twice as likely as those who 

did not to return to drinking or drug use while 

in treatment (Stanton, 1997). 

The ARISE process unfolds through three 

stages: 

 When a concerned person calls the 

clinic, an intervention specialist talks to her 

by telephone to determine the family

configuration and to identify who should be 

involved. The clinician sets up a time to 

meet with all concerned persons, making 

clear that the substance user should also be 

invited.

 In one to three sessions, as needed, 

the clinician works with the family to 

determine how best to urge the substance 

user to engage in treatment. Usually, the 

clinician suggests they telephone this person 

from the meeting. 

 If neither Stage 1 

nor Stage 2 results in the substance user 

entering treatment, the clinician uses an 

intervention derived from the Johnson 

Institute model but less negative and more 

gentle than the original model. This 

intervention also incorporates attention to 

intergenerational patterns of alcohol 

problems.

In a retrospective analysis, 55 percent of drug 

users who participated in some phase of ARISE 

entered treatment, as did 70 percent of those 

with drinking problems. The success rates for 

other small studies of ARISE ranged from 25 to 

92 percent. Tentative conclusions are that the 

strategy works best when the clinician is readily 

available to catch the identified substance user 

at the right moment for enrolling in treatment 

and when a large number of persons are 

assembled for an intervention (Stanton, 1997). 
Motivational

Enhancement and 

Coerced Clients: Special 

Considerations

An increasing number of clients are mandated 

to begin treatment by an employer or employee 

assistance program. Others are influenced to 

enter treatment because of legal pressures. In 

such cases, failure to enter and remain in 

treatment may result in specified sanctions or 

negative consequences (e.g., job loss, probation 

or parole revocation, prosecution, prison), often 

for a specified time or until satisfactory 

completion. Although generalizations are 

difficult to make from a number of separate 

studies, legal status at treatment entry does not 

seem to be related to treatment success (Anglin 

et al., 1992; CSAT, 1995b; Leukefeld and Tims, 

1988). Mandated clients generally respond as 

well as those who are self-referred. 

Your challenge is to engage coerced clients in 

the treatment process. As noted by Leukefeld 

and Tims, external pressures (e.g., legal) serve to 

influence an individual into treatment, but 

motivation and commitment to change must 

come from within the client (internal pressure) 

in order to effect and maintain recovery 

(Leukefeld and Tims, 1988). Although many of 

these clients are at the precontemplation stage of 

change, the temptation is to use action-oriented 

interventions immediately that are not 

synchronized with the client’s motivation level. 

As already noted, this can be counterproductive. 

Clients arrive with strong emotions as a result of 

the referral process and the consequences they 

will face if they do not succeed in changing a 

pattern of use they may not believe is 

problematic. As always, remember that their 

perceptions may be accurate. It may be true that 

they rarely drink excessively but did so on a 

particular occasion that led to the referral. 

In spite of these obstacles, coerced clients are 

at least as amenable to a motivational 

counseling style as any other. If you provide 

interventions appropriate to their stage, they 

may become invested in the change process and 

benefit from the opportunity to consider the 

consequences of use and the possibility of 

change, although that opportunity was not 

voluntarily chosen. 

You may have to spend your first session 

with a coerced client “decontaminating” the 

referral process. Some clinicians say explicitly, 

“I’m sorry you came through the door this 

way.” Important principles to keep in mind are 

as follows: 

Honor the client’s anger and sense of 

dehumanization. 

Avoid assumptions about the type of 

treatment needed. 

Make it clear that you will help the client 

derive what the client perceives is needed 

and useful out of your time together. 

TIP 12,

(CSAT, 1994e), offers 

suggestions for engaging offender clients as full 

participants in their treatment and recovery. 

A critical requirement in working with 

coerced clients is establishing what information 

will be shared with the referring agency. This 

must be formalized with both clients and the 

agency through a written consent for release of 

information that adheres to Federal 

confidentiality regulations. Clients must be 

informed about and agree to exactly what 

information (e.g., attendance, urine test results, 

treatment participation) will be released. Be 

sure they understand what choices they have 

about the information to be released and what 

choices are not yours or theirs to make (e.g., 

information related to child abuse or neglect). 
An Opening Dialog With a Coerced Client 

This dialog illustrates the first meeting between a counselor and a client who is required to attend 

group therapy as a condition of parole. The clinician is seeking ways to affirm the client, to find 

incentives that matter to the client, to support the client in achieving his most important personal goals, 

and to help the client regain control by choosing to engage in treatment with a more open mind. 

The setting is an outpatient treatment program that accepts both private referrals and court-ordered 

referrals to an evening counseling group for substance users. The program uses a cognitive behavioral 

approach based on the work of Drs. Albert Ellis and Maxie Maultsby. The primary interventional tool 

is rational behavior training. This is the first session between the counselor and the court-ordered 

probation client. 

Counselor: Good morning. My name is Jeff. You must be Paul. 

Client: Yep.

Counselor: Come on in and sit wherever you’re comfortable. I received some information from your 

probation officer, but what would really be helpful to me is to hear from you, Paul, a little 

bit more about what’s going on in your life, and how we might help. 

Client: The biggest thing going on in my life is this 4-year sentence hanging over my head and all 

this crap I have to do to stay out of prison. 

Counselor: Well, again, Paul, it sounds like you’re busy and you have a lot of pressures, but I wonder 

if there’s something the program offers that you could use. 

Client: What I need from you is to get that blasted probation officer off my back. 

Counselor: I’m not exactly sure what you mean, Paul. 

Client: What I mean is that, I’m already running all over the place to give urine samples and meet 

all the other conditions of probation, and now I learn that the court says that in order for 

me not to go to jail, I’ve got to participate in this drug treatment program. 

Counselor: I’m still a little confused. What is it that I can do that might help? 

Client: You can tell my probation officer that I don’t need to be here in the first place and that she 

should stay out of my business. 

Counselor: I may be wrong, Paul, but as I understand the situation, that’s not an option for either one 

of us. I certainly want to support you so that you do not get in conflict with your 

probation officer. For you and her to be in an angry relationship seems to me a real recipe 

for disaster. Further, I get the sense from listening to you that you are really committed 

not only to yourself, but to your family, and the last thing that you really want to do is to 

wind up in prison facing that 4-year sentence. 

Client: You got that straight. 

Counselor: So it seems to me you’ve made some good choices so far. 

Client: What do you mean? 

Counselor: Well, you could have just blown this whole appointment off, but you didn't. You made a 

series of choices that make it clear to me that you’re committed to your family, yourself, 

your business, and for that matter your freedom. I can respect that commitment and 

would like to support you in honoring the choices you’ve already made. 

Client: Does that mean I‘m not going to have to come to these classes? 
An Opening Dialog With a Coerced Client (continued) 

Counselor: No, I don't have the power to make that kind of decision. However, you and I can work 

together to figure out how you might use this course to benefit you. 

Client: I can’t imagine getting anything out of sitting around with a bunch of drunks, talking 

about our feelings and whining about all the bad things going on in our lives. 

Counselor: You just don’t seem like a whiner to me. And in any case, that’s not what this group is 

about. What we really do is give people the opportunity to learn new skills and apply 

those skills in their daily lives to make their lives more enjoyable and meaningful. What 

you’ve already shown me today is that you can use some of those skills to support even 

further the good choices that you’ve already made. 

Client: Man, that’s just a bunch of shrink talk. I already told you, all I need is to get my probation 

officer off my back and live my life the way I want to live it. 

Counselor: Completing this program is going to help you do that. I think from what you’ve already 

demonstrated that you’ll do well in the group. I believe you can learn something that you 

can use in your daily life and perhaps teach some of the other people in the group as well. 

I am certainly willing to work with you to help you accomplish your goal in terms of 

meeting the requirements of probation. My suggestion is that you take it one group at a 

time and see how it goes. All I would ask of you is what, in a sense, you have already 

demonstrated, and that is the willingness to keep your mind open and keep your goals for 

life clearly in front of you. I see that you’re committed to your family, you’re committed to 

yourself, and you’re committed to your freedom. I want to support all three of those goals. 

Client: Well, I guess I can do this group thing at least for now. I’m still not sure what I’m going to 

get from sitting around with a bunch of other guys, telling stories, but I’m willing to give it 

a try.

Counselor: That sounds like a reasonable and, once again, another good choice to me, Paul. Let me 

give you a handbook that will tell you a little bit more about Rational Behavioral Training, 

and I’ll see you tomorrow night at 6:30 p.m. at this office for our first group. It’s been nice 

to meet you. I look forward to getting to know you better. 

Client: I'll see you tomorrow night. You know, this wasn’t as bad as I thought it would be. 

Jeffrey M. Georgi, Consensus Panel Member 

It is wise to take into account the role of the 

client’s defense attorney (if any) in releasing 

information. Finally, clearly delineate different 

levels of permission. 

Other publications in the TIP series provide 

more specific guidance regarding legal and 

ethical issues affecting coerced clients and how 

to handle confidentiality issues. See Chapter 8 

of TIP 17, 

(CSAT, 1995b); Chapter 5 of TIP 11, 

(CSAT, 1994d); TIP 12, 

(CSAT, 1994e); and TIP 30, 

 (CSAT, 1998b). 
5 From Contemplation to 

Preparation: Increasing 

Commitment

DiClemente, 1991 

This chapter describes strategies to as clients get closer to making a decision to 

increase clients’ commitment to change change. 

by enhancing their decisionmaking Exploring and setting goals can also be 

capabilities. Central to most of the strategies is effective in strengthening commitment, 

the process of eliciting and exploring through primarily because the process of envisioning 

open-ended questioning and reflective listening what one’s life would be like after change has 

skills, as described in earlier chapters. The been accomplished may strongly tip the 

chapter begins with a discussion of extrinsic decisional balance toward positive change. 

(external) and intrinsic (internal) motivation, Finally, the important role of self-efficacy in 

describing ways to help clients connect with client goal-setting is reemphasized. Although 

internal motivators to enhance decisionmaking these strategies are introduced here in linear 

and thereby commitment. The second section fashion, with each process of exploration 

focuses on decisional balancing strategies— unfolding from the last, in discussions with 

effective ways to explore the benefits and costs clients these processes can occur simultaneously 

of change and clients’ values about changes they or in a different order from that used here. For 

might make. The third section highlights the example, clients may begin to set goals or 

importance of personal choice and responsibility formulate a specific change plan (see Chapter 6) 
while continuing to explore their ambivalence 

(see Figure 5-1). 

Changing Extrinsic to 

Intrinsic Motivation 

To help your clients prepare for change, seek to 

understand the range of both extrinsic and 

intrinsic motivators that have brought them to 

this point. Many clients move through the 

contemplation stage acknowledging only the 

extrinsic motivators that push them to change— 

and that brought them to treatment. As 

discussed in Chapter 4, many different external 

motivators may cajole or coerce clients into 

treatment, including a spouse, an employer, a 

physician, or family and criminal courts. 

Although extrinsic motivators can be useful in 

bringing a client into treatment and increasing 

retention, self- or intrinsic motivation is 

important for substantive and abiding change. 

Intrinsic motivation often begins at the point 

when clients recognize the discrepancies 

between “where they are” and “where they 

want to be.” An intensive exploration of life 

goals and deep-seated values can be a way to 

strengthen internal motivation. Some clients, as 

they mature, cast off the rebelliousness or 

apparent nonchalance of adolescence to explore 

more existential concerns such as, 

and In searching for answers, 

clients often reevaluate past mistakes and 

activities that were self-destructive or harmful to 

others. You can encourage this soul-searching 

through reflective listening. Then, through 

motivational strategies, you can promote the 

client’s recognition of discrepancies between the 

current situation and hopes for the future. As 

described in earlier chapters, this awareness of 

disparities often creates a strong desire to 

improve. This is an essential source of selfmotivation for positive change. 

Sometimes intrinsic motivation emerges 

from role conflicts and family or community 

expectations. For example, a mother who has 

lost custody of children because of substance 

use may have a strong motivation to fulfill her 

role as a good mother. Other clients’ chronic 

substance use severs cultural or community ties; 

they stop going to church or neglect culturally 

affirmed roles such as helping others or serving 

as role models for young people. A yearning to 

reconnect with cultural traditions as a source of 

identity and strength can be a powerful 

Figure 5-1 

Tips for Moving Clients Through Contemplation to Preparation 

Do not rush your clients into decisionmaking. 

Emphasize client control: “You are the best judge of what will be best for you.” 

Acknowledge and normalize ambivalence. 

Examine options rather than a single course of action. 

Describe what other clients have done in a similar situation. 

Present information in a neutral, nonpersonal manner. 

Remember that inability to reach a decision to change is not a failed consultation. 

Make sure that your clients understand that resolutions to change often break down; clients should 

not avoid future contact with you if things go wrong. 

Expect fluctuations in your client’s commitment to change—check commitment regularly and 

express empathy concerning the client’s predicaments. 

 Rollnick et al., 1992a. 
Linking Family, Community, and Cultural Values to a Desire for Change 

Working with a group of Hispanic men in the Southwest who were mandated into treatment as a 

condition of parole and had spent most of their lives in prisons, we found that as these men aged, they 

seemed to tire of criminal life. In counseling, some expressed concerns about losing touch with their 

families and culture, and many articulated a desire to serve as male role models for their sons and 

nephews. They all wanted to restore their own sense of pride and self-worth in the small community 

where many of their families had lived for generations. Newly trained in motivational interviewing, 

we recognized a large, untapped reservoir of self-motivation in a population that we had long before 

concluded did not want help. We had to change our previous conceptions of this population as not 

wanting treatment to seeing these men as requesting help and support to maintain themselves outside 

of the prison system and in the community. 

Carole Otero, Consensus Panel Member 

motivator for some clients, as can the desire to 

regain others’ respect. Positive change also 

leads to improved self-image and self-esteem. 

Helping clients change extrinsic to intrinsic 

motivation is an important part of helping them 

move from contemplating change to deciding to 

act. Start with the client’s current situation and 

find a natural link between existing external 

motivators and intrinsic ones the client may not 

be aware of or find easy to articulate. Through 

sensitive and respectful exploration, untapped 

intrinsic motivation may be discovered even in 

clients who seem unlikely to become selfmotivating. 

In addition to standard practices for 

motivational interviewing, several other 

strategies are useful for identifying and 

strengthening intrinsic motivation. First, show 

curiosity about your clients. Show interest and 

maintain this attention over time. Because 

clients’ desire to change is rarely limited to 

substance use, they may find it easier to talk 

about changing other behaviors. Most clients 

have concerns about several functional areas of 

their lives and wish they could reconnect with 

the community, improve their finances, find 

work, or fall in love. Many are highly functional 

and productive in some aspects of their lives 

and take great pride in special skills, knowledge, 

or other competencies they do not want to 

jeopardize. Do not wait for clients to talk 

spontaneously about their troubles or 

capabilities. Show interest and ask about how 

their substance use affects these aspects of their 

lives. Even with clients who do not 

acknowledge any problems, question them 

about their lives to show concern and thus 

strengthen the therapeutic alliance. 

Another useful strategy is to reframe clients’ 

negative statements about perceived coercion by 

re-expressing their resentment with a positive 

connotation. A classic example is to reinterpret 

a client’s hostility toward a threatening wife as a 

manifestation of his continued caring and 

investment in the marriage, which is pushing 

him to resolve and change the problem behavior 

and save the relationship. 

Clients who were openly coerced into 

entering treatment pose a special challenge. 

With these clients, identify and strengthen 

intrinsic motivation so that change can come 

from within, rather than from external threats. 

Not only can external threats provoke resistance, 

but any achieved change may collapse if the 

threatened contingencies do not happen—if, for 

example, the threat of divorce or separation is 

not carried out by the wife when her husband’s 

drinking resumes, or a parole officer does not 

revoke a client’s freedom when the released 

offender fails to continue treatment. These 
clients must choose positive change of their own 

free will because change makes good sense and 

is desired, not because a punishment might be 

exacted if a violation is detected. 

Tipping the Decisional 

Balance

In moving toward any decision, most people 

weigh the costs and benefits of the action being 

contemplated. In behavioral change, these 

considerations are known as ,

a process of cognitively appraising or evaluating 

the “good” aspects of substance use—the 

reasons to change, and the less good 

aspects—the reasons change. Research on 

self-change has shown that many people who 

have successfully modified addictive behaviors 

view this appraisal process as important to the 

resolution of their substance use problems 

(Sobell et al., 1996b). 

At some point in the decisionmaking process, 

the decisional balance is redistributed, and a 

decision is made. The objective in moving a 

client toward positive change, of course, is to 

help that person recognize and weigh negative 

aspects of substance use so that the scale tips 

toward beneficial behavior. In examining ways 

in which people make major life changes, 

Baumeister described the inner process that 

seems to occur when the decisional balance is 

weighted toward change as a “crystallization of 

discontent” (Baumeister, 1994). He notes that it 

involves a conscious linking, perhaps for the 

first time, of perceptions regarding costs, 

problems, and other undesirable features of a 

situation. This conscious linking of negative 

aspects changes the person’s perception of a 

situation “so that a broad pattern of 

dissatisfaction and shortcoming is discerned.” 

See Chapter 8 for tools to use in decisional 

balancing exercises. 

How do you shift the balance to the side of 

positive change and away from the status quo or 

negative change? Sobell and colleagues 

identified four overall objectives in using 

exercises to shift decisional balance with clients 

(Sobell et al., 1996b). The intent of such 

exercises, which weigh substance use and 

change separately, is to 

Accentuate or in a subtle manner make 

salient from the client’s perspective the costs 

of the client’s substance use. 

Lessen, when possible, the perceived 

rewards of substance use. 

Make the benefits of change apparent. 

Identify and attenuate, if possible, potential 

obstacles to change. 

Summarize Concerns 

If you have successfully elicited a client’s 

concerns while providing personalized feedback 

after an assessment (see Chapter 4) or while 

exploring intrinsic and extrinsic motivations, 

you have gathered important information for 

influencing your client’s decisional balance. 

You have a working knowledge, and perhaps 

even a written list, of issues and areas about 

which the client has negative feelings and which 

are important intrinsic motivators. A first step 

in helping the client to weigh the pros and cons 

is to organize the list of concerns and present 

them to the client in a careful summary that 

expresses empathy, develops discrepancy, and 

weights the balance toward change. Because it 

is important to reach agreement on these issues, 

the summary should end by asking whether 

your client agrees that these are her concerns. 

Explore Specific Pros and Cons 

Weighing benefits and costs of substance use 

and of change is at the heart of decisional 

balance work. Some clinicians find it helpful to 

ask the client to write out a two-column list. 

This can be done as homework and discussed 

during the session, or the list can be generated 

during a session. Some programs use a 

worksheet for listing pros and cons preprinted 
on two-copy carbonless paper so that clients can 

take one copy home and leave the other with the 

clinician for later use or revision during future 

sessions. A written list helps some clients 

quantify the factors going into the decision. 

Seeing a long list of reasons to change and a 

short list of reasons not to may finally upset the 

balance. On the other hand, a long list of 

reasons not to change and a short list of reasons 

to change can indicate how much work still 

must be done and can avert premature 

decisionmaking. Quantity is not the only 

determinant. Many clients find that one or two 

reasons not to change counterbalance the weight 

of a dozen reasons to change, creating powerful 

ambivalence. Knowledge about the true 

strength of each opposing force is important. 

Remember, too, that the reasons for and against 

continuing substance use—or the positive and 

negative aspects of change—are highly 

individual and emotional rather than rational. 

Factors that shift the balance toward positive 

change for one person may scarcely matter to 

another. Moreover, the value or weight given to 

a particular item in this inventory of pros and 

cons is likely to change over time. 

Whether or not you use a written worksheet, 

always listen carefully when clients express 

ambivalence and highlight their reasons for 

opposing change or thinking change is 

impossible. Encouraging clients to openly 

clarify and state their attraction to substances 

can be fruitful because they seldom have a 

chance in treatment programs to examine what 

they like or enjoy about substance use. In 

addition, asking clients to express what they like 

about substance use (e.g., that it is enjoyable, 

sociable, exciting) establishes rapport and 

reassures the client of your nonjudgmental 

perspective. Starting with positive aspects of 

substance use also seems to lead clients 

spontaneously to discussing what is 

about substance use (Saunders et al., 1991). 

Information about why substance use is 

attractive is helpful for judging the client’s 

degree of commitment and sense of self-efficacy. 

For example, some clients may enjoy little about 

substance use, and their ambivalence stems 

from a strong belief that they cannot change. 

Work with such a client will proceed along 

different lines than with a client who describes 

substance use in highly attractive terms and sees 

little reason to change. 

Another reason some clients cling to 

excessive substance use is pharmacological 

dependence. Some substances, including high 

levels of alcohol and barbiturates, have rebound 

effects of withdrawal that can be not only 

unpleasant but also dangerous. Tolerance— 

needing more of the substance to achieve the 

same effect—also explains why some users of 

sleeping pills or tranquilizers, for example, 

increase doses beyond the prescribed level. 

Habits developed in relation to drug taking or 

drinking are another powerful source of 

attachment to a substance and are difficult to 

break. The feeling of a glass in the hand when 

socializing at a party comes to be associated 

with relaxation and conviviality. Smokers may 

not know what to do with their hands or want 

some object in their mouths when they are 

trying to quit cigarette smoking. 

Although your client’s initial reasons for 

wanting to change may be few, each reason is 

important and should be explored and 

supported. Because support for change is often 

linked to a client’s intrinsic motivators, 

reviewing these may elicit more items for the 

positive side of the balance sheet. As noted 

earlier, concerns about identity, roles, selfesteem and self-image, and returning to 

traditional cultural or family values may be 

linked to specific reasons for change. 

Doing a decisional balance exercise with 

clients has yet another constructive function. 

Clients are forced to take both sides of the 

argument about change and articulate the 
competing sides of their ambivalence. This can 

be a complex process, however, requiring 

persistence and reanalysis of each factor several 

times as clients vacillate between determination 

and ambivalence. 

Normalize Ambivalence 

Clients engaged in decisional balance exercises 

often feel themselves moving closer to a 

decision—closer to changing long-standing 

behaviors than they may ever have ventured 

and, therefore, closer to inner conflict and doubt 

about whether they can or want to change. An 

important strategy at this point is to reassure 

your client that conflicting feelings, 

uncertainties, and reservations are common. 

Essentially, you normalize your client’s 

ambivalence by explaining that many former 

clients have experienced similar strong 

ambivalence at this stage, even when they 

believed they had resolved most of their mixed 

feelings and were nearing a decision. Clients 

need your reassurance that many other people 

who have reached this point and seemed 

suddenly to lose their nerve have been able to 

recover their direction by continuing the work 

of exploration and discussion. 

Reintroduce Feedback 

As discussed in Chapter 4, personalized 

feedback following assessment can be very 

helpful in motivating clients. You can continue 

to use assessment results to influence clients’ 

decisional considerations. Objective medical, 

social, and neuropsychological feedback from 

the assessment prompts many clients to 

contemplate change. Reviewing the assessment 

information can keep clients focused on the 

need for change. It has been noted that clients 

may become uneasy when the clinician seems 

more invested in their changing than they are 

(DiClemente and Scott, 1997). By reintroducing 

objective assessment data, you remind clients of 

their earlier insights about the need for change. 

For example, a client may be intrinsically 

motivated to stop excessive drinking because of 

health concerns, yet overwhelmed by fear that 

quitting will prove impossible. Reintroducing 

feedback from the medical assessment about the 

risk of serious liver damage or a family history 

of heart disease could add significant additional 

weight to the decisional balance. 

Examine the Client’s Understanding 

Of Change and Expectations of 

Treatment

In working toward a decision, it is important to 

understand what change means to clients and 

what their expectations of treatment are. Some 

clients believe that quitting or cutting down 

means changing their entire life—moving from 

their neighborhood or severing ties with all their 

friends, even their family. Some believe they 

have to change everything overnight—an 

overwhelming prospect. Based on friends’ 

experiences with treatment, some may think 

treatment involves stays of several weeks in an 

inpatient program or even longer sojourns in a 

residential treatment facility or that the leader of 

a therapy group will use confrontational 

methods in an attempt to “break them down,” 

as in boot camp. Other clients have been in 

numerous treatment programs and have made 

many unsuccessful attempts to change. To these 

clients, the very idea of treatment—of making 

another attempt to change—connotes failure. 

In exploring these meanings and 

expectations with the client, you will sense what 

actions might be negotiable and what are not. 

For example, a client might state that she could 

never move from her neighborhood, a wellknown drug market, because her family is there. 

Another says he will not consider anything but 

moderation of his drinking. A third client may 

just as strongly state that total abstinence and a 

stay in a therapeutic community are the only 

options possible because all others have failed. 
Exploration of treatment expectations 

provides an opportunity to introduce 

information about treatment and to begin a 

preliminary discussion with clients about 

available options. When clients’ expectations 

about treatment correspond to what actually 

happens in treatment, they have better outcomes 

(Brown and Miller, 1993). Thus, it is never too 

soon to elicit clients’ expectations and begin to 

educate them about treatment. 

Re-explore Values in Relation 

To Change 

Decisional balance exercises offer another 

opportunity to help clients explore and 

articulate their values and to make a connection 

between these values and positive change. Your 

clients’ values will be reflected both in their 

reasons to change and in the reasons given not 

to. For example, an adolescent involved in drug 

dealing with a gang in his neighborhood may let 

you know that the option of leaving the gang is 

nonnegotiable because of his loyalty to the other 

members. Loyalty and belonging are important 

values to him, and you can relate them to other 

groups that can inspire similar allegiance such 

as a sports team or the military—organizations 

that create a sense of belonging and reflect his 

core values. A young woman who comes from a 

family with a history of hard work and 

academic achievement may wish to return to 

those values by finishing high school and 

becoming financially independent. 

Hearing themselves articulate their core 

values helps your clients increase their 

commitment to positive change. If they can 

frame the process of change within the larger 

context of values shared with their family, 

community, and culture, they may find it easier 

to contemplate change. 

Other Issues in the 

Decisional Balance 

Loss and grief 

Because giving up a way of life can be as intense 

as the loss of a close friend, many clients need 

time for grieving. They have to acknowledge 

and mourn this loss before they are ready to 

move on and build a strong attachment to 

sobriety. Pushing them too fast toward change 

can ultimately weaken their determination. 

Patience and empathy are reassuring at this 

time. You can help clients believe that their 

losses will be replaced by gains. 

Reservations or resistance 

As discussed earlier, serious reservations about 

change, often called resistance (but more 

commonly misidentified as denial), can be a 

signal in motivational interviewing that you and 

your client have different perspectives. As 

clients move into the preparation stage, they 

may become defensive if pushed to commit to 

change before they are ready or if their goals 

conflict with yours. They may express this 

resistance in behaviors rather than words. For 

example, some will miss appointments, sending 

a message that they need more time and want to 

slow the process. Continue to explore 

ambivalence with these clients and reassess 

where they are in the change process. 

Premature decisionmaking 

Decisional balance exercises also give you a 

sense of whether your clients are ready for 

change. If clients’ articulation of pros and cons 

is unclear, they may express goals for change at 

this stage that are unrealistic or reflect a poor 

understanding of their abilities and resources. 

You may sense that clients are saying what they 

think you want to hear. In one way or another, 
clients who are not ready to make a decision to 

change will let you know. Allowing clients to 

set themselves up for failure could result in their 

abandoning the change process altogether or 

losing trust in your judgment and care. Delay 

the commitment process and return with them 

to the contemplation stage. 

Keeping pace 

Some clients enter treatment after they have 

stopped using substances on their own. Others 

stop substance use the day they call the clinic for 

the first appointment. They have already made 

a commitment to stop. If you try to elicit these 

clients’ concerns or conduct decisional balance 

exercises, you might fail to provide the 

encouragement, incentives, and skills needed to 

help the action-oriented and action-ready 

individual make progress. Such clients can 

become impatient or frustrated at having to 

articulate pros and cons and or describe the 

concerns that led to their decision. Move with 

these clients immediately to create a change plan 

and enter the action stage but be alert for 

ambivalence that may remain or emerge. 

Free choice 

Many people begin using drugs or alcohol out of 

rebelliousness toward their family or society, 

usually in adolescence. Continued substance 

use may be their expression of continued 

freedom—freedom from the demands of others 

to act or live in a certain way. (Tobacco 

advertisers often tap into this dimension of 

smoking as an expression of autonomy and 

independence.) Thus, you may hear clients say 

that they cannot change because they do not 

want to lose their freedom. Because this belief is 

tied to some clients’ early-forged identities, it 

may be a strong factor in their list of reasons not 

to change. However, as clients age they may be 

more willing to explore whether the freedom to 

rebel is actually freedom, or its opposite. If you 

are attuned to this issue, you can explain that 

adolescent rebellion may really reflect a 

limitation of choices—the person must do the 

opposite of what is expected. As clients age, 

they may be more open to making a choice that 

represents real freedom—the freedom not to 

rebel, but to do what they truly choose. 

Emphasizing Personal 

Choice and 

Responsibility

In a motivational approach to counseling, it is 

not your task to a client a choice—choice is 

not yours to give but the client’s to make. You 

do not a client to choose because the choice 

already and always belongs with the client. The 

 chooses. Your task is to help clients make 

choices that are in their best interests. A 

consistent message throughout the motivational

approach is the client’s responsibility and 

freedom of choice. At this stage of the change 

process, the client should be accustomed to 

hearing from you such statements as the 

following:

“It’s up to you what to do about this.” 

“No one can decide this for you.” 

“No one can change your drug use for you. 

Only you can.” 

“You can decide to go on drinking or to 

change.” 

Exploring and Setting Goals 

Once the client has decided to make a positive 

change and the commitment is clear, goals

should be set. Goal-setting is part of the 

exploring and envisioning activities

characteristic of the early and middle 

preparation stage. Having summarized and 

reviewed the client’s decisional considerations,

you are now prepared to ask about ways in 

which your client might want to address some 

of the reasons to change listed on the positive 

side of the balance sheet (see Figures 5-2 and 

5-3). Although goal-setting is an interactive 
Figure 5-2 

Recapitulation

At the end of decisional balance exercises, you may sense that the client is ready to commit to change. 

At this point, it is important to summarize once more the client’s current situation as reflected in your 

interactions thus far. The purpose of the summary is to draw together as many reasons for change as 

possible, while simultaneously acknowledging the client’s reluctance or ambivalence. Your 

recapitulation should include as many of the following elements as possible: 

A summary of the client’s own perceptions of the problem, as reflected in self-motivational 

statements

A summary of the client’s ambivalence, including what remains positive or attractive about the 

problem behavior 

A review of whatever objective evidence you have regarding the presence of risks and problems 

A restatement of any indication the client has offered of wanting, intending, or planning to change 

Your own assessment of the client’s situation, particularly at points where it converges with the 

client’s own concerns 

process, it is the client’s responsibility. The 

process of talking about and setting goals 

strengthens commitment to change. 

Clients may set goals in multiple areas of 

their life, not just for changing substance use 

patterns. Those who set several goals may need 

help with prioritization. Their goals should be 

as realistic and specific as possible and should 

address the concerns they articulated earlier 

about their substance use. Regaining custody of 

children, reentering the workforce, becoming 

financially independent, leaving an abusive 

relationship, and returning to school are all 

goals that clients may work toward. The more 

hopeful clients feel about future success in life, 

the more likely they are to follow through with 

treatment goals. Initial goals should be shortterm, measurable, and realistic so that clients 

can begin measuring success and feeling good 

about themselves as well as hopeful about the 

change. 

If your client sets goals that seem 

unreachable to you, discuss your concerns. This 

is an important part of the interactive process of 

goal-setting. Witnessing how your clients set 

goals and the types of goals they specify 

provides you with useful information about 

their sense of self-efficacy, level of commitment, 

and readiness for change. 

Your client might choose a course of action 

with which you do not agree or that is not in 

line with agency policy. A decision to reduce 

use, for example, may conflict with your strong 

belief in immediate abstinence or the agency’s 

policy of zero tolerance for illicit substance use. 

Figure 5-4 addresses this in more detail. 

Goal Sampling and Experimenting 

Before committing to long-term change, some 

clients may benefit from experimenting with 

abstinence or cutting down their use for a short 

period. Success—or failure—can greatly 

enhance commitment to a goal of abstinence and 

long-term change. Presenting the trial period as 

a personal challenge can be particularly 

effective. A 3-month experimental period is 

recommended, based on findings that 3 months 

of abstinence predict long-term remission of 

alcohol dependence. Some clients may find this 

too long, and a shorter trial can be negotiated. 

The following list summarizes advantages of an 

abstinence trial (Miller and Page, 1991): 

The client receives an opportunity to learn 

how it feels to be clean and sober. 
Figure 5-3 

Key Questions 

The recapitulation outlined in Figure 5-2 is a final step before the transition to commitment and leads 

directly to strategic, open-ended questions intended to prompt the client to consider and articulate the 

next step The following is a list of possible key questions: 

What do you think you will do? 

What does this mean about your drinking? 

It must be uncomfortable for you now, seeing all this. What’s the next step? 

What do you think has to change? 

What could you do? What are your options? 

It sounds like things can’t stay the way they are now. What are you going to do? 

Of the things I have mentioned here, which are the most important reasons for a change? 

How are you going to do it? 

Where do we go from here? 

How would you like things to turn out now for you, ideally? 

What concerns you about changing your use of drugs? 

What would be some of the good things about making a change? 

Miller and Rollnick, 1991. 

Current, habitual consumption patterns are

interrupted and tolerance reduced. 

You and the client are helped to discover the 

degree, if any, of physiological dependence. 

The client can demonstrate and experience a 

period of successful self-control. 

A period of recovery from acute cognitive 

impairment is provided. 

Others (e.g., a spouse, the court) are shown 

that the client is sincerely interested in 

changing and capable of taking a first step. 

Extra time is allowed for recovery and 

stabilization of health, mood, sleeping 

patterns, and so forth. 

You and the client are helped to ascertain 

situations in which the client needs 

additional coping skills to overcome 

psychological dependence on the substance.

The usefulness of a month-long abstinence 

trial for adult marijuana smokers has been 

examined (Stephens et al., 1994). The 

participants were assigned to a three-session 

intervention consisting of assessment, 

personalized feedback of the assessment results, 

and brief intervention counseling. At the end of 

the second session, the counselor announced 

that the third session would be a month later 

and also asked whether clients would like to try 

some changes during that time period so that 

they could discuss the results at the next 

meeting. A month of abstention was proposed 

as “do-able”—long enough to try out changes 

but not long enough to seem like too much 

commitment. In reference to marijuana use, the 

study found that the three-session clients had 

the same outcomes at periodic posttreatment 

followups as a group that received 18 sessions of 

treatment during the same period. 

Besides trial abstention, two other “warm 

turkey” approaches have been described (Miller 

and Page, 1991). 
Figure 5-4

When Goals Collide 

What do you do when your client’s goals differ from yours or those of your agency? This issue arises 

in all treatment but is particularly apparent in a motivational approach where you listen reflectively to 

your clients and actively involve them in decisionmaking. As you elicit goals for change and 

treatment, some clients may not reflect what you think is best for them. How you handle this sensitive 

clinical situation can determine whether the client continues to pursue change. 

Before exploring different ways of handling this common situation, try to clarify the differences and 

boundaries between the client’s goals and your own (or your agency’s). For clients, goals are by 

definition the objectives they are motivated (ready, willing, and able) to work toward. If the client is

not motivated to work toward it, it is not a goal. You or your agency, on the other hand, may have 

particular aspirations, plans, or hopes for the client. It is important to realize that can have 

different meanings to you and to your client. You cannot impose your hopes and plans on a client. If 

you want your client to adopt a goal, your task is to motivate. 

What are your clinical options when goals collide? You can choose from the following tactics: 

Give up on the client. Although it sounds unappealing, this option is surprisingly common. If 

clients do not accept the goals prescribed by the clinician or agency, they are dismissed. This often 

amounts to discharging clients for the same reasons they were admitted. In the past, this option 

arose from (or at least was rationalized by) a mistaken view of motivation as a slowly progressing 

linear process. Clients were actually told, “Go away and come back when you’re ready [i.e., to do 

what I tell you].” 

Negotiate. Find goals on which you and your client can agree and work together on those. Start 

with areas in which the client is motivated to change. Women with alcohol or drug problems, for

example, often come to treatment with a wide range of other problems, many of which they see as 

more pressing than making a change in substance use. Clinicians have had good results by starting 

with the problems that are most urgent from the client’s perspective and then addressing substance 

use when its relationship to other problems becomes apparent. 

Approximate. Even if a client is not willing to accept all your recommendations, it is often possible 

to agree on a goal that constitutes a step in the right direction. Your hope, for example, might be 

that the client would eventually become free from all psychoactive substance use. The client, 

however, is most concerned about cocaine and is not ready to talk about changing marijuana, 

tobacco, or alcohol use. Rather than dismiss the client for not accepting a goal of immediate 

abstinence from all substances, you can focus on stopping cocaine use and then consider a next step. 

Refer. If your client’s goals are personally unacceptable to you even after trying to negotiate or 

approximate, you can refer. Sometimes a client might benefit from working toward a goal, but the 

clinician is personally uncomfortable (e.g., for ethical or professional competency reasons) in 

continuing treatment. For example, some clients are unwilling to consider immediate abstinence 

when they enter treatment. Even though alternatives exist (e.g., tapering down, trying problem-free 

moderate use, agreeing on a short trial period of abstinence [Miller and Page, 1991]), not all 

clinicians are comfortable working toward any goal other than immediate abstinence. In such cases, 

it often is preferable to refer these clients to another clinician who will work with them, rather than 

terminate treatment altogether. 
Tapering down 

This “warm turkey” approach has been widely 

used with cigarette smokers to reduce their 

dependence level before the quit date. This 

approach consists of setting progressively lower 

daily and weekly limits on use of the substance 

while working toward a long-range goal of 

abstinence. The client keeps careful daily 

records of consumption and schedules sessions 

with the clinician as needed. 

Trial moderation 

Trial moderation may be the only acceptable 

goal for some clients who are highly resistant to 

abstinence. It is important to avoid sending the 

message: “Go try it, and when you’ve failed, 

come back.” A more friendly and motivational 

approach is: “If that’s what you want, let’s give 

it the best try we can and see how it works.” 

However, seek agreement from the client that, if 

the moderation experiment fails after a 

reasonable effort, abstinence will be considered. 

A long-term followup of 99 problem drinkers 

who systematically tried to moderate drinking 

showed that more of them ultimately decided to 

abstain than maintain stable and problem-free 

moderation. At followup, more than half of 

those who ultimately abstained attributed their 

success to the insight gained from the 

moderation trial about their need to abstain 

(Miller et al., 1992). 

Although immediate abstinence is the usual 

prescription, no studies have confirmed that 

cold turkey is the best or only way to initiate 

lasting sobriety. Additional studies are needed 

to determine who are optimal candidates for 

“warm turkey” approaches; clinical and

research experience indicates that these methods

are successful with some clients, particularly 

those with less severe problems (Miller et al., 

1992). 

Enhancing Commitment in the 

Late Preparation Stage 

Commitment to change still must be reinforced 

even after your client has initially decided to 

change and has begun to set goals. Vacillation is 

to be expected at any point in the change 

process. Three additional strategies are

available for enhancing commitment at this 

point: taking smaller steps, going public, and 

envisioning. 

Taking small steps 

You have asked your client key questions such 

as “What is next?” and have presented a variety 

of options (see Chapter 6) to convey the message 

that it is the client’s choice to change and to 

select the areas on which to focus. Reminders 

that clients have choices to make and that they 

control the change process can reinforce 

commitment. If clients seem overwhelmed by 

the changes they are contemplating, reassure 

them that they can moderate the pace of change 

and can choose to begin with small steps. With 

some clients, it might be especially helpful to 

provide a case history of someone who made 

large and seemingly impossible life changes by 

taking one step at a time. The importance of 

such stories and models should not be 

underestimated in motivating people to change. 

Going public 

Disclosing the desire to change to at least one 

other person besides the clinician seems to be 

very important in helping clients become 

accountable as well as aware of any inner 

resistance. This other person can be a spouse, 

friend, family member, coworker, church friend, 

or Alcoholics Anonymous (AA) member. 

Telling significant others about one’s desire to 

change usually enhances commitment to 

change. Going public can be a critical step for 
some clients in the late preparation stage who 

may not have been ready to tell others until this 

point. AA has applied the clinical wisdom of 

public commitment to change through use of the 

“white chip.” An attendee at an AA meeting 

who is not yet ready to quit but has a strong 

desire to do so can pick up a white chip, as a 

public acknowledgment of the desire to quit 

drinking. 

Envisioning 

Specifically envisioning a different life after 

changes are made can be a powerful motivator 

and an effective means of strengthening your 

client’s commitment. In addition, stories about 

how others have successfully achieved their 

goals can be excellent motivators. An exercise 

for envisioning change is to ask clients to picture 

themselves after a year has passed, during 

which time they have made the changes they 

desire in the areas of their lives most hurt by 

their substance use. Some clients may find it 

valuable to write a letter to themselves that is 

dated in the future and describes what life is like 

at that point. The letter can have the tone of a 

vacation postcard, wishing you were here. 

Others will be more comfortable describing 

these scenes to you. 

The Importance of 

Self-Efficacy

Even clients who acknowledge a serious 

problem are not likely to move toward positive 

change unless they have some hope of success. 

Self-efficacy is a critical determinant of behavior 

change—it is the belief that they can act in a 

certain way or perform a particular task and 

thereby exercise control over events. Selfefficacy can be thought of as hope or optimism, 

but clients do not have to have an overall 

optimistic perspective to believe a particular 

behavior can be changed. 

Clients are most likely to make statements 

about self-efficacy when they are negotiating 

goals or developing a change plan (see Chapter 

6). Statements about self-efficacy could include 

the following: “I can’t do that,” “That is beyond 

my powers,” “That would be easy,” or “I think I 

can manage that.” From such statements, you 

can ascertain what the client feels able—and 

unable—to do. 

Self-efficacy is not a global measure, like selfesteem. Rather, it is behavior-specific. 

Underlying any discussion of self-efficacy is the 

question, “efficacy to perform what specific 

behavior?” In relation to substance dependency, 

self-efficacy can be conceptualized into five 

categories (DiClemente et al., 1994): 

1. involves successful 

coping with specific situations that might 

tempt a person to use the substance, such as 

being assertive with friends or talking with 

someone when upset rather than using the 

substance. 

2. involves the 

client’s ability to perform behaviors relevant 

to treatment, such as self-monitoring or 

stimulus control. 

3. relates to the client’s 

ability to recover from a recurrence of the 

addictive behavior. 

4. focuses on the client’s 

confidence in her ability to control the 

behavior in a variety of provocative 

situations. 

5. involves the client’s 

confidence in her ability to abstain from 

substance use in the various situations that 

are cues or triggers. 

Another way to conceptualize self-efficacy is 

as the client’s perceived ability to engage in 

meaningful or pleasurable, nonsubstancerelated activities. This should be assessed before 

you engage in change strategies related to your 

client’s daily activities. 

Self-efficacy is a dynamic rather than a static 

construct. Self-efficacy for coping with each 
particular situation increases with success and 

decreases with failure. Thus, it is important to 

give clients skills to be successful in situations 

that present a risk for recurrence of use in order 

to enhance their belief that they can maintain 

desired changes. 

Clinicians and researchers have found it 

useful to measure self-efficacy by examining 

situations or states that present a risk for 

recurrence of substance use. Clients may have 

high self-efficacy in some situations and low 

self-efficacy in others. (See Chapter 8 for 

descriptions of instruments you can use to 

measure a client’s self-efficacy in particular 

situations.) According to one study, most 

recurrence of substance use occurs in one or 

more of the following four situations 

(Cummings et al., 1980): 

1. such as anger,

depression, or frustration

2. such as seeing others 

drinking at a bar or being on vacation and 

wanting to relax 

3. such as having a 

headache, feeling tired, or being worried 

about someone 

4. such as 

craving or feeling drawn to test one’s 

willpower

Before you and the client discuss self-efficacy 

for changing substance use behavior, explore 

other areas and activities in the client’s life for 

which the client has demonstrated high selfefficacy. Then you can discuss how your client’s 

skills could apply to new efforts to change. For 

example, a client who is working on restoring an 

old car may spend dozens of hours figuring out 

why the engine will not run smoothly— 

systematically taking apart and reassembling 

various parts of the engine until the problem is 

found. This persistent and patient approach to 

problem solving and the curiosity behind it can 

be reframed as valuable strengths for identifying 

and solving problems with substance use. Other 

ways to support your client’s self-efficacy 

include the following (Marlatt and Gordon, 

1985):

Stress that change is a gradual process. 

Focus on acquisition of new skills versus 

cessation of “immoral” activity. 

Provide timely and specific feedback 

regarding progress. 
6 From Preparation to Action: 

Getting Started 

At the end of the preparation stage, 

clients make a plan for change to guide 

them into the action stage. This 

chapter focuses on negotiating this specific 

change plan with clients. Changing any longstanding, habitual behavior requires preparation 

and planning. As your clients move from 

contemplating to actually implementing change 

in their lives, they are in an intermediate stage in 

which they increase their commitment to change 

by exploring, clarifying, and resolving their 

ambivalence and making a decision to act. In 

the transtheoretical model, this stage is known 

as preparation. Clients must see change as in 

their best interest before they can move into 

action. The negative consequences of ignoring 

the preparation stage can be a brief course of 

action followed by rapid return to substance 

use.

During the preparation stage, your tasks 

broaden. Where before you were using 

motivational strategies to increase readiness— 

the goals of the precontemplation and 

contemplation stages—now you will use these 

DiClemente, 1991 

strategies to strengthen your client’s 

commitment and help this person make a firm 

decision to change. Clients who are committed 

to change and who believe change is possible 

are prepared for action. 

Clients and clinicians in the preparation 

stage are equipped with important knowledge 

from the personalized feedback of assessment 

information described in Chapter 4. The 

activities and strategies described in Chapter 5 

were intended to solidify your client’s 

commitment to change and set the stage for 

developing a plan for moving into action. 

Clients should now have a clearer picture of 

how their substance use affects many aspects of 

their lives, and they should have begun to 

recognize some of the consequences of 

continued use. In addition, many clients sense 

the hopeful possibilities inherent in the growing 

therapeutic alliance. If you have exercised the 

principles of motivational interviewing, your 

clients should recognize that they are in a safe 

environment for exploring their feelings and 
thoughts about change and that they are in 

control of the change process. 

This chapter explains how and when to 

negotiate a change plan with the client and 

suggests ways to ensure a sound plan—by 

offering the client a menu of options, contracting 

for change, identifying and lowering barriers to 

action, enlisting social support, and helping the 

client anticipate what it will be like to participate 

in treatment. 

Recognizing Readiness 

To Move Into Action 

As clients proceed through the preparation 

stage, be alert for signs of their readiness to take 

action. Clients’ recognition of important 

discrepancies in their lives is an uncomfortable 

state in which to remain for long; thus change 

should be initiated to decrease discomfort, or 

clients may retreat to using defenses such as 

minimizing or denying. Mere vocal fervor 

about change, however, is not necessarily a sign 

of determination to change. Clients who are 

vehement in declaring their readiness may be 

desperately trying to convince themselves, as 

well as you, of their commitment (DiClemente, 

1991). The following are several confirming 

signs of readiness to act: 

The client stops arguing, 

interrupting, denying, or objecting. 

The client 

seems to have enough information about his 

problem and stops asking questions. 

The client appears to have reached a 

resolution and may be more peaceful, calm, 

relaxed, unburdened, or settled. Sometimes 

this happens after the client has passed 

through a period of anguish or tearfulness. 

The client makes 

direct self-motivational statements reflecting 

openness to change (“I have to do 

something”) and optimism (“I’m going to 

beat this”). 

The client asks 

what she could do about the problem, how 

people change once they decide to, and so 

forth.

The client begins to talk about 

how life might be after a change, to 

anticipate difficulties if a change were made, 

or to discuss the advantages of change. 

If the client has had time 

between sessions, he may have begun 

experimenting with possible change 

approaches (e.g., going to an Alcoholics 

Anonymous [AA] meeting, reading a selfhelp book, stopping substance use for a few 

days) (Miller and Rollnick, 1991). 

When you conclude that a client is becoming 

committed to change, determine what is needed 

next by asking a key question (see Chapter 5). 

You might say, “I can see you are ready for a 

change. How would you like to proceed?” If 

the client indicates that she wishes to pursue 

treatment with your help, you can begin 

negotiating a plan for change. 

Negotiating a Plan for 

Change

Creating a plan for change is a final step in 

readying your client to act. A solid plan for 

change enhances your client’s self-efficacy and 

provides an opportunity to consider potential 

obstacles and the likely outcomes of each change 

strategy before embarking. Furthermore, 

nothing is more motivating than being well 

prepared—no matter what the situation, a wellprepared person is usually eager to get started. 

A sound change plan can be negotiated with 

your client by the following means: 

Offering a menu of change options 

Developing a behavior contract 

Lowering barriers to action 

Enlisting social support 

Educating your client about treatment 
Chapter 5 describes the process of exploring 

clients’ goals as a way of enhancing 

commitment and envisioning change. The 

change plan can be thought of as a roadmap to 

realizing those goals. Some clients begin 

spontaneously suggesting or asking about 

specific things they can do to change. You can 

prompt others to make suggestions by asking

key questions such as, “What do you think you 

will do about your drinking/drug use?” or 

“Now that you’ve come this far, I wonder what 

you plan to do?” (see Chapter 5 for a list of key 

questions). 

Clients will create plans that reflect their 

individual concerns and goals. Most plans are 

not limited to stopping or moderating substance

use, and ensuring success is the central focus of 

the plan. The plan can be very general or very 

specific, and short term or long term. Indeed, 

some clients may be able to commit only to a 

very limited plan, such as going home, thinking 

about change, and returning on a specific date to 

talk further. Even such a restricted and shortterm plan can include specific steps for helping 

the client avoid high-risk situations as well as 

specific coping strategies for the interim. 

Some clients’ plans are very simple, such as 

stating only that they will enter outpatient

treatment and attend an AA meeting every day. 

Other plans include details such as handling 

transportation to the treatment facility or 

arranging alternative ways to spend Friday 

nights. As discussed below, specific steps to 

overcome anticipated barriers to success are 

important components of many change plans. 

Some plans lay out a sequence of steps. For 

example, working mothers with children who 

must enter inpatient treatment may develop a 

sequenced plan for arranging for child care and 

training temporary replacements for their jobs 

before entering treatment. 

Although the change plan is the client’s, 

creating it is an interactive process between you 

and the client. One of your most important 

tasks is to ensure that the plan is feasible. When 

the client proposes a plan that seems unrealistic, 

too ambitious, or not ambitious enough, a 

process of negotiation should follow. The 

following areas are ordinarily part of interactive 

discussions and negotiations: 

—for 

example, the use of only self-help groups, 

enrolling in intensive outpatient treatment, 

or entering a 2-year therapeutic community 

—a short- rather than a long-term 

plan and a start date for the plan 

—including who will 

be involved in treatment (e.g., family, 

Women for Sobriety, community group), 

where it will take place (at home, in the 

community), and when it will occur (after 

work, weekends, two evenings a week) 

—for example, first to stop dealing 

marijuana, then stop smoking it; to call 

friends or family to tell them about the plan, 

then visit them; to learn relaxation 

techniques, then to use them when feeling 

stressed at work 

—for

example, how to deal with legal, financial, 

and health problems 

Clients may ask you for information and 

advice about specific steps to incorporate in the 

plan. Provide accurate and specific facts, and 

always ask whether they understand them. 

Eliciting responses to such information by 

asking, “Does that surprise you?” or, “What do 

 think about it?” can also be helpful in the 

negotiation process. 

How prescriptive should you be when clients 

ask what think they should do? Providing 

your best advice is an important part of your 

role. It is also appropriate to provide your own 

views and opinions, although it is helpful to 

insert qualifiers and give clients permission to 

disagree. 
Other techniques of motivational 

interviewing, such as developing discrepancy, 

empathizing, and avoiding argument, remain as 

useful during these negotiations as they are at 

all other stages of the change process. Guard 

against becoming overly focused on the 

negotiations and on the plan such that you 

forget to use these strategies. Acknowledge and 

affirm the client’s effort in making the plan. 

Some clients have found the Change Plan 

Worksheet (see Figure 6-1) a useful tool in 

focusing their attention on the details of the 

plan. The following is a list of considerations for 

completing the worksheet (Miller et al., 1995c): 

Be specific. 

Include goals that are positive (wanting to 

increase, improve, do more of something), 

and not just negative goals (stop, avoid, or 

decrease a behavior). 

What are the likely 

consequences of action or inaction? Which 

motivations for change are most compelling? 

How can the desired change be 

accomplished? What are some specific, 

concrete first steps? When, where, and how 

will the steps be taken? 

What specific events or problems could 

undermine the plan? What could go wrong? 

How will the client stick with the plan 

despite these particular problems or 

setbacks?

Figure 6-1 

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: 

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: 

I hope that my plan will have these positive results: 

I will know that my plan is working if: 

 Miller and Rollnick, 1991; Miller et al., 1995c. 
What specific things can another 

person do to help the client take the steps to 

change? How will the client arrange for such 

support?

What 

will happen as a result of taking the different 

steps in the plan? What benefits can be 

expected?

It can be helpful to estimate your client’s 

readiness and self-efficacy for the changes that 

your client lists in the plan. For example, on a 

scale from 1 to 10 (1 = no confidence, 10 = most 

confidence), the client may rate himself as a “9” 

in regard to readiness for a making a particular 

change in behavior, but only as a “4” on selfefficacy. This could help you guide your client 

about where to start on the change plan. 

Offering a Menu of 

Change Options 

Researchers and clinicians working in the 

motivational framework find that one way to 

enhance motivation is to offer clients a choice 

from a variety of treatment alternatives. For 

example, a client who will not go to AA may go 

to a meeting of Rational Recovery or Women for 

Sobriety, if such groups are available. A client 

who will not consider abstinence may be more 

amenable to a “warm turkey” approach (Miller 

and Page, 1991), as described in Chapter 5. 

Encouraging clients to learn about treatment 

alternatives and to make informed choices 

enhances commitment to the change plan. 

Choices can be about treatment options or about 

other types of services. 

Treatment Options and Resources 

In our alcohol treatment program, I found that having lists of both community resources and diverse 

treatment modules enables case managers to engage clients, offer individualized programming, and 

meet clients’ multiple needs. The following are some options we offer our clients: 

Treatment Module Options 

Values clarification/decisionmaking 

Social skills training (assertiveness, communication) 

Anxiety management/relaxation 

Anger management 

Marital and family therapy 

Adjunctive medication (disulfiram [Antabuse], naltrexone [ReVia]) 

Problem-solving group 

Intensive group therapy 

Community Treatment Resources 

Halfway houses 

Support groups (AA, Narcotics Anonymous [NA], Rational Recovery, Women for Sobriety) 

Social services (child care, vocational rehabilitation, food, shelter) 

Medical care 

Transportation 

Legal services 

Psychiatric services 

Academic and technical schools 

Carlo C. DiClemente, Consensus Panel Member 
No single approach to treating substance 

abuse works equally well for all clients. 

Determining what works best for whom and 

under what conditions can be a difficult 

undertaking. Evidence of treatment 

effectiveness is becoming increasingly 

specialized and, to some extent, more confusing, 

as more elements are added to evaluation 

formulas, including client characteristics, 

outcome measures, therapist qualities, treatment 

components, and quality of implementation. 

Familiarity with the available treatment 

facilities in your community and with the 

relevant research literature pertaining to optimal 

choices for the types of clients you see is 

enormously helpful in providing your clients 

with appropriate options. It is also useful to 

know about the range of community resources 

in other service areas, such as food banks, job 

training programs, special programs for patients 

with coexisting disorders, and safe shelters for 

women in abusive relationships. A clinician 

who knows not only program names but also 

contact persons, program graduates, typical 

space availability, funding issues, eligibility 

criteria, and program rules and idiosyncrasies is 

an invaluable resource for clients. Additionally, 

knowledge about clients’ resources, insurance 

coverage (or participation in some form of 

managed care), employment situation, parenting 

responsibilities, and other relevant factors is 

obviously crucial in considering alternatives. 

Information from an initial assessment is 

helpful, too, in establishing a list of possible 

treatment options and setting priorities. 

Although you may have a wealth of 

knowledge about local resources, your 

program’s administration has the final 

responsibility for developing liaisons with other 

agencies to ensure appropriate referrals for 

services and for keeping clinicians informed. In 

many places, a central agency compiles and 

regularly updates a comprehensive directory of 

community resources that contains information 

about services, costs, location, hours of 

operation, and eligibility criteria. Every 

program should have a manual of appropriate 

referral resources, with cross-references by 

program type, or should obtain current listings 

from local, State, or national sources (see 

Chapter 5 of TIP 24, 

 [CSAT, 1997]). 

The Internet offers new possibilities for 

accessing information about community 

resources and for linking clients with programs 

and services. For example, in Washington, DC, 

a computer system linking criminal justice 

agencies with substance abuse treatment 

programs gives up-to-the-minute information 

about space availability and program changes. 

Workers in the justice system can set up intake 

appointments for clients online. Those in rural 

areas where resources are scarce may find the 

Internet especially valuable. 

As you discuss treatment choices with 

clients, you can acquaint them with the concepts 

of levels of care, intensities of care, and 

appropriate fit. Do not, however, overwhelm 

them with a complicated description of all 

possibilities. Avoid professional jargon and 

technical terms for treatment types or 

philosophies. Limit options to several that are 

appropriate, and describe these, one at a time, in 

language that is understandable and relevant to 

individual concerns of clients. Explain what a 

particular treatment is intended to do, how it 

works, what is involved, and what clients can 

expect. Ask clients to postpone a decision about 

treatment until they understand all the options. 

As each option is discussed, ask clients if 

they have questions and ask for their opinions 

about how they would handle each alternative. 

Although the goal is to choose the right 

approach initially, some clients may choose an 

option that you believe is inappropriate. Offer 

advice based on your clinical experience and 

knowledge of the research. You are searching 

for change strategies with which to begin, and, 
ideally, the client will view some appropriate 

options positively. 

While you are exploring treatment options 

with a client, also review the concept of change 

as a wheel or cyclical process (see Chapter 1). 

Each person moves through the stages of 

change—forward or backward—over a 

substantial period of time (Prochaska and 

DiClemente, 1984; Prochaska et al., 1992b). This 

cycling sometimes takes the form of an upward 

spiral, with gradual improvement in the 

spacing, length, and severity of periods of 

problematic behavior (Miller, 1996). Because 

most people typically move around the cycle 

several times before exiting into stable recovery, 

let clients know that they should not become 

discouraged if their first treatment option does 

not work. Point out that, with all the 

possibilities, they are certain to find some form 

of treatment that will work. Reassure them that 

you are willing to work with them until they 

find the right choice. 

Clients sometimes resist the idea that change 

is a cyclical process and prefer to view change as 

“all or nothing.” The resistance may stem from 

fear that acknowledging the possibility of a 

lapse represents giving oneself permission to 

actually have one. It is of the utmost importance 

to convey to your clients that they can return to 

see you no matter what, even after a slip. 

You also should be sensitive to the client 

who resists an idea you have found motivational 

for others. In this case, you might say, “It 

sounds like this issue is really important to you. 

Tell me more about that,” or “It sounds like you 

would not want to go through that again, and I 

can understand why, at this point, you would 

not want to talk about those things. So, to help 

you with this, let me know how I can help you 

avoid the things that led to recurrence in the 

past, while at the same time help you avoid 

discussing the things that you do not think are 

helpful.” The hope is that in discussing 

previous returns to problem behavior (while 

conveying your agreement with the client’s wish 

that it not happen) you can “ease” into the 

possibility of recurrence and how to handle it. 

Clinicians are accustomed to the idea that 

treatment success means completing a formal 

program and, conversely, dropping out means 

treatment failure. However, research has shown 

that a significant number of clients stop 

treatment because they do not need further help 

and can implement change on their own 

(DiClemente and Scott, 1997). Often, they only 

need assistance in maximizing their readiness to 

change and enhancing their motivation. No 

further aid is wanted—no negotiating, no plan, 

no contract—just encouragement and 

reassurance that they can return if they need 

more help. The danger is that some clients, such 

as those with a long history of excessive and 

relatively uninterrupted substance use, may take 

this opportunity to run away from treatment. 

When these clients suggest trying to change on 

their own, discuss your concerns about their 

leaving prematurely. 

Several programs offer time-limited check-in 

modules to prepare clients for change. For 

example, a treatment program in Austin, Texas, 

periodically offers a 2-hour group for people 

who smoke. The program contains educational 

and motivational components as well as some 

elements of self-help through group support. 

Although participants are told how to access 

treatment if necessary, the group is designed to 

help participants initiate self-change. Research 

suggests that some people can change 

substance-dependent behaviors on their own 

without treatment (DiClemente and Prochaska, 

1985; Klingemann, 1991; Sobell et al., 1993b; 

Tuchfield, 1981). 

Developing a Behavior Contract 

A written or oral contract is a useful tool for 

helping clients start on their change plans. A 

contract is a formal agreement between two 

parties. Literate clients may choose to make a 
signed statement at the bottom of the Change 

Plan Worksheet or may prefer a separate 

document. Explain to literate clients that other 

people have found contracts useful at this stage 

and invite them to try writing one. The act of 

composing and signing a contract can be a small 

but important ceremony of commitment. Avoid 

writing the contract for clients and encourage 

them to use their own words. With some, a 

handshake is an adequate substitute for a 

written contract, particularly with the client who 

lacks literacy. 

Establishing a contract raises issues for 

fruitful discussion about your client’s reasons 

for desiring change. Whom is the contract with? 

What parties does it involve? Some contracts 

include the clinician as a party in the contract, 

specifying the clinician’s functions and 

responsibilities. Other clients regard the 

contract as a promise to themselves, to a spouse, 

or to other family members. 

Contracts are often used in treatment 

programs that employ behavioral techniques. 

For many clinicians, contracts mean 

contingencies—rewards and punishments—and 

programs often build contingencies into the 

structure of their programs. For example, in 

many methadone maintenance programs, takehome medications are contingent on substancefree urine screens. Rewards or incentives have 

been shown to be highly effective reinforcers of 

abstinence. In a treatment program study of 40 

cocaine-dependent adults (Higgins et al., 1994b), 

one group received vouchers exchangeable for 

retail items contingent on submitting cocainefree urine specimens during weeks 1 through 12 

of treatment. The other group received no 

vouchers. Seventy-five percent of the voucher 

group completed 24 weeks of treatment, 

compared with 40 percent of the control group, 

and the duration of continuous cocaine 

abstinence in the voucher group was nearly 

twice as long as that of the control group (11.7 

weeks versus 6 weeks). See Chapter 7 for more 

discussion of incentives. 

In developing a contract, the client may 

decide to include contingencies, especially 

rewards or positive incentives. Rewards can be 

highly individual. Enjoyable activities, favorite 

foods, desired objects, or rituals and ceremonies 

can all be powerful objective markers of change 

and reinforcers of commitment. Rewards can be 

tied to duration of abstinence, to anniversaries 

of the quit date, or to achievement of subgoals. 

One client might plan to spend the afternoon at 

a baseball game with his son to celebrate a 

month of abstinence. Another might buy a pair 

of red shoes after attending her 50th AA 

meeting. Still another might light a candle at 

church, and another might hike to the top of a 

nearby mountain to mark an improvement in 

energy and health. 

Lowering Barriers to Action 

Identifying barriers to action is an important 

part of the change plan. As clients decide what 

options are best for them, ask whether they 

anticipate any problems with those options or 

any obstacles to following the plan and 

achieving their goals: What could go wrong? 

What has gone wrong in past attempts to 

change? As mentioned earlier, certain clients 

resist the idea that something could go wrong. 

Here, it is better to get the information by asking 

about what has gone wrong in the past. It is 

sometimes easier to discuss past difficulties than 

to acknowledge the possibility of difficulties in 

the future. 

One common barrier to action involves 

referring your client to another treatment 

program or other services following initial 

consultation or evaluation. When you refer 

clients, make sure they have all the necessary 

information about how to get to the program, 

whom and when to telephone, and what to 

expect during the call (e.g., what type of 

personal information might be requested). 
Giving your client “insider information also 

reduces the client’s anxiety and eases the way. 

For example, you may know that the 

receptionist at the program is a friendly person, 

or that many people get lost by entering the 

building on the wrong side, or that a nearby 

lunch counter serves good food. One inpatient 

program takes clients on field trips to the 

outpatient aftercare site before discharge to 

ensure a smooth transition. 

Research has shown that giving the client a 

name and telephone number on a piece of paper 

is far less effective than more personalized 

referral methods (Miller, 1985b). Consider 

helping your client make the telephone call to 

set up the intake appointment at the chosen 

program. Some clients may want to make the 

phone call from your office, whereas others 

might wish to call the program from home and 

call you later to inform you that they made an 

appointment. Still others prefer to think things 

over first and make the call from your office at 

the next session. Let your clients know that you 

are interested in knowing how everything goes. 

Anticipating problems 

As suggested in the Change Plan Worksheet, 

one question to ask clients is, “If down the line 

the plan fails, what do you envision might be 

the cause?” Clients can predict some barriers 

better than you can, and it is important to allow 

them to identify and articulate these problems. 

Do not try to anticipate everything that could go 

wrong; focus on events or situations that are 

likely to be problematic and build alternatives 

and solutions into the plan. 

Some problems may be clear from the outset. 

A highly motivated client sitting in your office 

may plan to attend an outpatient treatment 

program 50 miles away three times a week, even 

though such a plan involves both bus and train 

schedules and late-night travel. Referral to a 

less distant program may be the solution, 

although helping the client make some 

telephone calls to the program could identify a 

participant willing to provide a ride. 

Recognizing barriers to action 

Barriers to action are frequently encountered 

and should be discussed, if only briefly, when 

the change plan is being negotiated. Consider 

specific strategies and coping behaviors, and 

help clients explore what works best for them. 

Potential barriers exist in several areas. 

 can be critical barriers to 

initiating and maintaining action. A client’s 

changed behavior may throw family 

relationships off balance, and problems that 

were suppressed as long as family dynamics 

centered on the substance use behavior may 

begin to surface. For example, the client may 

want to take back control. A wife who has made 

all family decisions by herself for a long time 

may react negatively to sharing power. A 

teenager who is used to coming and going 

unnoticed may rebel over a new curfew. Some 

family members may have deep resentment and 

criticism about the client’s past behavior that 

they cannot wait any longer to express. 

Such family disruptions and crises can 

contribute to a return to substance use, and 

clients can anticipate and learn specific 

strategies and coping behaviors to avoid such an 

outcome. Some clients may decide to institute a 

family meeting at a certain time each week for 

discussing problems and averting crises; the first 

one can be scheduled in your office. Some 

families benefit from more formal family 

therapy, which can be incorporated into the 

change plan. Other clients may identify a 

respected older person, such as a grandfather or 

friend, who would be willing and capable of 

acting as an arbiter in family disagreements. 

Also, people in recovery attend frequent 

meetings, which decreases the time they have 

available for family. Clients may consider 

attending meetings during the lunch hour or at 

other times that do not reduce family time. 
Sometimes, fellow attendees in AA and 

Narcotics Anonymous groups provide unsound 

advice that is not in the family’s best interest. 

Another important issue is the rebonding of a 

relationship or a marriage. Usually the male 

client is eager to return to a sexual relationship, 

and the female is cautious because of the past 

pain and mistrust. The male then reacts to the 

tension that develops from not having a 

commitment for sexual activity from his partner. 

In some cases, sexual behavior is used as a 

device to control the recovering person, and 

when the expectations of the recovering person 

are not met, tension builds. 

 present obstacles to recovery 

for many clients with serious physical or mental 

health disorders. Some become sick after 

entering treatment; others have chronic 

conditions that require monitoring and 

treatment and can produce periodic health crises 

(e.g., HIV/AIDS, diabetes, hypertension). 

Clients may be in chronic pain from injuries or 

self-neglect (e.g., back pain, dental problems). 

Abstinence sometimes reveals underlying 

mental illnesses, such as depressive or psychotic 

disorders (see TIP 9, 

[CSAT, 1994b]; and TIP 29, 

[CSAT, 1998a]). 

Medications taken for physical and mental 

health problems may cause distressing side 

effects. 

All of these conditions and situations can 

increase the risk of returning to substance use. 

Although some of these problems cannot be 

anticipated, clients may have to build health 

supports and improvements into the plan. 

Some clients, especially those with strong 

concerns about their health, may wish to include 

a schedule for physical and dental checkups or 

arrangements with specific physicians and 

clinics for ongoing care of chronic problems. 

Subgoals for acquiring medical care may involve 

applying for entitlement programs or checking 

insurance coverage. A depressed client, for 

example, may plan to see a mental health 

worker for an evaluation if she is still feeling 

depressed after 30 days of abstinence, or she 

may decide to see one sooner if her symptoms 

increase the risk of returning to substance use. 

It should be reemphasized that some clients 

(e.g., those with coexisting disorders) need more 

intensive services. 

in the treatment program 

itself can be obstacles to immediate and 

sustained recovery. For example, many facilities 

have long waiting lists. Some programs require 

a great deal of paperwork to enter, which may 

put off clients with poor literacy skills. Clients 

with outstanding legal problems are not 

accepted in some programs. Financial support 

that clients counted on for treatment may 

disappear. For instance, a mother whose 

treatment is covered by Medicaid may lose her 

eligibility when she takes a higher paying job. 

Some highly motivated clients encounter 

significant language barriers at local programs if 

they do not speak English well. Clients with 

coexisting disorders who are on psychoactive 

medications may not be welcome at some AA 

groups. 

Second thoughts and doubts occur to even 

the most highly motivated clients with carefully 

considered change plans. It is not uncommon to 

have an attack of regret or “cold feet.” An 

expression used by AA members is “to come off 

the pink cloud.” Second thoughts may emerge 

as soon as the client leaves your office—or 

several weeks into the change plan. Normalize 

this experience for clients and, at the same time, 

make specific plans for dealing with it. It is an 

important task to help clients overcome their 

doubts. You can insist that your client call you 

as soon as second thoughts arise or discuss other 

strategies such as attending extra AA meetings 

or calling a trusted support person (see below). 

Some clients keep a supply of disulfiram to use 
when they feel overwhelmed by urges and 

cravings. 

Enlisting Social Support 

Social support is an important influence on 

whether change happens and whether it is 

maintained (Sobell et al., 1993b). It is not 

sufficient to think of social support in terms of 

amount or even quality. When treating 

substance abuse, question whether the client’s 

social support system is supporting continued 

substance use. For example, within Project 

MATCH, treatment outcomes were predictable 

from the extent to which the client’s social 

network supported continued drinking or 

sobriety (Project MATCH Research Group, 

1997a, 1997b). Those with good social support 

for sobriety fared better overall. Those whose 

social networks at intake supported continued 

drinking tended to have less abstinence at 

followup, with an important exception. These 

clients did much better if their treatment helped 

them get engaged in AA. In essence, AA 

provided them with a new social network 

supportive of sobriety (Project MATCH 

Research Group, 1997b). When your client has 

few or no significant others who are 

encouraging sobriety, it is important to help 

your client build a new social structure that will 

support the effort to change. 

As a clinician, you are a central support for 

your clients, but you cannot provide all the 

support they need. In general, a supportive 

person is someone who will listen and not be 

overly judgmental (or who will at least withhold 

judgment). This supportive person should have 

a helpful and encouraging attitude toward the 

client, rather than being critical or nagging. 

Ideally, this person does not use or misuse 

substances and understands the processes of 

substance dependency and change. The Change 

Plan Worksheet (given in Figure 6-1) includes 

space for listing supportive persons and 

describing how they can help. As discussed in 

Chapter 4, concerned significant others can learn 

the skills and techniques of motivational 

interviewing and become effective partners in 

change. 

Because social support often entails taking 

part with the client in activities that are 

alternatives to substance use, close friends with 

whom the client has a history of shared interests 

other than substance use are good candidates for 

this helpful role. Of course, members of social 

groups organized around drinking and drug use 

are not likely to offer the kind of support your 

client needs during recovery. 

In addition to repairing or resuming ties with 

helpful family members and significant others, 

clients can find supportive people in, for 

example, churches, recreational centers, and 

community volunteer organizations. To make 

these connections, encourage clients to explore 

and discuss a time in their lives before substance 

use became a central focus. Ask them what gave 

meaning to their lives at that time. 

Clients may find supportive new friends in 

such prosocial organizations as mentoring 

groups modeled after Big Brothers and Big 

Sisters. Fellow members of AA and other selfhelp groups are important supports in the lives 

of many recovering clients. Oxford Houses and 

similar treatment-housing options have built-in 

social support systems. For some clients, 

especially those with chronic physical problems 

or severe mental illness, case management teams 

provide a sense of safety, structure, and support. 

When helping clients to enlist social support, 

be particularly alert for those who have poor 

social skills or scant social networks. Some 

clients may have to learn social skills and ways 

to structure leisure time, and such small steps 

can be incorporated into the change plan. Some 

clients may not be connected to any social unit 

that is not organized around substance use. 

Furthermore, substance dependency may have 

so narrowed their focus that they have trouble 

recalling activities that once held their interest or 
appealed to them. However, most people 

harbor secret, unfulfilled wishes to pursue an 

activity at some time in their lives. Ask about 

these wishes. One client may want to learn 

ballroom dancing, another to learn a martial art 

or take a creative writing class. Planning for 

change can be a particularly fertile time for 

clients to reconnect with such lost hopes, and 

pursuing such activities provides opportunities 

for making new friends. 

Finally, in helping clients enlist social 

support, avoid the stereotype of the selfsufficient loner. Although early views of people 

with substance dependency characterized them 

as cut off from primary relationships and living 

a kind of “alley cat” existence, accumulating 

evidence from several countries indicates that 

most are closely tied to their families (Stanton, 

1997). In fact, their rates of contact with family 

members—especially mothers—are often much 

higher than rates for adults with no substance 

use problems. In addition to presenting 

evidence of these close ties and of the 

effectiveness of family support, Stanton 

provides a valuable overview of seven 

approaches to engaging clients in treatment by 

enlisting the support of family members and 

significant others. Describing these methods is 

beyond the scope of this TIP; however, this 

review is a valuable reminder that stereotypes 

such as the loner are significant barriers to 

effective treatment (Stanton, 1997). 

Educating Your Client 

About Treatment 

To ensure a smooth transition into treatment, 

elicit and explore your clients’ expectations to 

search for any misunderstandings or 

misinformation they may have. This step is 

called role induction, which is the process of 

educating clients about treatment and preparing 

them to participate fully and obtain what they 

need. Ask them to anticipate what feelings they 

might have when they attend group therapy or a 

self-help meeting. Role induction brings the 

expectations of the client in line with the 

realities of treatment and reduces the probability 

of surprises. Research consistently 

demonstrates that retention in treatment has a 

strong positive relation with a client’s 

expectancy and that role induction prevents 

early dropout (Zweben and Li, 1981). 

If you refer clients to another program, 

review with them what you know of its 

philosophy, structure, and rules, as well as any 

idiosyncrasies with which you may be familiar. 

Available videotapes can give clients some sense 

of what individual and group therapy is like, or 

what to expect when attending an AA or other 

12-Step meeting. Most programs also conduct 

their own role induction. For example, at intake 

clients are given a list of their rights and 

responsibilities, including rules about 

involuntary discharge, and have an opportunity 

to discuss the list. 

When providing information about a 

program, be sure to check with your client that 

nothing you have described will disrupt the 

change plan. Some aspects of the program, such 

as cost, a requirement to bring a significant other 

to certain meetings, or location, could cause 

clients to believe that the program will not work 

for them. They may be reluctant to bring up the 

issue after progressing so far in the change plan. 

Such reactions should be explored, especially in 

terms of recurrent ambivalence. Often they 

involve a misunderstanding about the program. 

Another important aspect of role induction is 

educating clients about what to expect in terms 

of physical withdrawal from substances. The 

symptoms—or rebound reaction—can range 

from minimal to extremely difficult and 

prolonged. Accurate information helps give 

clients a sense of control, although many 

reactions are subjective and difficult to 

anticipate. Nevertheless, it is important to tell 

your clients that certain physical and 

psychological reactions to stopping substance 
use are normal and relatively predictable. For 

example, many former heroin users report that 

the fourth day of abstinence is the most difficult. 

Clients may have a strong and visceral reaction 

to the sight of needles. A television commercial 

that shows a white powdered detergent may 

produce urgent cravings. Protracted and 

unexpected withdrawal syndromes can occur as 

long as 30 days after last use of some substances, 

such as benzodiazepines and cocaine. Some 

clients have such vivid dreams of using 

substances that they awaken believing they have 

actually returned to substance use, with all the 

accompanying fears and confusion. During the 

first weeks of abstinence, some clients report 

feeling as if they are going crazy. Knowing 

what to expect, then, will provide them needed 

reassurance. 

Initiating the Plan 

Many change plans have a specific start date. 

Some clients like to mark this new beginning 

with a ritual that not only looks forward but also 

symbolically leaves old behaviors behind. For 

example, some may burn or ritually dispose of 

substance paraphernalia, cigarettes, beer mugs, 

or liquor. Depending on whether clients plan to 

continue regular treatment sessions with you, 

follow up on a referral, or initiate self-change, 

decide with them whether and how often they 

will check in with you. Alternatively, if they do 

not expect to continue in counseling with you, 

you may arrange to call them periodically to 

show your support and continuing interest. 

Whatever the arrangements, all clients 

should leave your office with the understanding 

that they can return or call for additional 

encouragement and support, or renegotiate the 

change plan. Many programs have agreements 

about communicating with other facilities or 

services to which they refer clients in order to 

ascertain whether the transition is completed 

satisfactorily. If not, you should have a protocol 

for contacting clients who do not follow through 

on the referral and inviting them back for 

further help. 

Clients with a carefully drafted change plan, 

a knowledge of both risky situations and 

potential barriers to getting started, and a group 

of supportive friends or concerned relatives 

should be fully prepared and ready to move into 

action. 

7 From Action to Maintenance: 

Stabilizing Change 

DiClemente, 1991 

Prochaska and DiClemente, 1984 

Amotivational counseling style has been 

used mostly with clients in the 

precontemplation through preparation 

stages as they move toward initiating behavioral 

change. Many clients and clinicians believe that 

formal treatment is a different domain— 

conducted according to various philosophies 

and procedures that guide separate modalities— 

where motivational strategies are no longer 

required. This is not true for two reasons. First, 

clients still need a surprising amount of support 

and encouragement to stay with a chosen 

program or course of treatment. Even after a 

successful discharge, they need support and 

encouragement to maintain the gains they have 

achieved and to handle crises that may return 

them to problem behaviors. Second, many 

clients arrive at treatment in a stage of change 

that actually precedes action or they vacillate 

between some level of contemplation—with 

associated ambivalence—and continuing action. 

Moreover, clients who do take action are 

suddenly faced with the reality of stopping or 

reducing substance use. This is more difficult 

than just contemplating action. The early stages 

of recovery require only thinking about change, 

which is not as threatening as actually 

implementing it. 

This chapter addresses ways in which 

motivational strategies can be used effectively at 

different points in the formal treatment process. 

The first section discusses the importance of 

understanding and offsetting clients’ natural 

doubts and reservations about treatment 

immediately after admission so that they stay 

long enough to benefit from the process rather 

than dropping out prematurely. The next part 

outlines ways to help your clients plan for 
stabilizing change, develop coping strategies to 

avoid or defuse high-risk situations, and enlist 

family and social support. The third section 

describes types of alternative reinforcers that 

can be used, including a broad-spectrum 

approach that attempts to make a nonusing 

lifestyle more attractive and rewarding than 

previous self-destructive behavior. 

Engaging and Retaining 

Clients in Treatment 

Premature termination of treatment—early 

dropout—is a major concern of clinicians and 

researchers (Kolden et al., 1997; Zweben et al., 

1988). The literature on treatment for users of 

illicit substances finds that the amount of time 

spent in treatment is a consistent indicator of 

more favorable outcomes (e.g., Simpson et al., 

1997). Poorer outcomes in terms of continuing 

substance use and criminal behavior as well as a 

rapid return to daily substance use are 

associated with shorter treatment episodes 

(Pickens and Fletcher, 1991). This robust finding 

from outcome literature contrasts with other 

research findings that brief interventions can be 

as effective as more intensive care (Bien et al., 

1993b) and that outcomes seldom differ when 

clients are randomly assigned to more versus 

less intensive treatment. 

Causes of premature termination of 

treatment are varied. For some clients, 

dropping out, missing appointments, or failing 

to comply with other aspects of the treatment 

program are clear messages of discouragement, 

disillusionment, or change of heart. For others, 

dropping out of treatment without discussing 

this option with you may not indicate 

dissatisfaction or resistance, but rather a 

decision that things are going well and desired 

change can be achieved and maintained without 

your continuing help or monitoring 

(DiClemente, 1991). 

Perhaps the strongest predictor of success 

versus failure or dropout in outpatient 

treatment is severity of substance dependence at 

treatment entry (McLellan et al., 1994) and, more 

specifically, submission of a drug-negative 

versus drug-positive urine specimen at 

treatment entry (Alterman et al., 1996, 1997). 

For example, one study found that cocaineusing patients with a positive urine screen at 

intake were less than half as likely to complete 

treatment or achieve initial abstinence as those 

submitting negative urine samples (Alterman et 

al., 1997). With alcohol problems, the 

relationship between severity and outcome is 

less obvious (Project MATCH Research Group, 

1997a). 

Although much research focuses on 

predictors of treatment retention, including 

client and therapist characteristics, treatment 

environment, therapeutic elements, and 

interactions among these variables, Kolden and 

colleagues conclude that there are too many 

factors for practical analysis and thus predictors 

of treatment compliance remain elusive (Kolden 

et al., 1997). 

Nevertheless, these investigators and others 

report on variables that show some correlation 

with treatment retention or that seem, 

intuitively, to affect early termination. For 

example, the degree of congruence between 

clients’ and clinicians’ expectations about 

treatment elements and duration plays some 

role in retention, as does clinician interest 

expressed through such small actions as 

telephone calls between sessions or interactive 

exploration and agreement on the goals of 

treatment. “Failure” may be tied to a poor 

therapeutic alliance, which may reflect on 

clinical skillfulness. Social stability, previous 

treatment, expectations for reducing future 

substance use, higher methadone doses, and 

higher motivation—defined here as a desire or 

perceived need for help—seemed to predict that 

opiate-using clients would stay in methadone 
treatment for more than 60 days (Simpson and 

Joe, 1993). Furthermore, studies of therapeutic 

communities demonstrate that less severe 

psychopathology and higher motivation and 

readiness—defined as the wish to change and 

the use of treatment to change—are positive 

predictors of retention (e.g., DeLeon et al., 1994). 

By contrast, a combination of distrust of 

treatment programs and a sense of self-efficacy 

that says “s will work for me” are 

predictors of success in achieving sobriety 

through AA (Longshore et al., 1998). Studies 

also show large differences among clinical staff 

in the percentage of clients who drop out of 

treatment (Miller, 1985b). 

At least three studies suggest that 

motivational interviewing can be a useful 

adjunct for increasing client retention and 

participation in treatment. In the first study, one 

group of residents admitted to a 13-day 

alcoholism treatment program received two 

sessions of assessment and prompt feedback 

provided in a motivational style stressing 

empathy and support (see Chapter 4) as part of 

the intake process (Brown and Miller, 1993). 

Although the motivational intervention added 

only 2 hours to the routine protocol, the 

therapists reported that residents who 

participated were more fully involved in later 

treatment than were counterparts not assigned 

to the motivational intervention. Moreover, the 

extra attention and support offered by the 

motivational intervention resulted in 64 percent 

of the group having favorable outcomes (i.e., 

abstinent or asymptomatic) at 3-month 

followup, compared with only 29 percent of the 

control group. 

Similarly, Aubrey found significantly better 

treatment retention, lower alcohol use, and 

lower illicit drug use among adolescents given 

one session of motivational interviewing and 

personal feedback on entry to substance abuse 

treatment (Aubrey, 1998). Adolescents who 

received the motivational interviewing session 

completed nearly three times as many sessions 

(average of 17) compared with those receiving 

the same outpatient program without 

motivational interviewing (average of six 

sessions). Abstinence at followup was also 

twice as high when the single initial session was 

added. 

In the third study, of opiate users in an 

outpatient methadone maintenance treatment 

program in Australia, an hour-long intervention 

that used motivational interviewing techniques 

at treatment initiation resulted in increased and 

more immediate commitment to treatment and 

abstention among participants (Saunders et al., 

1995). Rather surprisingly for such a brief 

adjunct to treatment, these outpatients appeared 

to have fewer problems, more treatment 

compliance, better retention, and less rapid 

return to opiate use following treatment than a 

control group that received an educational 

intervention. Although 40 percent of the clients 

studied dropped out of treatment by the end of 

6 months, only 30 percent of the clients who 

participated in the adjunct motivational 

intervention left treatment by this time, 

compared with nearly half (49 percent) of the 

control group. 

Another interesting finding was that clients 

entering methadone treatment were not 

necessarily in an action stage of change as 

expected. Rather, they seemed to represent all 

stages and to cycle rapidly back and forth from 

precontemplation through maintenance. A 

large percentage (38 percent) of the group 

participating in the motivational intervention 

were contemplating change at admission, and 37 

percent of this group were in an action stage 3 

months later. By contrast, 35 percent of the 

control group were not yet considering change 

(precontemplation) at admission and an 

increased percentage (47 percent) were still in 

this stage of the change process at 3 months. 

This accentuates the need for assessing how 

 clients are for change, no matter what the 
external circumstances. The boundaries 

between stages of change seem to be fluid, even 

for clients whose motivation for change is 

enhanced by the clinician’s counseling style and 

therapeutic strategies. 

Specific Strategies To Increase 

Engagement and Retention in 

Treatment

The strategies discussed in this section have 

been found by some clinicians to be useful in 

increasing clients’ involvement or participation 

in treatment and decreasing early dropout. All 

entail some application of motivational 

approaches already outlined in earlier chapters. 

Develop rapport 

As noted in Chapters 3 and 4, clinician style is 

an important element for establishing rapport 

and building a trusting relationship with clients. 

The principles of motivational interviewing 

exemplify proven methods to get in touch with 

and understand your clients’ unique 

perspectives and personal values, as opposed to 

yours or your program’s. Accurate empathy 

and reflective listening (client-centered skills for 

eliciting clients’ concerns through an interactive 

process that facilitates rapport) have been well 

described and tested in clinical research. 

Clients will confide in you if they feel 

comfortable and safe within the treatment 

setting. Their natural reactions may depend on 

such factors as their gender, age, ethnicity, and 

previous experience. For example, ethnic 

minorities may bring a reticence to the clinic 

situation that is based on negative life 

experiences or problems encountered with 

earlier episodes of treatment. Initially, for these 

clients and others who have been oppressed or 

abused, safety in the treatment setting is a 

particularly important issue. 

Programs can devise innovative ways to 

make their clients feel welcomed into a familiar 

milieu or a shared effort. For example, AfricanAmericans call each other brother and sister, 

and Native Americans consider each other 

relatives. Some treatment programs refer to 

clients as members, a term that denotes 

participation and inclusion. Programs 

sometimes provide a meal to help clients feel 

part of a family. In one program that serves 

Native Americans, a client’s trauma and pain 

are addressed with “honoring.” For example, if 

a person is experiencing a problem, a sweat 

lodge can be requested as an appropriate and 

safe setting in which to disclose feelings and 

obtain feedback. It is important to honor the 

request, and it is an honor to be invited. 

Participating in a sweat lodge allows Native 

Americans to embrace their ethnic identity, gain 

ethnic pride, and honor Native American 

spirituality, thus encouraging a sense of 

belonging. In another Native American 

program, a young woman who was struggling 

to stop using substances had returned to using 

them. Rather than punish and isolate her, the 

group selected her to be fire keeper at the sweat 

lodge, a position of honor. The group’s respect 

for the individual transcended her current 

behavior. The rationale is that without this 

continued bond, the woman would not have 

had an opportunity to choose to change her 

future behavior. 

Indirect expression is another way of helping 

clients from some cultures feel comfortable. 

Metaphors, stories, legends, or proverbs can 

explain, through example, a situation that clients 

can then interpret. For instance, for those clients 

who appear to have trouble asking others for 

help, you might tell a story or use an expression 

to illustrate that point. Most clients will “get it” 

and have a clear understanding of what is being 

communicated without feeling any disrespect. 

You simply bring a concept to the table; clients 

then interpret it and draw their own 

conclusions. 

Induct clients into their role 

As discussed in Chapter 6, your clients must 

become acquainted with you and the agency. 
Tell your clients explicitly what treatment 

involves, what is expected, and what rules there 

are. If the client has not been prepared by a 

referring source, review exactly what will 

happen in treatment so that any confusion is 

eliminated. Use language the client 

understands. Also be sure to encourage 

questions and provide clarification of anything 

that seems perplexing or not justified. Some will 

want to know why the clinic does not have more 

desirable hours, why loitering is discouraged, 

why they must come to group sessions on a 

particular schedule, or what it means to 

participate in treatment. This is the time to 

explain what information must be reported to a 

referring agency that has mandated the 

treatment, including what it means to consent to 

release information. Role induction by itself is 

not likely to prevent premature termination, but 

it does clarify to the client what is expected from 

the program’s perspective (Zweben et al., 1988). 

Explore client expectancies and 

determine discrepancies 

One of the first things to discuss with new 

clients is their expectations about the treatment 

process, including past experiences, and 

whether there are serious discrepancies with the 

reality of the upcoming treatment. To decrease 

intrusiveness, ask permission before delving 

into these private and sometimes painful areas. 

Then ask clients to elaborate on what they 

expect and what their initial impressions, hopes, 

and fears about treatment are. Showing clients a 

list of concerns other people in treatment have 

had can help them feel more comfortable 

expressing their own, which will likely be 

similar. Some of these fears include the 

following: 

The clinician will be confrontational and 

impose treatment goals. 

Treatment will take too long and require the 

client to give up too much. 

The rules are too strict, and the client will be 

discharged for the slightest infringement. 

Medication will not be prescribed for painful 

withdrawal symptoms. 

The program does not understand women, 

members of different ethnic groups, or 

persons who take a particular substance or 

combination of substances. 

A spouse or other family member will be 

required to participate. 

Many clients will have negative expectations 

based on previous and usually unsuccessful 

treatment episodes. A motivational approach 

can elicit a client’s concerns without being 

judgmental. Each client needs an opportunity to 

vent anxieties or negative reactions to the 

treatment process and have these validated as 

normal—not punishable, but therapeutic. This 

is particularly important for clients who feel 

coerced into treatment to appease someone else 

(e.g., employer, court, wife) and fear revealing 

any worries or negative reactions lest these be 

used against them. 

Unrealistic hopes about what treatment can 

accomplish—particularly without much work 

by the client—are equally dangerous and 

seductive but have to be brought out. The client 

may believe, for instance, that treatment will 

restore a marriage or erase guilt about the fatal 

auto accident that preceded admission. Perhaps 

the client hopes the program will include 

acupuncture as part of the treatment, and this is 

not an option. Be honest about what the 

program can do and what it cannot do (e.g., pay 

rent, remove effects of childhood sexual abuse, 

counteract a poor education). 

It is important that you reach understanding 

with the client about positive and negative 

expectancies before you enter into the real work 

of change. Perceptions, hopes, and concerns 

will change: As old ones are resolved, new ones 

will likely emerge. 
“Immunize” the client against 

common difficulties 

During treatment, clients may have negative 

reactions or embarrassing moments when they 

reveal more than they planned, react too 

emotionally, realize discrepancies in the 

information they have supplied, or pull back 

from painful insights about how they have hurt 

others or jeopardized their own futures. One 

way to forestall impulsive early termination in 

response to these situations is to “immunize” or 

“inoculate” your client: Anticipate and discuss 

such problems before they occur, indicate they 

are a normal part of the recovery process, and 

develop a plan to handle them. Warn the client, 

for example, that he may not want to return to 

treatment immediately after such a situation and 

that this is a common reaction. Clients may 

want to keep a diary of any strong or adverse 

reactions so that these can be discussed or 

revealed to you in subsequent sessions or even 

by telephone between sessions (Zweben et al., 

1988). Be culturally aware as you attempt to 

immunize clients against expected difficulties. 

The Native American culture, for example, is 

more comfortable with visual and oral exchange 

of information than with the written word. The 

use of art (e.g., drawing, collage) or the talking 

feather (in group) may be helpful in identifying 

common and expected difficulties to these 

clients. 

Investigate and resolve 

barriers to treatment 

As treatment progresses, clients may experience 

or reveal other barriers that impede progress 

and could result in early termination unless 

resolved. These barriers can include not 

understanding written materials easily, having 

difficulty making transportation or child care 

arrangements, or having insufficient funds or 

insurance coverage to continue treatment as 

initially planned. Sometimes clients do not feel 

ready to participate, or suddenly reconsider. 

This is usually because a planned change is too 

threatening in reality or in anticipation. 

If barriers cannot be overcome by some 

mutually satisfactory arrangement, it may be 

necessary to interrupt treatment or make 

another referral. Discuss early disengagement 

from therapy at the onset and consider what 

options might be acceptable to you and your 

client. Stress that it is all right to take a break 

from treatment, if necessary, to allow time to 

consider alternatives and prepare to act on 

them, but set up the expectation for or schedule 

a return to treatment. This type of “therapeutic 

break” is an option when other motivational 

techniques have failed (Zweben et al., 1988). 

Increase congruence between 

intrinsic and extrinsic motivation 

Ryan and colleagues found that internal 

motivation is associated with increased client 

involvement and retention in treatment, but a 

combination of internal and external motivation 

seems to promote an even more positive 

treatment response. They concluded that 

coercion or external motivation can actually fit 

into the clients’ perceptions of problems and the 

need for treatment and change (Ryan et al., 

1995). Thus, explore the significance of external 

motivators to your clients. Perceiving coercive 

forces as positive—and compatible with the 

clients’ concerns—may be more helpful than 

trying to convert all external motivation to 

intrinsic motivation. These investigators also 

hypothesized that some amount of emotional 

distress about problems, rather than a rational 

catalog of the negative impact of substance use, 

may be helpful to enhance client motivation for 

change. Anxiety or depression about life 

problems may be more significant indicators of 

readiness to change than the intensity of 

substance use itself. 
Figure 7-1 

Options for Responding to a Missed Appointment 

Telephone call 

Personal letter 

Contact with preapproved relatives or significant or concerned others 

Personal visit 

Contact with referral source 

Examine and interpret 

noncompliant behavior 

Noncompliant behavior often is a thinly veiled 

expression of dissatisfaction with treatment or 

the therapeutic process. For example, clients 

miss appointments, arrive late, fail to complete 

required forms, or remain mute when asked to 

participate. Any occurrence of such behavior 

provides an opportunity to discuss the reasons 

for the behavior and learn from it. Often, the 

client is expressing continuing ambivalence and 

is not ready to make a change. You can explore 

the incident in a nonjudgmental, problemsolving manner that probes whether it was 

intentional and whether a reasonable 

explanation can be found for the reaction. For 

example, a client might be late as a gesture of 

defiance, to shorten what is anticipated as a 

distressing session, or because her car broke 

down. The significance of the event must be 

established and then understood in terms of 

precipitating emotions or anxieties and ensuing 

consequences.

As with all motivational strategies, drawing 

out your client’s perceptions and interpretation 

of the event is important. Generally, if you can 

get clients to voice their frustrations, they will 

come up with the answers themselves. Asking a 

question such as, “What do you think is getting 

in the way of being here on time?” is likely to 

elicit an interpretation from clients and open a 

dialog. You can respond with reflective 

listening and add your own interpretation or 

affirmation. For example, you can observe that 

clients who come late to appointments often do 

not complete treatment and describe how other 

clients solved the problem in the past. 

However, do not forget to commend the client 

for simply getting there. 

Finally, alternative responses to similar 

situations have to be explored so that the client 

finds a more acceptable coping mechanism that 

is consistent with the expectations of treatment. 

Often, this exploration of noncompliant 

behavior reveals ways in which the goals or 

activities of treatment should be slowed or 

changed. Use noncompliance as a signal that 

you have to get more information or shift your 

strategy. This is much more useful than the 

client’s simply retreating and dropping out 

(Zweben et al., 1988). Means of responding to 

missed appointments are listed in Figure 7-1. 

Research-based clues or indicators of 

continuing ambivalence or lack of readiness that 

could result in premature and unanticipated 

dropout unless explored and resolved include 

the following (Zweben et al., 1988): 

The client has a history of appointment 

cancellations or early dropout from 

treatment. 

The client feels coerced into treatment and 

fears offending that coercive source. 

The client has little social stability. 

The client is hesitant about scheduling 

appointments or does not think that he can 

follow a routine schedule. 

The client does not appear to feel confident 

about capabilities for positive change and 

seems to resent the loss of status involved in 

getting help. 
The client resents completing intake forms or 

assessments. 

The treatment offered is significantly 

different from any the client has been 

exposed to previously. 

The client has difficulty expressing feelings

and revealing personal information. 

Reach out 

Certain life events, such as a client’s wedding, 

the birth of a child, a client’s traumatic injury or 

illness, or several missed appointments, might 

require you to reach out to the client to 

demonstrate personal concern and continuing 

interest in the interest of preserving the 

therapeutic relationship and enhancing the 

recovery process. However, you must be careful 

not to cross professional boundaries or put the 

therapeutic relationship at risk by violating a 

client’s privacy or confidentiality rights. An 

example of a violation might be attending the 

funeral for a member of a client’s family, 

without the client’s consent, when the family 

and friends do not know the client is receiving 

substance abuse treatment. 

Any contemplated change in the boundaries 

of the clinician−client therapeutic relationship 

must be supported theoretically, well thought 

out, discussed with your clinical supervisor, 

consistent with program policies, and reviewed 

for any legal or ethical issues that could arise.

For example, it may be your program’s policy 

that clients are treated only in the program’s 

offices. If a client is hospitalized, however, it 

may be necessary for you to go to the hospital to 

continue the client’s treatment. Such a move 

should be discussed with your supervisor. 

Privacy and confidentiality issues that should be 

addressed include obtaining the client’s written 

authorization for release of information to the 

hospital, the client’s physician, and ancillary 

personnel; and what to do if the client has a 

roommate, receives a phone call during the 

treatment session, and if a session is interrupted 

by hospital staff. 

Early in treatment, you should identify the

client’s social support network. Tactfully 

discuss with the client her preferred avenues for 

keeping in touch with her, such as written 

consent to contact certain relatives or friends. 

She will perhaps want to provide letters to 

referral sources authorizing them to respond if 

you contact them. In addition, you should be 

aware of and abide by your clients’ cultural 

mores regarding contact outside the substance 

abuse treatment setting. 

Brief adjunctive motivational 

intervention

The brief adjunctive motivational intervention in 

one study (Saunders et al., 1991) used the 

following strategies: 

Elicit the client’s perceptions of the so-called 

“good” things about substance use. 

Help the client inventory less good things 

about substance use. 

Invite the client to reflect on the lifestyle once 

envisaged, current life satisfactions, and 

what lifestyle is anticipated for the future. 

Have the client determine which, if any, of 

the elicited problems are of real concern. 

Assist the client in comparing and 

contrasting the costs and benefits of 

continuing current behavior. 

Highlight areas of greatest concern, 

emphasizing discrepancies that generate 

discomfort and genuine emotional reactions 

to the current behavior and consequences. 

Elicit and agree on future intentions 

regarding the target behavior. 

Planning for Stabilization 

In addition to handling problems that can 

interrupt treatment prematurely, work to 

stabilize actual change in the problem behavior. 

This requires considerable interactive planning, 

including conducting a functional analysis, 
developing a coping plan, and ensuring family 

and social support. 

Conducting a Functional Analysis 

Although a functional analysis can be used at 

various points in treatment, it can be 

particularly informative in preparing for 

maintenance. A functional analysis is an 

assessment of the common antecedents and 

consequences of substance use. Through 

functional analysis, you help clients understand 

what has “triggered” them to drink or use drugs 

in the past and the effects they experienced from 

using alcohol or drugs. With this information, 

you and your clients can then work on 

developing coping strategies to maintain 

abstinence. The following approach is adapted 

from Miller and Pechacek, 1987. 

To begin a functional analysis, first label two 

columns on a sheet of paper or blackboard as 

“Triggers” and “Effects.” Then begin with a 

statement such as “I’d like to understand how 

substance use has fit into the rest of your life.” 

Next, find out about your client’s 

antecedents: “Tell me about situations in which 

you have been most likely to drink or use drugs 

in the past, or times when you have tended to 

drink or use more. These might be when you 

were with specific people, in specific places, or 

at certain times of day, or perhaps when you 

were feeling a particular way.” Make sure to 

use the past tense because the present or future 

tense may unsettle currently abstinent clients. 

As your client responds, listen reflectively to 

make sure that you understand. Under the 

Triggers column, write down each antecedent. 

Then ask, “When else in the past have you felt 

like drinking or using drugs?” and record each 

response.

If your client completed a pretreatment 

questionnaire about substance use, you may be 

able to use this information to elicit any triggers 

the client did not mention. For example, “I 

notice on this questionnaire you marked that 

you might be ‘very tempted’ to drink when 

you.... Tell me about this.” Then write down 

any additional antecedents in the Triggers 

column.

After the client seems to have exhausted the 

antecedents of substance use, ask about what the 

client liked about drinking or using drugs. Here 

you are trying to elicit the client’s own 

perceptions or expectations from substance use, 

not necessarily the actual effects. 

As the client volunteers this information, 

respond with reflective listening to ensure that 

you understand, and make sure not to 

communicate disapproval or disagreement. 

Write down each desired consequence in the 

Effects column. Then ask, “What else have you 

liked about drinking or using drugs in the 

past?” and record each response. 

Again, if the client completed a pretreatment 

questionnaire about the desired consequences of 

substance use, you can use this information to 

elicit more consequences the client may not have 

brought up. For example, “I notice on this 

questionnaire you marked that you often used 

drugs to.... Tell me about this.” Write down 

any new consequences in the Effects column. 

Once the client has finished giving 

antecedents and consequences, you can point 

out how a certain trigger can lead to a certain 

effect. First, pick out one item from the Triggers 

column and one from the Effects column that 

clearly seem to go together. Then ask the client 

to identify pairs, letting the client draw 

connecting lines on the paper or blackboard. 

For trigger items that have not been paired, 

ask the client to tell you what alcohol or drug 

use might have done for her in that situation, 

and draw a line to the appropriate item in the 

Effects column. Sometimes there is no 

corresponding item in the Effects column, which 

suggests that something has to be added. Then 

do the same thing for the Effects column. It is 

not necessary, however, to pair all entries. 
With this information, you can develop 

maintenance strategies. Point out that some of 

the pairs your client identified are common 

among most users. Next, you can say that if the 

only way a client can go from the Triggers 

column to the Effects column is through 

substance use, then the client is psychologically 

dependent on it. Then make clear that freedom 

of choice is about having options—different 

ways—of moving from the Triggers to the 

Effects column. You can then review the pairs, 

beginning with those the client finds most 

important, and develop a coping plan that will 

enable the client to achieve the desired effects 

without using substances (Miller and Pechacek, 

1987). 

Developing a Coping Plan 

You can conduct functional analyses and 

develop coping strategies for every treatment 

goal. This approach addresses many factors that 

influence the well-being of the client trying to 

cope with recovery. Developing a coping plan is 

a way of anticipating problems before they arise 

and of recognizing the need for a repertoire of 

alternative strategies (see Figure 7-2). A list of 

coping strategies that others have found 

successful can be particularly useful in 

developing a plan and in brainstorming ways to 

deal with anticipated barriers to change. 

One way to help your client learn how to 

develop coping strategies is to conduct a 

functional analysis on a pleasurable activity. 

The process of developing a coping plan 

Figure 7-2 

Coping Strategies 

Coping strategies are not mutually exclusive (i.e., different ones can be used at different times) and not 

all are equally good (i.e., some more than others involve getting close to trigger situations). The point 

is to brainstorm, involve the client, reinforce successful application of coping strategies, and consider it 

as a learning experience if a particular strategy fails. 

Example #1: Client X typically uses cocaine whenever his cousin, who is a regular user, drops by 

the house. Coping strategies to consider would include (1) call the cousin and ask him not to come by 

anymore, (2) call the cousin and ask him not to bring cocaine anymore when he visits, (3) if there is a 

pattern to when the cousin comes, plan to be out of the house at that time, or (4) if someone else lives in 

the house, ask them to be present during the cousin’s visit. 

Example #2: Client Y typically uses cocaine when she goes out for the evening with a particular 

group of friends, one of whom often brings drugs along. She is particularly vulnerable when they all 

drink alcohol. Coping strategies to consider might include (1) go out with a different set of friends, (2) 

go along with this group only for activities that do not involve drinking, (3) leave the group as soon as 

drinking seems imminent, (4) tell the supplier that she is trying to stay off cocaine and would 

appreciate not being offered any, (5) ask all her friends, or one especially close friend, to help her out 

by not using when she is around or by telling the supplier to stop offering it to her, or (6) take 

disulfiram [Antabuse] to prevent drinking. 

Example #3: Client Z typically uses cocaine when feeling tired or stressed. Coping strategies might 

include (1) scheduling activities so as to get more sleep at night, (2) scheduling activities so as to have 1 

hour per day of relaxation time, (3) learning and practicing specific stress relaxation techniques, or 

(4) learning problem-solving techniques that can reduce stressful circumstances. 
provides an opportunity for positive 

reinforcement. You can use the activity to boost 

a client’s self-esteem by saying, “What can we 

learn about where you are in recovery from 

your actions? For example, when you went to 

the trigger location and didn’t use alcohol, how 

did you do it?” You can point out that 

something must have changed if the client can 

now go into a bar or restaurant and not drink. 

However, explore the motivation for going to 

the bar and ascertain whether there is a good 

reason or whether the behavior is reckless. A 

client who has developed sound coping 

strategies should be conscious of the danger, but 

not reckless. 

Occasionally, you may find that your clients 

have not pursued the new activities you have 

suggested. In these situations, strategies similar 

to those suggested earlier for a missed 

appointment may help strengthen coping 

strategies. Reevaluate the plan and modify it as 

necessary. Ask your client to rehearse coping 

strategies while in a counseling session and then 

try to implement the strategy in the real 

environment.

Ensuring Family and Social Support 

Clients are embedded in a social network that 

can be either constructive or destructive. One 

task for you and your client is to determine 

which social relationships are supportive and 

which are risky. 

Substance-free family and friends can be 

especially helpful in stabilizing change because 

they can monitor the client and model and 

reinforce new behavior. They can keep track of 

the client’s whereabouts and activities, involve 

the client in new social and recreational 

activities, and be a source of emotional and 

financial support. Other types of support are 

instrumental (e.g., babysitting, carpooling), 

romantic, spiritual, and communal (i.e., 

belonging to a particular group or community). 

Sources of support, however, also can be 

stressors—for example, if a female client has

family members who both depend on her and 

support her. Support can have costs that 

sometimes leave your client feeling, “Now I owe 

you.” Help the client pinpoint the reasons for 

using or not using different sources of support.

Ask clients the following questions: 

What kinds of support do you want? 

What sources of support do you have? 

What holes are there in your network of 

support?

By identifying the array of support sources 

your client has available, you can help 

determine any gaps in the support system. At 

the same time, caution the client not to rely too 

heavily on any one source of support. Next, you 

can help the client develop an early warning 

system with a partner or significant other; this 

person can learn to recognize the triggers and 

signs that your client is returning to substance 

use and can intervene effectively (Meyers and 

Smith, 1997). In a 12-Step program, the sponsor 

fills this role. 

Try to ascertain what clients are willing to 

change in their lives. How your clients want to 

make changes and what timing is appropriate 

are of particular concern. In many communities, 

although it can be dangerous to interact with 

active users in terms of triggers and ready 

access, for some clients it is just as dangerous to 

cut ties with their substance-using social 

network.

Sometimes, heroin users will welcome a 

member of the group who has stopped using 

back into the network. Clients who use 

substances have to be innovative in coming up 

with solutions to unique problems. Clients 

surrounded by substance-using friends may

have to have acceptable reasons to offer as to 

why they are not currently using substances— 

for example, the client’s wife is pregnant and 
can’t use, or the client must submit drug-free 

urine regularly to keep a job. 

Your clients also need help in figuring out 

how to handle drug suppliers. Assist them in 

describing the nature of these relationships and 

the level of emotional support provided. Some 

clients do not really know the meaning of 

friendship—what they can expect or count on 

for support as well as their reciprocal 

responsibilities. Use motivational interviewing 

techniques to develop discrepancies, find out 

what clients intend and are willing to do to 

decrease perceived discrepancies, and introduce 

the concept of setting boundaries. The case 

studies in Figures 7-3, 7-4, and 7-5 depict 

different support scenarios you and your clients 

may encounter. 

Involving a spouse or significant other in the 

treatment process also provides an opportunity 

for a firsthand understanding of the client’s 

problems. The significant other can offer 

valuable input and feedback in the development 

and implementation of treatment goals. 

Additionally, the client and the significant other 

can work collaboratively on issues that might 

stand in the way of attainment of treatment 

goals. Project MATCH, a multisite clinical trial 

of patient–treatment matching sponsored by the 

National Institute on Alcohol Abuse and 

Alcoholism, included motivation enhancement 

therapy (Miller et al., 1992). In this trial, the 

greatest number of subjects chose spousal 

support as the maintenance factor most helpful 

in maintaining their resolution to change. This 

finding is consistent with those of treatment 

Figure 7-3 

Case Study 1: Client With Drug-Using Social Support 

Client context: Mary is a pregnant 30-year-old woman who lives with her young son. Her 

boyfriend, the father of both children, visits frequently and provides total financial support for Mary. 

He is a crack dealer and user. Mary’s urine test, administered in routine prenatal care, was positive for 

cocaine. Her health care provider referred Mary to a treatment clinic. 

Therapeutic realities: In Mary’s situation, the goal of ending her relationship with the boyfriend is 

not realistic, although, in the long term, she may be able to break away from this man. A direct 

confrontation on this issue would be counterproductive. 

Therapeutic strategies: It is possible to use motivational counseling to encourage Mary’s progress. 

Functional analysis can be used to develop some discrepancy and tension between her goal to cease 

cocaine use during pregnancy and the realities of her living situation. The pros of maintaining the 

relationship include continued financial and emotional support. The cons include exposing her son 

and unborn child to cocaine. Given the situation, what is Mary willing to do? 

Developing options: Mary never uses cocaine in front of her son, but she doesn’t feel she can ask 

her boyfriend not to. Through therapy, Mary does some problem solving and develops coping 

strategies to allow her to continue seeing the father of her children without having drugs in her house. 

The therapeutic relationship is used to enhance her motivation to take some kind of positive action, to 

revisit her motivation and commitment (which currently is to the boyfriend), and to explore potential 

responses that will begin to put limits on this situation. 

Note that you might be legally required to report to the child welfare agency any concern about 

drug use occurring in front of the woman’s son. (For more information on this issue see the 

forthcoming TIP, [CSAT, in 

press (b)]). 
Figure 7-4 

Case Study 2: Client Lacking Social Support 

Client context: Susan is a 41-year-old woman in an abusive marital relationship. She has suffered 

from alcohol dependence most of her adult life but has initiated recovery efforts through five counseling 

sessions. Her mother has paranoid schizophrenia, and therapy reveals that her father, also suffering from 

alcohol dependence, molested Susan for years when she was a child. 

Therapeutic realities: Susan is estranged from her mother and abusive husband. Therapy now 

reveals that Susan’s sole source of support is the father who molested her. She telephones him and cuts 

off contact. As she progresses in recovery, however, she is no longer numbed and made compliant by 

alcohol and begins to have serious problems with her own children. They do not support her recovery 

efforts—they want her to return to being an easygoing drinking mom. The therapeutic reality is that 

now, because of the recovery process, Susan has less emotional and social support. 

Therapeutic strategies: As a starting point, Susan can be brought into a 12-Step program or similar 

mutual-help group to replace the support for recovery she has lost. Additionally, your support as a 

clinician is integral to her recovery. Provide support, referral, and followup, and make special efforts to 

be available to her. 

studies and natural recovery studies that family 

environment is one of the most notable factors 

associated with positive outcomes (Azrin et al., 

1982; Sobell et al., 1993b). 

Finally, some therapists model social 

behaviors in public for their clients as part of 

therapy. Examples would include modeling the 

behavior and skills required for everyday 

activities, such as opening a bank account or 

going grocery shopping. Some theoreticians 

argue that providing realistic guidance is 

preferable to rehearsed and stilted play-acting in 

the office. 

Whether or not you choose to provide this 

type of “help” depends, of course, on your 

therapeutic orientation, guidelines, program 

policies, and awareness of the client’s cultural 

mores. Before undertaking such a strategy you 

should carefully think through it, weighing the 

benefits versus the potential harm and 

discussing the plan with your supervisor. For 

example, going out with a client can be easily 

misinterpreted by the client as an act of 

friendship or even intimacy rather than therapy. 

This can lead to boundary and therapeutic 

relationship problems that can put both you and 

your client in awkward situations that 

complicate treatment. 

Developing and Using 

Reinforcers

After clients have planned for stabilization by 

identifying risky situations, practicing new 

coping strategies, and finding sources of 

support, they still have to build a new lifestyle 

that will provide sufficient satisfaction and 

compete successfully against the lure of drug 

use. Ultimately, a broad spectrum of life 

changes must be made if the client is to maintain 

lasting abstinence. These changes must be 

adequately extensive and pervasive so that they 

supplant the client’s former substance-using 

lifestyle. This represents a formidable task for 

the client whose life has become narrowly 

focused on acquiring and using substances. You 

can support this change process by using 

competing reinforcers and external contingent 

reinforcers in the early phases of treatment to 

encourage positive behavioral change. 
Figure 7-5 

Case Study 3: Payday as a Trigger 

Client context: Joseph is a member of the Mohawk, living on tribal lands in New York State. Along 

with the other members of the band, Joseph receives regular payments from the Federal government for 

land use and treaties, as well as checks for his share of the proceeds from the group’s casino. Receipt of 

these checks is often a trigger for substance use. The checks have replaced Joseph’s motivation for 

gainful employment; they also have removed the need for criminal behavior to procure drugs. Because 

casino checks are becoming larger, the issue is becoming increasingly severe for Joseph. 

Therapeutic reality: Joseph uses his casino checks as sole support, yet receiving them may serve as a 

trigger to his drinking. 

Therapeutic strategies: The paychecks in this case are an example of ongoing support that occurs 

regardless of substance abuse. Elicit from the client other ways in which the money could be used that 

would be rewarding, consistent with the client’s life goals, constructive to family or community, healthpromoting, and so forth. Elicit from the client practical ideas about how to prevent the receipt of checks 

from triggering substance use. Consider how supportive others might help the client redirect income 

from substance use to other reinforcing options. 

Natural Competing Reinforcers 

Competing reinforcers are effective in reducing 

substance use. A competing reinforcer is any 

source of satisfaction for the client that can 

become an alternative to drugs or alcohol. 

Research has demonstrated, for example, that 

laboratory animals are less likely to begin and 

continue taking cocaine when an alternative 

reinforcer (in this case, a sweet drinking 

solution) is available in their cages (Carroll, 

1993). This principle applies to humans as well; 

other studies in laboratory settings have shown 

that if given a choice between substances and 

money, people will choose to forgo substances 

when the alternative is sufficiently attractive 

(Hatsukami et al., 1994; Higgins et al., 1994a, 

1994b; Zacny et al., 1992). Clearly, people do 

make choices about their substance use, and it 

helps when the alternative choices are explicit, 

immediately available, and sufficiently 

attractive to compete with substance use. This is 

the ideal you are trying to work toward, and 

external reward systems can be especially 

helpful. (See the section on the voucher 

incentive system later in this chapter.) 

The essential principle in establishing new 

sources of positive reinforcement is to get clients 

to generate their own ideas. You can guide 

them toward social reinforcers, recreational 

activities, 12-Step programs, and other positive 

behavioral reinforcements by developing a list 

of common pleasurable activities (Meyers and 

Smith, 1995). Couples therapy is useful to help 

clients reconnect to things they used to do 

before they became heavily involved in 

substance use, or to activities that never 

occurred during a couple’s relationship because 

they came together as a substance-using couple. 

It is important to examine all areas of a 

client’s life for new reinforcers, which should 

come from multiple sources and be of various 

types. Thus, a setback in one area can be 

counterbalanced by a positive reinforcer from 

another area. Additionally, because clients have 

competing motivations, help them select 

reinforcers that will prevail over substances over 

time. Especially when substances permeate 

their lives, stopping can be a fundamental life 

change. As the motivation for positive change 

becomes harder to sustain, clients need strong 
reasons for overcoming the challenges they will 

face. 

Small steps are helpful, but they cannot fill a 

whole life. Abstaining from substances is an 

abrupt change and often leaves a large blank 

space to fill. You can help your client fill this 

void by suggesting potential activities, such as 

the following: 

Do volunteer work. This alternative is a link 

to the community. The client can fill time, 

reconnect with prosocial people, and 

improve self-efficacy. Volunteering is a

direct contribution that can help resolve guilt

the client may feel about previous criminal or 

antisocial behavior. For example, a 

California program for Hispanics and 

African-Americans in recovery involved 

clients in a door-to-door survey, collecting 

data for the community and identifying 

people in crisis following the Los Angeles 

earthquake. Although the clients themselves 

did not get a monetary reward, the 

community benefited, and the daily 

debriefing solidified clients’ commitment to 

their recovery by affirming their ability to 

help someone else. 

Become involved in 12-Step activities. 

Similar to volunteering, this fills a need to be 

involved with a group and contribute to a 

worthwhile organization. 

Set goals to improve work, education, health, 

and nutrition. 

Spend more time with family, significant 

others, and friends. 

Participate in spiritual or cultural activities. 

Learn new skills or improve in such areas as 

sports, art, music, and hobbies. In the Native 

American community, for example, 

counselors take clients to the country and 

teach them about the gifts of nature (e.g., 

herbs, trees, animals) and how these gifts 

contribute to healing and continued 

recovery.

Clients do not have to make a big 

commitment or investment; they can just sample 

available opportunities (Meyers and Smith, 

1997). Peer acceptance and meeting peer 

expectations within the context of a residential 

treatment or high-functioning therapeutic group 

serve as reinforcement. People in 12-Step 

programs, for example, try to excel in a 

newfound social network with the goal of 

reaching an altruistic state in the 12th step. 

External Contingent Reinforcers 

The principles of contingent reinforcement can 

be applied to sustain abstinence while clients 

work on building a substance-free lifestyle. The 

specific awards chosen can be tailored to the 

values of the clients and resources of the 

program. Besides natural reinforcers, some 

programs have used temporary contingencies to 

change substance use. Voucher incentive 

programs have several benefits that recommend 

their use. First, they introduce a clear and 

systematic point system that provides structure 

and clarifies expectations for both clients and 

staff. Second, they allow clients to select for 

themselves the rewards that they find desirable, 

which should maximize the effectiveness of the 

procedure. Finally, voucher systems have been 

tested in research and shown to be effective 

(Budney and Higgins, 1998). Because it may 

take some time to establish the other new 

behaviors, these programs probably should be 

in place a minimum of 3 to 6 months. 

Voucher incentives 

Voucher programs are a type of contingency 

reinforcement system, and research has shown 

that they can be effective for sustaining 

abstinence in substance users. The rationale is 

that an appealing external motivator can be an 

immediate and powerful reinforcer to compete 

with drug reinforcers. Because a common 

correlate of substance addiction is the need for 

immediate gratification, vouchers and other 
incentives can be used to satisfy this need 

appropriately. 

The reinforcers used in voucher incentive 

programs should be attractive and engaging to 

the individual client. Research has 

demonstrated that money or an equivalent 

alternative is nearly always appealing. 

Vouchers are slips of paper showing points the 

client has earned for abstinence. Each point has 

a cash value (e.g., $1). Additional points are 

accumulated each time the client submits drugfree urine, for example. The voucher acts as an 

IOU from the program. In a typical voucher 

system, clients trade in their points for goods 

and services. Clients often want to pay bills 

with their voucher or spend their money on 

retail purchases (e.g., groceries, clothing, shoes). 

Staff members arrange to pay the bills and 

purchase these items. An alternative to this 

system is to give the clients cash and let them 

make the purchases themselves. This is a risky 

option, however, because clients could use the 

money to buy substances. Therefore, the extra 

work for staff can be worth the effort. 

Research has shown that voucher reinforcers 

work well to promote treatment retention and 

sustained abstinence among cocaine abusers 

enrolled in outpatient treatment. For example, 

Higgins and colleagues, who developed and 

tested voucher incentives, showed that this 

procedure combined with an intensive 

behavioral counseling program could retain 

between 60 and 75 percent of cocaine abusers in 

an outpatient treatment program for 6 months 

(Higgins et al., 1993, 1994b). In contrast, control 

patients in the investigators’ clinic who received 

intensive counseling therapy but no vouchers 

had a 40 percent retention rate, and control 

patients who received 12-Step counseling had an 

11 percent retention rate. In voucher programs, 

patients not only stay in treatment but also 

remain substance free. In two published 

studies, 68 percent and 55 percent of patients in 

the voucher program were cocaine free for 8 

consecutive weeks, whereas only 11 and 25 

percent of the control patients who did not 

receive vouchers stayed cocaine free. In these 

studies, voucher incentives were given only for 

the first 3 months of treatment, with lottery 

tickets offered during the second 3 months as an 

incentive for drug-free urine (Higgins et al., 

1993, 1994b, 1995). 

Voucher incentives can be effective for 

controlling cocaine use among methadone 

maintenance patients who chronically abuse 

cocaine (Silverman et al., 1996). In this study, 

patients receiving vouchers for cocaine-free 

urine samples achieved significantly more 

weeks of cocaine abstinence and significantly 

longer durations of sustained abstinence than 

controls. Forty-seven percent of patients who 

were offered vouchers sustained 7 or more 

weeks of continuous cocaine abstinence whereas 

only one control patient achieved more than 2 

weeks of sustained abstinence. These results are 

impressive because it is typically difficult to get 

methadone maintenance patients to stop using 

supplemental drugs during treatment. Voucherlike interventions have been used effectively to 

motivate reductions in substance use and other 

behavior change among schizophrenics, people 

with tuberculosis, homeless, and other special 

populations of illicit substance abusers (Higgins 

and Silverman, 1999). 

Other innovative programs have been tried. 

For example, one program used vouchers to 

encourage pregnant women to quit smoking. 

Staff solicited retail items from the community 

that could be earned by clients following each 

appointment if they passed a carbon monoxide 

breath test indicating they had not smoked. 

Although a range of products and services were 

available for purchase by the vouchers, mothers 

most often chose baby items, affirming their 

motivation to quit smoking for their children’s 

health.

A reinforcement system that is monetary but 

relies on the individual rather than a voucher is 
to help clients identify specific items they would 

like to have or enjoy—for example, a new 

bedroom set or computer. Clients then set aside 

money on a daily or weekly basis that would 

have been spent on substances and eventually 

purchase the item. Obviously, there would be 

concern that any accumulated money could be 

used as part of a recurrence. As a solution to 

this problem, the saved money could be kept 

with a nonusing family member or friend. 

In the Community Reinforcement Approach 

(CRA), monetary incentives (external 

motivators) are meant to be spent on activities 

or retail items that will directly increase the 

client’s chance of achieving stated goals 

(intrinsic motivators). Under this model, 

external and intrinsic factors must be congruent 

or the voucher system will have little influence 

(see the section later in this chapter). 

When families are included in treatment, a 

voucher incentive can be developed with the 

client and key family members. For example, 

when the client is abstinent for 90 days, he can 

visit his parents for Sunday dinner, or when 

another client has made 90 meetings she can 

have her children over for a visit. Parents might 

want to work out vouchers with recovering 

children; for example, after six therapy sessions 

the child can go out on the weekend or use the 

car, and after 90 days of sobriety the allowance 

or other “goodies” can be reinstated. 

What types and amounts of incentives 

should be used? The voucher programs tested 

so far have offered more than $1,000 that could 

be earned during a 3-month period. Research 

with cocaine abusers has demonstrated that the 

greater the value of the monetary incentive, the 

more powerful a reinforcer it is—that is, more 

people become abstinent (Silverman et al., 1997). 

Aside from theoretical issues about the 

optimal size of rewards, there are practical 

considerations having to do with financial, 

staffing, and administrative resources of the 

clinic. Voucher systems offering smaller 

incentive values have not been systematically 

tested yet, but they are likely to work for some 

clients. Treatment programs can consider 

soliciting prizes from local businesses as a 

source of program incentives. 

Clinicians and programs may also find 

creative ways to make naturally occurring 

sources of financial support contingent on 

abstinence. Family members have often spent 

large amounts of money treating, supporting, 

and handling the adverse consequences 

experienced by a substance-dependent loved 

one. It is possible to negotiate with the family to 

stop all such noncontingent support, and 

instead, offer financial support in a manner that 

helps the person establish sobriety. By special 

arrangement (e.g., with the client’s consent), 

noncontingent support checks could be 

channeled through a contingency plan. 

Not all contingent incentives must have a 

monetary value. In many cultures, money is not 

the most powerful reinforcer. For example, 

offering money would be disrespectful among 

cultures that value benefits to the community 

over individual gain. In more communal 

cultures (e.g., Native American, AfricanAmerican), spirituality may be interwoven in 

the ethnic value system. Contingency incentives 

can reflect those ceremonies and activities that 

support the sacred. In the Native American 

community, these can include gifting, earning a 

feather, honoring spiritual kinship, using a 

talking feather, and smoking a prayer pipe. The 

case study in Figure 7-6 highlights the 

importance of cultural values as motivators for 

change. Contingency incentives should be 

culturally appropriate and linked to the clients’ 

values.

Community Reinforcement 

Approach

CRA emphasizes the development of new 

natural reinforcers that are available in the 

everyday life of the substance user and that can 
Figure 7-6 

Using Cultural Values as Motivators 

John and Mary Red Fox, surviving through part-time jobs and seasonal work, lived in fairly 

impoverished circumstances on a reservation with their three children. Both were high school 

dropouts. John, age 27, and Mary, age 22, abused alcohol, although John completed an inpatient 

treatment program for alcoholism just prior to his recent return to use. The children were described by 

their parents as unmanageable, easily distracted, difficult to communicate with, and hyperactive. 

There were indications that Mary had been physically and sexually abused as a child and that Mary’s 

stepbrother had sexually abused her two older children. 

The Tribal Law Enforcement Center made the referral to a rural social work agency after John was 

arrested for suspicion of spouse abuse. As he began an assessment, the social worker learned that 

members of the family had periodically received counseling from various agencies and that John and 

Mary had sporadically attended AA meetings. Apart from medical and dental services, however, the 

services they had received were deemed ineffective. 

On the face of it, the problems seemed overwhelming: (1) family instability and crisis were 

heightened by the couple’s use of alcohol and John’s threatening behavior to Mary; (2) the couple’s lack 

of job skills and education elevated their risk of poverty; (3) frequent marital discord was partly a 

result of alcohol abuse and inconsistent parenting; (4) the children were struggling with significant 

impairments, perhaps contributed to by fetal alcohol syndrome; and (5) alcohol abuse was ubiquitous 

in the community in which they were living. 

However, there were also several strengths. The family had remained intact, with both parents 

eager to salvage their relationship. John and Mary had developed their talents, and their neat and 

orderly home was colorfully decorated with Native American arts and crafts. Finally, the recent 

establishment of a program in their community, designed to revitalize traditional Indian beliefs and 

culture, offered an alternative to traditional agency-oriented interventions. This program included a 

summer camp for children in beautiful surroundings with canoes, wigwams, tepees, and an earth 

lodge. 

The social worker encouraged the school system to refer John and Mary’s children to this camp, and 

then encouraged the camp director to reach out to John and Mary and invite them to become teachers. 

Mary responded positively and helped teach skills in making Indian dance regalia. While initially 

hesitant, John eventually agreed to help with the planning of a children’s powwow, including building 

a sweat lodge. Both parents became invested not only in their children’s experiences in the camp but 

also in earning respect for themselves. John participated in many sweats and aspired to live his 

recovery and life to earn the honor to become a pipe carrier and to take part in the Sun Dance 

Ceremony.

As the family became more involved in the program, there were no further instances of alcohol 

abuse or domestic violence. Both parents rejoined AA, completed their general equivalency diplomas, 

and began college, and their children had fewer problems in school. 

Wahlberg, 1996. 

compete with powerful psychoactive this holistic approach uses behavioral strategies 

substances. (See Chapter 4 for a discussion of in an attempt to make a person’s abstinent 

CRA in the contemplation stage.) Essentially, lifestyle more rewarding than the destructive 
patterns associated with drinking or drug use. 

This entails bolstering alternative sources of 

positive reinforcement derived from legitimate 

employment, family support, and social 

activities. Furthermore, the clinician tries, 

insofar as possible, to make these alternative 

sources of reinforcement immediately 

contingent on sobriety in order to boost 

motivation for remaining substance free. CRA 

also builds new competencies through skills 

training, with information about the need for 

particular coping skills derived from a 

functional analysis that identifies high-risk 

situations. Some of the strategies used in CRA

include 

Using motivational counseling to move 

participants toward their goals 

Building competency 

Applying competing reinforcers 

Tying reinforcers to abstinence 

Emphasizing the multifaceted nature of 

recovery

Tying natural reinforcers to abstinence is a 

central feature of CRA. Unlike vouchers, 

natural reinforcers such as praise for a job well 

done, occur in a client’s normal, daily 

environment. A natural, uncontrived reinforcer 

can also be internal, such as perceiving oneself 

as a good worker. While straightforward in 

concept, the attempt to link reinforcers to 

abstinence can be difficult to implement in 

practice. For example, an ideal situation would 

be one in which an employer would agree to 

allow people to work and earn money only on 

days when they test drug and alcohol free. In 

this way, the benefits of work, including the 

money that can be earned, are tied to abstinence 

and denied temporarily in the event of 

substance use. The treatment program would 

either have to make special arrangements with 

employers or operate its own worksite, and easy 

access to a drug-testing laboratory would be 

needed to provide immediate feedback. The 

workplace described in Figure 7-7 is an example 

of this type of program. 

Another source of immediate reinforcement 

is the romantic or marital partner or other 

substance-free supporter. Much research 

indicates the efficacy of behavioral marital 

therapy (O’Farrell, 1993). In CRA, a contract can 

be negotiated between clients and their partners 

that outlines abstinence contingent interactions. 

For example, partners may agree to prepare 

special meals or take part in activities that 

clients enjoy so long as they remain abstinent. 

Alternatively, if there is evidence of a recurrence 

of substance use, the partner agrees to forego 

favored activities and withhold social 

reinforcers, possibly even leaving the home 

temporarily until there is evidence of return to 

abstinence. To make this work, the treatment 

program should provide regular information to 

partners about drug-test results (after obtaining 

consent from clients) so they can take 

appropriate action in accordance with the 

contract. Partners also most likely need support, 

encouragement, and problem-solving help from 

the clinician. 

New social and recreational activities can be 

important sources of alternative reinforcement. 

This is often a difficult area in which to make 

changes, however, and clients may need support 

to get started on new activities. CRA involves 

the clinician as an active change agent, helping 

the client directly achieve the goal and modeling 

new behaviors. This can be especially valuable 

in encouraging new social or recreational 

activities. 

In addition to arranging for appropriate 

delivery of reinforcers in the natural 

environment, setting goals, and modeling new 

behaviors, the CRA clinician teaches skills that 

the client may need for acquiring and sustaining 

alternative reinforcers. This may include social 

skills, problemsolving skills, and various selfmanagement skills such as assertiveness. 

Particularly for clients from disadvantaged 
Figure 7-7 

Therapeutic Workplaces for Individuals With Substance Abuse Disorders 

The opportunity to learn and work can be reinforcing for persons with substance abuse disorders, 

particularly if they are paid for participating. Remedial academic programs, vocational training, and 

actual worksites all can be places where skills are enhanced while abstinence is sustained. This is done by 

allowing these individuals to participate and be paid only when their urine tests are drug free. 

A therapeutic workplace developed by Dr. Kenneth Silverman in Baltimore, Maryland, illustrates this 

principle. This workplace offers intensive remedial academic training and job skills to drug users who 

grew up in an impoverished inner city environment and may never have learned basic reading or 

mathematics. So far, the program has been tested only with women who are concurrently enrolled in a 

comprehensive program for pregnant drug users. Participants report every weekday for 3 hours of 

training and can earn voucher points at a rate that corresponds to their duration of abstinence and 

participation (average compensation is roughly $10 per hour). A skilled remedial education teacher 

conducts an intensive class, where participants can rapidly improve their academic skills and learn jobrelated skills. 

Research has shown that the women who participate in this program have long periods of abstinence 

from heroin and cocaine and that they have much better drug use outcomes than a similar sample of 

control women who were not invited to participate in the therapeutic workplace. The women who join 

this program are happy with their chance to improve their academic and job skills and believe that this 

training will better prepare them to compete in the job market. 

Silverman et al., 1997. 

groups, it may be especially important to teach 

the skills needed to get a job. 

A special component of CRA called the Job 

Club offers clients skills training, critique of job 

applications, tips on making telephone calls to 

potential employers and dressing for interviews, 

and practice in being assertive and positive with 

potential employers Azrin and Besalel, 1980; 

Meyers and Smith, 1995). The four key areas of 

emphasis are 

Telephone contact skills 

Telephone contact goals 

Job application skills 

Job interview skills 

Job Club is a highly structured program that 

guides participants toward higher levels of 

concrete action—for example, by making 10 

phone calls per day to relatives or friends who 

have jobs and making “cold calls.” Research 

supports its efficacy in helping clients find 

employment (see, for example, Azrin and 

Besalel, 1982). 

The program also coaches individuals with 

substance abuse disorders on the sensitive issues 

they face. A man, for example, who spent 

several years in jail can benefit by learning how 

to handle gaps in his employment history that 

may be questioned during a job interview. The 

program also emphasizes identifying 

competencies from the client’s history and 

putting them in the résumé. For example, a 

woman with young children may not have held 

a paying job for years, but she may have 

performed volunteer work. This experience 

should be included in her résumé. 

Job Club counselors make clear that finding a 

job is sometimes difficult. Because 

disappointments inherent in any job search can 

present the first setback for clients after they 

enter treatment, Job Club coaches them on how 

to handle rejection and gives them a safe setting 
in which to work through any sense of failure. 

It also gives participants a forum where they can 

talk and reduce their feelings of isolation and 

loneliness.

When clients get jobs, their participation in 

Job Club ends. At that point, it is usually up to 

the counselor or clinician to continue any work 

needed for sustaining employment (i.e., check 

client expectations versus perceived realities, 

identify and solve job-related problems). 

Job Club is particularly valuable because 

employment and financial support are crucial 

elements of identity and lifestyle. Both stopping 

substance use and getting a job reflect large, 

abrupt changes in lifestyle; however, the skills 

needed to achieve one goal can complement 

attainment of the other. Job Club fills a need 

because it helps clients take action. In terms of 

the model of change, research shows that clients 

need to feel successful in changing behavior to 

stay in the action and maintenance phases. 

Although Job Club may seem directive, it assists 

with behavioral change that can promote 

treatment success. 

Motivational techniques can be used when 

talking to clients about their vocational goals 

and even when implementing skills training 

aimed at finding a job. The clients’ commitment 

to becoming employed may have to be revisited 

using decisional balance techniques. 

Expectancies can be discussed about both the 

skills-training and job-finding processes. The 

value of program-based skills training, however, 

is that fears can be allayed by repeated roleplaying performed in a protected environment 

with a clinician who will provide objective, 

nonjudgmental feedback. 

Finally, job-skills training may have to be 

broadened to include a component on job 

maintenance—or how to keep a job. Keeping a 

job requires skills that are often eroded by 

substance abuse disorders, including being 

punctual and organized, being able to solve 

problems that arise on the job, and being able to 

trust others and work effectively in a team. 

Employment serves as an immediate 

reinforcer by meeting the practical need for 

money, but other aspects of employment take 

time to become reinforcing. For example, 

employment builds self-efficacy. It also gives 

clients an opportunity to learn new work skills 

and meet new drug-free people. Other areas of 

a client’s life—socializing, romance, family, 

recreation, education, and spirituality—also 

may take time to realize full potential as 

alternative reinforcers. For this reason, voucher 

incentive programs can be useful at the start of 

therapy to bridge the gap. The delay in 

gratification inherent in starting new activities 

also suggests that the CRA counselor should 

encourage and assist clients in developing new 

behaviors and contacts in as many areas as 

possible because clients may not follow through 

in all areas and some areas may become 

reinforcing sooner than others. 

As your clients focus on changing each area 

of their lives, there will be new opportunities 

both to teach skills and to enhance the network 

of nondrug social reinforcers. For example, 

studies have shown that women who attend 

parenting classes to learn about normal stages of 

child development generally develop social ties 

with other mothers and reap social benefits in 

addition to improving parenting skills. 

Peterson’s research in this area suggests that it 

would be beneficial to build parenting classes 

into treatment programs because of these 

multiple benefits (Peterson et al., 1996; Van 

Bremen and Chasnoff, 1994). Another novel 

concept is a parenting class for parents of 

teenagers, which would serve a similar need 

while enhancing social ties. Although such 

programming is not provided in most 

community treatment programs, it could be 

valuable. 

CRA is a comprehensive approach to 

delivering therapy to clients. CRA counseling 
on its own has proven effective when tested 

with alcoholics, and CRA plus vouchers has 

proven highly effective as a treatment with 

cocaine abusers. CRA recognizes the 

importance of motivation and incorporates 

motivational techniques including abstinence 

contingencies to build alternative substance-free 

lifestyles. Establishing a satisfying substancefree life takes time and perseverance, with many 

hurdles along the way. Commitment and 

motivation are recurrent issues. CRA and other 

motivational techniques can be valuable tools 

for the clinician as clients seek to change their 

lifestyles. 

Motivational Counseling 

During Maintenance 

To this point, this chapter has focused on 

helping clients prepare for and stabilize their 

recovery. As a final note, a motivational 

approach can also be quite useful in counseling 

clients during the maintenance stage. The most 

likely reason for your seeing a client after actionoriented treatment has concluded, of course, is a 

recurrence of substance use and related 

problems.

As described in the opening chapters, this 

TIP has been developed with a keen awareness 

of the language that is used in treatment and the 

underlying assumptions implied by common 

terms. The term “relapse” has been 

intentionally omitted because of the baggage it 

carries. The Consensus Panel sought not to find 

a euphemism for relapse but to write in a 

manner that fundamentally reconceptualizes the 

recurrence of substance use after treatment. 

This reconceptualization recognizes several 

well-documented observations: 

Recurrence of use is the norm rather than the 

exception after treatment. It is so common as 

to be thought of now as a normal part of the

change and recovery process. 

The term “relapse” itself implies only two 

possible outcomes—success or failure—that 

do not describe well what actually occurs. 

Client outcomes are much more complex 

than this. Often in the course of recovery, 

clients manage to have longer and longer 

periods between episodes of use, and the 

episodes themselves grow shorter and less 

severe.

The binary assumptions inherent in the 

“relapse” concept can also be a self-fulfilling 

prophecy, implying that once use has 

resumed there is nothing to lose, or little that 

can be done. Instead, the point is to get back 

on track as soon as possible. 

The relapse concept, when applied to 

substance abuse, also lends itself to 

moralistic blaming or self-blaming. In fact, 

recurrence of symptoms is common to 

addictive behaviors, and indeed to chronic 

health problems in general. 

Part of a motivational approach in 

maintenance, then, has to do with a mental set

about the meaning of recurrent use and how to 

respond. When one thinks in terms of “relapse,” 

there is a temptation to lapse into lecturing, 

educating, even blaming and moralizing (“I told 

you so”). The very same principles described 

for helping precontemplators and contemplators 

can be used here. In fact, recurrence of use in a 

way constitutes a return to one of these stages. 

The reason for not considering change may be 

different, of course, the second or fifth time 

around. It may have more to do with 

discouragement, low confidence in the ability to 

change, or a defensive rationalization of 

resumed use. Your job is to help your client not 

get stuck at this point but move back into 

preparation and action. 

There are no special tricks here. The 

approach is the same. Ask for your client’s own 

perceptions and reactions to resumed use. Elicit 

from your client the self-motivational reasons 

for change, the reasons to get back on track. 

Explore what can be learned from the 

experience; a functional analysis of the process 
of resumed use may be helpful. Normalize the 

experience as a common and temporary part of 

the spiral of recovery. Have your client talk 

about the advantages of abstinence. Use plenty 

of reflective listening, not just a string of 

questions. Explore the client’s values, hopes, 

purpose and goals in life. Ask a key question— 

what does the person want to do now—and 

move on toward a plan for renewed change. 

8 Measuring Components of 

Client Motivation 

Motivation is multidimensional, not a

single domain that can be easily 

measured with one instrument or 

scale. This chapter describes a variety of tools 

for measuring the building blocks of motivation 

discussed throughout this TIP. This chapter 

should be regarded as a progress report because 

concepts of motivation for change are evolving, 

and new approaches for assessment are being 

tested. Measures often have to be adapted, and 

their psychometric characteristics change when 

they are applied to new problems and 

populations. There are also specificity 

challenges in assessing motivation. For 

example, clients are often at very different 

points of readiness with regard to different 

substances. A person may be in the action stage 

for cocaine, the contemplation stage for alcohol, 

and the precontemplation stage for marijuana 

and tobacco. No doubt, motivation measures 

will become more precise in the years ahead. 

In this chapter is a set of measures endorsed 

by the Consensus Panel. For most measures, 

there is good psychometric documentation, but 

some are at earlier stages of validation. Most 

have not been normed for different racial or 

ethnic groups. Many clinicians have found 

these formal tools to be valuable and appreciate 

the structure and focus these instruments can 

provide—the sense that their work with the 

client is task-centered and grounded in reality. 

The results also provide one more type of 

feedback to use with clients throughout the 

change process to enhance motivation. For

some clients, test scores add a dimension of 

objectivity to the counseling situation, which 

may otherwise seem highly subjective. One risk 

to be aware of in using these tools, however, is 

that some clients might focus too heavily on 

scores indicating their vulnerabilities rather than 

on those indicating their strengths. 

This chapter offers ways of measuring the 

following dimensions of motivation: 

Self-efficacy 

Readiness to change

Decisional balancing 

Motivations for using substances 

Goals and values 

The purpose of this chapter is to aid you in 

assessing where clients are in terms of 

motivation levels and also to help you apply the 

motivational principles and appropriate 

strategies for different stages of change that are 

discussed in Chapters 4 through 7. A variety of 

valuable and psychometrically sound 

instruments and scales that are easy to 

administer are now available (Allen and 

Columbus, 1995). You may wish to try several 

different instruments to find those that work

best with your clients, that measure the 

dimensions of most interest to you, and that 

match your clinical style. Many of the 
instruments discussed in this chapter appear in 

Appendix B. 

Self-Efficacy

Individuals in recovery have very different 

levels of confidence regarding their ability (selfefficacy) to change and abstain from substances. 

Some are overly confident, while others feel 

hopeless about achieving sobriety or even 

reducing use. Self-efficacy, particularly with 

respect to capabilities for overcoming alcohol 

dependence or abuse, is an important predictor 

of treatment outcome (DiClemente et al., 1994). 

Because certain situations are more likely to lead 

to setbacks for those in recovery (Marlatt and 

George, 1984), identifying these high-risk 

situations is an important step in treatment. 

Self-efficacy questionnaires ask clients to rate 

how risky certain situations are and to estimate 

their confidence in how well they would do in 

avoiding the temptation to use substances in 

these situations. The numerical scores provide 

an objective measure of a client’s self-efficacy for 

a specific behavior over a range of provocative 

situations. Some computerized versions of these 

instruments generate small bar graphs that add 

a visual dimension to the numbers. By using 

these tools, clients gain an understanding of 

where their individual risks lie—high-risk 

situations in which they have low self-efficacy. 

This information can be extremely useful in 

setting realistic goals and developing an 

individualized change plan and can provide a 

sound basis for self-monitoring. Clients who 

rank many situations as high risk (i.e., low selfefficacy) may need to learn new coping 

strategies.

Situational Confidence 

Questionnaire 

The Situational Confidence Questionnaire (SCQ) 

has been used specifically with those who drink 

heavily. The instrument consists of 100 items 

that ask clients to identify their level of 

confidence in resisting drinking as a response to 

the following eight types of situations (Marlatt 

and Gordon, 1985): 

1. Unpleasant emotions 

2. Physical discomfort 

3. Testing personal control over substance use 

4. Urges and temptations to drink 

5. Pleasant times with others 

6. Conflicts with others 

7. Pleasant emotions 

8. Social pressure to drink 

Clients are asked to imagine themselves in 

each situation and rate their confidence on a 6-

point scale, ranging from not at all confident (a 

rating of 0) to totally confident (a rating of 6) 

that they can resist the urge to drink heavily in

that situation. The SCQ generally takes about 20 

minutes to complete, using either pencil and 

paper or computer software that automatically 

scores answers and generates a profile of the 

client’s alcohol use. The SCQ is accompanied by 

an Inventory of Drinking Situations that assesses 

the frequency of heavy drinking in different 

situations. The results of this questionnaire can 

be used to provide personalized feedback to the 

client as well as for treatment planning (Annis 

and Davis, 1991). High confidence scores have 

been shown to predict positive treatment 

outcomes (Annis and Davis, 1988), whereas low 

confidence scores have identified clients who are 

likely to have poor treatment outcomes (Sobell 

et al., 1997). An amended version of the SCQ, 

the SCQ-39, is the version recommended by the 

questionnaire’s developer (see Appendix B). 

Brief Situational Confidence 

Questionnaire 

The Brief Situational Confidence Questionnaire 

(BSCQ) was developed as an alternative to the 

SCQ because some treatment programs found 

the length and scoring and graphing systems of 

the original instrument to be too timeconsuming in clinical practice (Sobell, 1996). 
The eight items of the BSCQ, reproduced in 

Appendix B, correspond to the eight subscales 

in the original SCQ. Respondents in a 

community study (Sobell et al., 1996b) were 

asked to rank their confidence at the time of 

taking the questionnaire in resisting using 

alcohol or a primary drug in each situation on a 

scale from 0 (not at all confident) to 100 (totally 

confident). A comparison of the brief and long 

versions of the SCQ (Breslin et al., 1997) found 

that the shorter version is also effective and 

corresponds well with the longer version on 

most subscales. The BSCQ, although not as 

comprehensive and not yet as extensively tested, 

has several clinical advantages over the longer

version. It can be administered in a few 

minutes, is easily interpreted by clinicians, 

provides immediate feedback for the client, and 

can be used easily in primary care and other 

nonaddiction-specific settings (Breslin et al., 

1997). The BSCQ is also available in Spanish. 

Alcohol Abstinence 

Self-Efficacy Scale 

The Alcohol Abstinence Self-Efficacy Scale 

(AASE) measures an individual’s self-efficacy in 

abstaining from alcohol (DiClemente et al., 

1994). Although similar to the SCQ, the AASE 

focuses on clients’ confidence in their ability to 

abstain from drinking across a range of 20 

different situations derived from the eight highrisk categories listed above. The AASE consists 

of 20 items and can be used to assess both the 

temptation to drink and the confidence to 

abstain (see Figure 8-1). Clients rate their 

temptation to drink and their confidence that 

they would not drink in each situation on 

separate 5-point Likert scales that range from 1

(not at all likely) to 5 (extremely likely). Scores

are calculated separately for temptation and 

self-efficacy (DiClemente et al., 1994). The items 

in this version are divided into several 

subcategories that measure four types of 

recurrence precipitants: negative affect, social 

situations, physical or other concerns, and 

craving and urges. A study conducted on 266 

adults in treatment at an outpatient treatment 

program for alcohol use disorders over a 24-

month period found strong indices of reliability 

and validity for this scale (DiClemente et al., 

1994). This brief version also appears to be

equally effective with men and women. It is 

easy to use, comprehensive, and a 

psychometrically sound measure of self-efficacy 

to abstain from drinking. 

Readiness To Change 

An instrument for assessing the importance of 

change has been developed (Sobell et al., 1996b), 

based on a four-question scale originally used 

with smokers (Richmond et al., 1993). The 

questions were modified to inquire about 

drinking, with responses in a specific range for 

each question. A composite motivation score is 

calculated with a possible range from 0 to 10, 

based on the sum of the responses. The four 

questions are 

1. Would you like to reduce or quit drinking if 

you could do so easily? (No = 0, Yes = 1) 

2. How seriously would you like to reduce or 

quit drinking altogether? (Not at all 

seriously = 0, Not very seriously = 1, Fairly 

seriously = 2, Very seriously = 3) 

3. Do you intend to reduce or quit drinking in 

the next 2 weeks? (Definitely no = 0, 

Probably no = 1, Probably yes = 2, Definitely 

yes = 3) 

4. What is the possibility that 12 months from 

now you will not have a problem with 

alcohol? (Definitely not = 0, Probably not = 

1, Probably will = 2, Definitely will = 3) 

As discussed throughout this TIP, readiness 

to change can be considered a prerequisite for 

responding to treatment. However, 

motivational states are not binary with clients 

either motivated or not motivated. Rather, 

readiness exists along a continuum of steps or 
Figure 8-1 

20-Item Alcohol Abstinence Self-Efficacy Scale 

Negative Effect 

When I am feeling angry inside 

When I sense everything is going wrong for me 

When I am feeling depressed 

When I feel like becoming angry because of frustration 

When I am very worried 

Social/Positive 

When I see others drinking at a bar or at a party 

When I am excited or celebrating with others 

When I am on vacation and want to relax 

When people I used to drink with encourage me to drink 

When I am being offered a drink in a social situation 

Physical and Other Concerns 

When I have a headache 

When I am tired 

When I am concerned about someone 

When I am experiencing some physical pain or injury 

When I dream about taking a drink 

Craving and Urges 

When I am in agony because of stopping or withdrawing from alcohol use 

When I have the urge to try just one drink to see what happens 

When I am feeling a physical need or craving for alcohol 

When I want to test my will power over drinking 

When I experience an urge or impulse to take a drink that catches me unprepared 

DiClemente et al., 1994. 

stages and can vary rapidly, sometimes from 

day to day. The stages-of-change model has 

inspired instruments for assessing readiness to 

change or a client’s motivational change state. 

Depending on the level of readiness—or change 

stage—different motivational intervention 

strategies will be more or less effective (see 

Chapters 2 through 7). 

Readiness Ruler 

The Readiness Ruler, developed by Rollnick and 

used extensively in general medical settings, is a 

simple method for determining clients’ 

readiness to change by asking where they are on 

a scale of 1 to 10 (see Figure 8-2). The lower 

numbers indicate less readiness, and the higher 

numbers indicate greater readiness for change. 

Depending on how ready to change clients think 

they are, the conversation can take different 

directions. For those who rate themselves as 

“not ready” (0 to 3), some clinicians suggest 

expressing concern, offering information, and 

providing support and followup. For those who 

are unsure (4 to 7), explore the positive and 

negative aspects of treatment. For clients who 
-EASURING#OMPONENTSOF#LIENT-OTIVATION

are ready for change (8 to 10), help plan action, 

identify resources, and convey hope (Bernstein 

et al., 1997a). As clients continue in treatment, 

you can use the ruler periodically to monitor 

how motivation changes as treatment 

progresses. Remember that clients can move 

both forward and backward. Also, helping 

clients move forward, even if they never reach a 

decisionmaking or action stage, is an acceptable 

outcome. Most clients cycle through the change 

stages several times, sometimes spiraling up and 

sometimes down, before they settle into 

treatment or stable recovery. One significant 

feature of the readiness to change scale is that 

clients assess their own readiness by marking 

the ruler or voicing a number. Another feature 

is that the clinician can pose the question, “What 

would it take to move from a 3 to a 5?” or can 

recognize movement along the continuum by 

asking, “Where have you come from last year to 

now?” Chapter 4 provides more information 

about fostering readiness. 

In other similar studies (Sobell et al., 1993b; 

Sobell and Sobell, 1993, 1995b), clients 

responded on a scale of 0 to 100 to the following 

two questions: 

1. At this moment, how important is it that 

you change your current drinking? (Not 

important at all = 0, About as important as

most of the other things I would like to 

achieve now = 50, Most important thing in 

my life now = 100) 

2. At this moment, how confident are you that 

you will change your current drinking? (I

do not think I will achieve my goal = 0, I 

have a 50 percent chance of meeting my 

goal = 50, I think I will definitely achieve my 

goal = 100) 

Both goal importance and confidence ratings 

have been associated with better treatment 

outcomes (Sobell et al., 1996b). 

University of Rhode Island Change 

Assessment Scale 

The University of Rhode Island Change 

Assessment Scale (URICA) was originally 

developed to measure a client’s change stage in 

psychotherapy (McConnaughy et al., 1983) in 

terms of four stages of change: 

precontemplation, contemplation, action, and 

maintenance. The scale has 32 items, with eight 

items for each of the four stage-specific 

subscales (see Appendix B). Respondents rate 

items on a five-point Likert scale from 1 (strong 

disagreement) to 5 (strong agreement). Scores 

for each of the four stages are obtained. The 

instrument is designed for a broad range of 

concerns and asks clients general questions 

about their “problem.” 

A 28-item version of the URICA, with seven 

items corresponding to each stage, has also been 

used with clients in alcoholism treatment 

(DiClemente et al., 1994). Subscale scores from 

this instrument can then be used to create 

profiles related to the stages of change or to 

create a single readiness score by adding 

together the contemplation, action, and 

maintenance mean scores and subtracting the 

precontemplation score. In various research 

studies, these scores have been related to 

treatment outcome. In Project MATCH, a 

multisite clinical trial of psychosocial treatments 
for alcohol problems that involved 1,726 clients, 

the readiness score predicted abstinence from 

drinking outcomes at a 3-year followup (Project 

MATCH Research Group, 1997a). 

Stages of Change Readiness and 

Treatment Eagerness Scale 

The Stages of Change Readiness and Treatment 

Eagerness Scale (SOCRATES) measures 

readiness to change, with items specifically 

focused on problem drinkers. Developed in 

1987 by William R. Miller, the initial set of items 

was circulated for comment among colleagues 

in substance abuse treatment research. A 32-

item version was then produced, using fivepoint scales ranging from five (strongly agree) to 

one (strongly disagree). The current 19-item 

version of SOCRATES, reproduced in Appendix 

B, was initially developed in 1991 and was used 

as a self-administered paper-and-pencil 

questionnaire in Project MATCH (Miller and 

Tonigan, 1996). The items on this short version

do not measure the five stages of change 

constructs, but relate to three factors that have 

little overlap with each other: taking steps, 

recognition, and ambivalence. 

Clinicians can use SOCRATES to provide 

clients with feedback about their scores as a 

starting point for discussion. Changes in scores 

when the scale is readministered could assess

the impact of an intervention on problem 

recognition, ambivalence, and progress on 

making changes. Parallel forms have been 

developed to assess motivation to change 

substance use as well as the motivation of a

significant other to help change a partner’s 

substance-using patterns. The SOCRATES 

variables can also be helpful, in combination 

with other measures, for understanding the 

structure of motivation and readiness for 

change. Spanish translations are available. 

Readiness To Change 

Questionnaire 

The Readiness To Change Questionnaire (RCQ) 

was developed to help professionals who are 

not substance abuse treatment specialists assess 

the change stage of clients who drink 

excessively (Rollnick et al., 1992b). The 12 items, 

which were adapted from the URICA items, 

correlate closely with three change stages— 

precontemplation, contemplation, and action— 

and reflect typical attitudes of persons in each of 

those readiness levels. For example, a person 

not yet contemplating change would likely give 

a positive response to the statement, “Drinking 

less alcohol would be pointless for me,” whereas 

a person already taking action would agree with 

the statement, “I have just recently changed my 

drinking habits.” Another individual already 

contemplating change would be expected to 

agree with the item, “Sometimes I think I should 

cut down on my drinking.” A five-point scale is 

used for rating responses, from strongly agree 

(5) to strongly disagree (1). 

The RCQ which can be self-administered, 

has been shown to have good psychometric 

properties with heavy drinkers in nontreatment 

settings. When the instrument was used as a 

screening tool with heavy drinkers in general 

hospitals, it accurately reflected patients’ 

readiness to change and also predicted changes 

in respondents’ alcohol consumption patterns at 

8 weeks and 6 months following hospital 

discharge. That is, those who were least ready 

to change showed the least improvement in 

drinking patterns at followup, whereas those 

who were most ready to act did so (Heather et 

al., 1993). An additional test of the instrument 

found that men identified as heavy drinkers in 

general hospital wards and as being in early 

stages of change responded more favorably to 

brief motivational interviewing than to skillsbased counseling with respect to reduced 
Measuring Components of Client Motivation 

alcohol consumption. The inverse, however, 

was not found to be true. Men rated as ready to 

change did not respond any more favorably to 

skills-based counseling than to brief 

motivational interviewing. The study authors 

concluded that more research is necessary to 

ascertain what type of counseling is most 

suitable for persons identified as excessive

drinkers in opportunistic settings who are also 

in a state of readiness to change (Heather et al.,

1996a).

In repeated uses of the RCQ, Heather and 

colleagues have refined the scoring method for 

this instrument. The initial “quick method” 

simply sums the raw scores for each separate 

change-stage scale and uses the score that is

farthest along the continuum of change stages as 

the most accurate reflection of the client’s

readiness to change. This method is appropriate

if you need a quick way of determining

readiness. A more accurate and refined method 

and a better predictor of change for research and 

clinical purposes is to omit any illogical and 

unreliable responses and add a preparation

stage to the calculations. A revised version of 

the Readiness To Change Questionnaire User’s 

Manual provides more specific information

about calculating scores using this method.

The RCQ (Treatment Version) (RCQ [TV]) is

a recent revision of the original RCQ (Heather et 

al., 1996b) that is a more appropriate alternative

for determining the stage of change for persons 

who are seeking or already undergoing 

treatment for alcohol problems. This version,

reproduced in Appendix B, responds to 

criticisms that the original RCQ was intended 

only for use with heavy or hazardous drinkers 

identified in opportunistic settings (Gavin et al.,

1998), although it was being administered,

inappropriately, to some alcohol-dependent 

persons already applying for treatment of a 

substance use disorder. The major problem was 

that drinkers identified in health care settings

often chose to reduce consumption to safe limits

instead of abstinence, which is the more typical

decision of severely impaired persons in need of 

traditional treatment.

Although the developers of the revised

instrument initially hoped to add questions that 

would identify persons in the five stages of 

change and to modify the questions to reflect 

goals of either reduced drinking or abstinence,

only the latter aim was achieved with the 

revised instrument (Heather et al., 1996b). The 

RCQ (TV) has 30 items, with six questions 

corresponding to each change stage, which are 

rated on a five-point scale ranging from strongly 

agree to strongly disagree. Many of the 

questions and statements are adaptations of 

those in the original RCQ that now include

abstinence as a goal. For example, “I have 

started to carry out a plan to cut down or quit

drinking.” Other new questions reflect the two 

additional change stages, “I’ve succeeded in

stopping or cutting down drinking and I want to 

stay that way” (maintenance) or, “I have made a 

plan to stop or cut down drinking and I intend

to put this plan into practice” (preparation).

The developers of this psychometrically

sound instrument claim it is clinically useful for 

deciding what types of services are most 

appropriate for persons entering treatment.

Those who are identified as ready to change can 

immediately be offered skills-based, actionoriented services, while those who are not yet in

an action stage should be given further 

motivational interventions until they progress 

further along the readiness continuum. More 

research is necessary to strengthen one of the 

scales and to determine the instrument’s ability

to predict drinking outcomes accurately 

(Heather et al., 1996b).

Note: Shortly after this TIP was published

with the account given directly above, the 

instrument was further developed into a 15-item

form (Heather et al. 1999c). Appendix B now 

contains this 15-item form and related scoring

information. This 1999 15-item RCQ-TV is

141
Chapter 8 

designed for use with populations in treatment.

For wider research purposes, other forms of the 

RCQ may be worth considering.

Decisional Balancing 

As discussed in Chapter 5, exercises and 

instruments that examine decisional balancing 

investigate the positive and negative aspects of a 

particular behavior. The general benefits of the 

behavior—and also of changing it—are weighed 

against the costs, allowing clients to appraise the 

impact of their behavior and make more 

informed choices regarding changing it. The 

scale reproduced in this section can be used to 

accentuate the costs of the client’s substance use, 

lessen its perceived rewards, make the benefits 

of recovery more apparent, and identify possible 

obstacles to change.

The decisional balancing exercise was 

developed by Sobell and colleagues to help 

individuals identify benefits and costs of 

substance use as part of a cognitive appraisal 

process often associated with self-directed 

change (Sobell et al., 1996b). Such a purposeful 

comparison of the costs and benefits appears to 

facilitate the recognition and resolution of 

associated problems. Ask individuals who are 

interested in making a behavioral change to list 

benefits and costs of changing and not changing 

in parallel columns. Then ask them to carefully 

consider, “Are the costs worth it?” Figure 8-3 is 

an example of an exercise on the decision to 

change.

In another decisional balancing exercise, the 

Alcohol (and Illegal Drugs) Decisional Balance 

Scale, developed by DiClemente and 

reproduced in Appendix B, respondents are 

asked to indicate on a five-point scale how 

important each statement is in making a 

decision to change drinking or drug-using 

behavior.

Alcohol and Drug Consequences 

Questionnaire 

The Alcohol and Drug Consequences 

Questionnaire (ADCQ) is a relatively new 

instrument for assessing the costs and benefits 

of changing a substance problem (Cunningham 

et al., 1997). It is reproduced in Appendix B.

Figure 8-3 

Deciding To Change 

Changing Not Changing 

Benefits 

 Increased control over my life 

 Support from family and friends 

 Decreased job problems 

 Financial gain 

 Improved health 

Benefits 

 More relaxed 

 More fun at parties 

 Don’t have to think about my problems 

Costs 

 Increased stress/anxiety 

 Feel more depressed 

 Increased boredom 

 Sleeping problems 

Costs 

 Disapproval from friends and family 

 Money problems 

 Could lose my job 

 Damage to close relationships 

 Increased health risks 

Source: Sobell et al., 1996b.

142 
Measuring Components of Client Motivation 

The 29 items included on the questionnaire were 

derived from information reported by clients 

participating in a brief cognitivebehavioral 

intervention for guided self-change at an 

outpatient substance abuse treatment facility.

The items are divided into two categories: costs 

of change and benefits of change. Respondents 

are asked the importance of each item if they 

were to stop or cut down their use of substances 

(0 = not applicable, 1 = not important, 3 = 

moderately important, 4 = very important, 5 = 

extremely important). The score is determined 

by adding the cost items and the benefits items 

to obtain two separate scores that can be 

compared.

In initial tests of the instrument, respondents’ 

anticipated costs and benefits of change were 

significantly related to the importance they 

attached to achieving treatment goals, and, for 

problem drinkers, to their drinking outcomes. 

Respondents whose scores were higher on the 

costs of change measures were more likely to 

have consumed more drinks in the year 

following treatment, whereas those who 

believed the benefits of change were more 

important than costs were likely to reduce 

drinking levels posttreatment (Cunningham et 

al., 1997).

Motivation for Using 

Substances 

An underlying purpose of the instruments 

described in this section is to encourage clients 

to express their expectations about substance 

use by completing such statements as, “If I were 

to stop using substances, I would expect to 

feel....” Research suggests that expectancies 

play an important role in the progression from 

use to abuse (Brown, 1993; Connors and Maisto, 

1988; Leigh, 1989a). Knowledge of clients’ 

expectations regarding the effects of substances 

may help you understand the rationale for their 

substance-using behavior—clients who expect 

good things from substance use in most 

situations are likely to continue using at the 

same level until there is a change in perspective. 

Based on clients’ expectations, find 

discrepancies between clients’ behaviors and 

hopes and select strategies to help them address 

reasons for their substance use.

As with other measurement areas, less is 

known about motivations for using drugs than 

for using alcohol. The scales discussed in this 

section vary in length and have not all been 

tested on clinical samples. Leigh has reviewed 

and presented sample items and instructions for 

several questionnaires that purport to measure 

motivation (Leigh, 1989a).

Alcohol Expectancy Questionnaire 

The Alcohol Expectancy Questionnaire is the 

most widely used of these instruments (Brown 

et al., 1987). It is reproduced in Appendix B. It 

contains 90 items and uses a dichotomous 

agree/disagree response format. The items are 

grouped into six categories of perceived benefits 

from alcohol: 

1. Global positive changes 

2. Social and physical pleasure 

3. Sexual enhancement 

4. Increased social assertion 

5. Tension reduction/relaxation 

6. Increased arousal and aggression 

This scale measures only positive 

expectancies, not negative ones, and has been 

useful in showing that clients with continued 

positive expectancies at the end of treatment 

have poorer outcomes. It has been used with 

adults in both clinical and nonclinical 

populations (Sobell et al., 1994). A 120-item 

version that used the same format was 

developed for adolescents (Christiansen et al., 

1982).

Alcohol Effects Questionnaire 

The Alcohol Effects Questionnaire, reproduced 

in Appendix B, was constructed after 

143 
Chapter 8 

researchers questioned whether the original 

Alcohol Expectancy Questionnaire measured the 

strength or intensity of alcohol-related 

expectancies (Collins et al., 1990). Subjects in a 

study were asked to rate the strength of their 

beliefs in addition to the agree/disagree 

responses in the standard Alcohol Expectancy 

Questionnaire. It was hoped that this study 

would clarify the distinction between two types 

of alcohol expectancies—the nature of an 

attitude toward a behavior and the strength of 

that attitude or confidence about behavior 

change. Subjects were asked to report how 

strongly they agreed or disagreed with a 

particular belief on a 10-point Likert scale where 

1 = mildly believe and 10 = strongly believe. 

The results supported the idea that the strength 

of an individual’s belief or disbelief in alcoholrelated expectancies assessed by the Alcohol 

Expectancy Questionnaire is different from 

merely agreeing or disagreeing with these same 

expectancies.

Other Scales 

The Effects of Drinking Alcohol scale has 20 

items, each rated on a five-point scale that 

ranges from unlikely to very likely. The items, 

which reflect expected reactions to alcohol use, 

are grouped into five factors: nastiness, 

cognitive/physical impairment, disinhibition, 

gregariousness, and depressant effects (Leigh, 

1989a).

The Alcohol Effects Scale is a 37-item, forcedchoice adjective checklist that measures three 

factors: stimulation/perceived dominance, 

pleasurable disinhibition, and behavioral 

impairment (Southwick et al., 1981). This scale 

measures client expectations of how a moderate 

amount or excessive amount of alcohol would 

affect them.

The Alcohol Belief Scale was developed to 

assess clients’ expectations regarding the 

usefulness of drinking different amounts of 

alcohol in different contexts (Connors and 

Maisto, 1988; Connors et al., 1987). The scale 

measures clients’ beliefs regarding whether, for 

example, alcohol reduces discomfort in 

proportion to the amount consumed (“The more 

I drink, the better I feel”) (Connors et al., 1987). 

The greatest positive expectations are reported 

by those with the most severe drinking 

problems.

The Marijuana Effect Expectancy 

Questionnaire (MEEQ) and the Cocaine Effect 

Expectancy Questionnaire (CEEQ) are two 

related scales that assess motivation to use 

substances (Schafer and Brown, 1991). The 

MEEQ (70 items) and CEEQ (64 items) use a 

yes/no format with agree/disagree instructions 

similar to those of the AEQ. Subjects are asked 

to respond to the items according to their own 

beliefs and whether they have actually used the 

substance. Further research is needed; it 

appears, however, that expectancies differ 

across substance types in relation to the 

properties of the substance (e.g., expectation of 

arousal from alcohol and cocaine use but not 

from marijuana use).

Goals and Values 

Your clients must value a treatment goal to 

progress toward it. In fact, unless clients value 

them, they are not goals from the clients’ 

perspectives. From a motivational standpoint, 

you should understand what your clients’ goals 

are and what they value in life. It is usually best 

to start where your clients are—with what is 

important from their own perspective.

Clinicians can assess goals and values 

through an open-ended interview, asking 

questions like, “What things are most important 

to you?” or, “How would you like your life to be 

different 5 years from now?” or “What would 

you like to have happen in treatment?” As an 

aid to this process, some clinicians use a sheet 

showing a number of bubbles that contain the 

names of issues that a client might wish to 

144 
discuss and ask, “Which of these would you like 

to work on while you are here?” or “What might 

you like to work on first?” Some bubbles should 

be left empty, too, because clients may have 

goals other than those listed on the sheet. In 

developing a treatment plan, one can begin with 

all blank bubbles and fill in possible goals of 

treatment, then prioritize them. Miles Cox has 

developed and tested a clinical Motivational 

Structure Questionnaire for identifying goals 

and their associated degrees of commitment, 

outcome expectancy, and self-efficacy (Cox et 

al., 1993).

There are also more structured ways to 

assess what clients want and value. Clinicians 

can use the What I Want From Treatment 

Questionnaire, which lists a number of possible 

goals and aspects of treatment and asks new 

clients to rate the importance of incorporating 

each item into their own treatment (see 

Appendix B for a copy of this questionnaire).

Clients can also be asked at the end of treatment 

the extent to which they received these same 

treatment elements. One study using this 

Measuring Components of Client Motivation 

instrument found a positive relationship 

between favorable outcomes and clients 

reporting at discharge that they had received 

those treatment elements they said they wanted 

at intake (Brown and Miller, 1993). Receiving 

other treatment elements they did not want was 

unrelated to outcomes. In other words, clients 

improve to the extent they receive what they 

want from treatment.

Extensive literature exists on measuring 

values in general. For example, the Study of 

Values Questionnaire developed in 1960 has 

been widely used (Allport et al., 1960). In a 

classic volume on the subject, Rokeach 

introduced a method for ranking instrumental 

(means) and terminal (ends) values (Rokeach, 

1973). His well-researched instrument, which is 

available in a published form, allows clients to 

prioritize their values by arranging small labels 

in hierarchical fashion (Rokeach, 1983). Another 

instrument has clients sort and prioritize cards 

dealing with a wide variety of values expressed 

in contemporary language (Miller and C’de 

Baca, 1994).

145 

9 Integrating Motivational 

Approaches Into Treatment 

Programs

How do the motivational approaches 

discussed in this TIP fit into the real 

world of health care delivery? 

Although the demand for treatment of 

substance abuse continues to far exceed its 

availability, changes in health care economics 

are placing greater pressure on providers and 

their clients. Payors increasingly demand 

evidence that the services being provided are 

not only effective, but cost-effective. Clinicians 

and programs are increasingly challenged if 

they do not use research-supported, current 

methods. Public funding is scarce, and thirdparty payors exert great pressure to provide 

treatment that is shorter, less costly, and more 

effective. In sum, clinicians are asked to do 

more with less. 

The incorporation of motivational 

approaches and interventions into treatment 

programs may be a practical and efficacious 

response to many of these challenges. Recent 

research (Brown and Miller, 1993; Kolden et al., 

1997; McCaul and Svikis, 1991) supports the 

integration of motivational interviewing 

modules into programs to reduce attrition, to 

enhance client participation in treatment, and to 

increase the achievement and maintenance of 

positive behavioral outcomes. Other studies 

have shown brief interventions using 

motivational strategies and motivational 

interviewing to be more effective than no 

treatment or being placed on a waiting list, and 

not inferior to some types of more extensive care 

(Bien et al., 1993a, 1993b; Noonan and Moyers, 

1997). A review of the cost-effectiveness of 

treatments for alcohol use disorders concluded 

that brief motivational counseling ranked 

among the most effective treatment modalities, 

based on weighted evidence from rigorous 

clinical trials (Holder et al., 1991). Brief 

motivational counseling was also the least 

costly—making it the most cost-effective 

treatment modality of the 33 evaluated. 

Although cautioning that it was an 

approximation that requires refinement, the 

same study found a negative correlation 

between effectiveness and costs for the most 

traditional forms of treatment for alcohol use 

disorders and highlighted a growing trend to 

favor effective outpatient care over less effective 

or less studied—but far more expensive— 

inpatient, hospital-based, or residential care 

(Holder et al., 1991). 

This chapter begins with a discussion of the 

treatment continuum into which motivational 

interventions must be incorporated and ends 

with descriptions of motivational approaches 

that have been used in specific treatment 

settings. Also discussed is the importance of 
involving a significant other to enhance a 

client’s motivation for change. 

The Treatment 

Continuum and 

Stepped Care 

In 1990, the Institute of Medicine (IOM), in a 

special report to Congress, called for broadening 

the base of treatment for alcohol use disorders 

(IOM, 1990a). Both before and after that 

summons, modalities and special interventions 

to treat problems related to substance use have 

proliferated. In the year following the IOM 

report, Holder and associates reviewed the 

effectiveness and costs of 33 separate types of 

treatment for alcohol problems that had been 

subjected to controlled clinical trials (Holder et 

al., 1991). The costs are much larger if 

specialized treatment services for substancerelated problems are added to the base. 

However, these multiple modalities are not 

always used appropriately. Moreover, services 

are not always available to all who need or want 

them because of costs, lack of physical 

accessibility, and too few staff members. 

The IOM report called attention to several 

important suppositions that underlie its efforts: 

Substance use problems are not 

homogeneous—they differ in intensity, 

duration, effects, and other important 

dimensions.

Individuals who have problems with 

substance use are also diverse and have 

preferences about the treatments they will 

accept.

The magnitude of substance-related 

problems is too large to be handled by 

specialized treatment programs that are 

isolated from mainstream health care and 

other social services. 

In an era of managed care and decreasing 

public funds for services that are demonstrated 

as not cost-effective, the provision of health care 

must necessarily be limited. However, funds 

can still be allocated in a rational, fair, and 

effective way if the most expensive treatments 

are reserved for the most serious cases and the 

least intensive interventions that have a 

reasonable chance of success are applied as a 

first response. This approach to 

delivering treatment services operates according 

to the following principles (Sobell and Sobell, 

1999):

Both assessment and treatment should be 

individualized, with different types and 

intensities tailored to the presenting problem 

(or problems) and client characteristics. 

The treatment initially recommended should 

be the least intensive and least costly 

treatment that is most likely—based on 

research, assessment findings, and clinical 

judgment—to resolve the identified problem. 

More intensive and expensive treatments 

should be reserved for more serious 

problems and for clients who do not respond 

to less intensive interventions. 

Where two interventions are equally effective 

for clients with certain characteristics, the 

less costly treatment should be tried first.

This principle applies to the use of group 

treatment instead of individual care and to 

counseling by telephone, Internet, or mail 

instead of a personal meeting when these 

approaches are demonstrated to be equally 

effective. 

All recommended treatments should be 

based on solid research or, in the absence of 

adequate data, peer-established best practice 

guidelines.

When making recommendations, clinicians 

should consider the client’s preferences 

regarding treatment. “It makes little sense to 

refer clients to treatments that they believe 

are inappropriate and where the referrals are 

likely to result in those individuals dropping 

out of treatment” (Sobell and Sobell, 1999). 
Both assessments and treatments should be 

ongoing, increasingly comprehensive 

processes, not one-time activities. That is, 

simple screening and brief interventions may 

be sufficient for excessive drinkers identified 

in opportunistic settings, but more 

comprehensive assessments and more 

intensive treatments should follow if clients 

do not respond satisfactorily to initial care 

based on empirically established outcome 

measures. The need for additional treatment 

is based on both performance in the initial 

setting and another, more thorough 

assessment. Additional treatment may 

consist of more sessions in the original 

setting or referral to an alternative 

intervention, depending on clinical 

judgment, assessment findings, and client 

preferences. 

The implications for motivational 

interventions of a stepped care approach to 

planning and service delivery are many. First, 

this model reflects many of the same principles 

underlying motivational approaches, including 

the importance of offering treatment options to 

clients and respecting their informed choice in 

treatment decisions. Second, the stepped care 

model supports an increase in brief outpatient 

interventions that could effectively address 

mildly impaired persons without providing 

unnecessary services for them, while meeting 

public health objectives for reducing the high 

social costs of hazardous drinking and drug use. 

Motivational approaches entailing an 

assessment and only a few clinical sessions have 

proven effective and could be offered in a wide 

range of health care settings, provided staff 

members are properly trained and agree with 

the method. Finally, since a stepped care 

approach to planning and allocating treatment 

services is performance-based and does not 

specify a hierarchy of interventions, 

motivational approaches can be applied in 

different formats. For example, clinicians can 

experiment with the number, duration, or 

frequency of sessions to find the format that best 

meets individual needs. 

Applications of 

Motivational Approaches 

In Specific Treatment 

Settings

No single method to incorporate motivational 

approaches into service delivery systems is 

superior to others. A few obvious opportunities 

present themselves, but applications have been 

and continue to be a matter of clinical creativity. 

Some of the ways in which motivational 

interventions have been used are as 

A means of rapid engagement in the general 

medical setting to facilitate referral to 

treatment

A first session to increase the likelihood that 

a client will return and to deliver a useful 

service if the client does not return 

An empowering brief consultation when a 

client is placed on a waiting list, rather than 

telling a client just to wait for treatment 

A preparation for treatment to increase 

retention and participation 

A help to clients coerced into treatment to 

move beyond initial feelings of anger and 

resentment

A means to overcome client defensiveness 

and resistance 

A stand-alone intervention in settings where 

there is only brief contact 

A counseling style used throughout the 

process of change 

Often, there is a relatively short period of 

time in which you, the clinician, can make a 

beneficial impact. This may be because length of 

service is restricted by reimbursement policies 

or by the nature of a program (e.g., an employee 

assistance program) or the setting may allow for 

only a single encounter, such as an emergency 
department. Moreover, the average length of 

stay in substance abuse treatment is very short. 

If you do not make an impact in the first session 

or two, you may make no impact at all. Thus, it 

is wise to make the best use of the first contact 

with a client. 

However, this may conflict with the practical 

demands of a clinical setting in which 

paperwork must be done for admission, a 

waiting room is full of clients, or a treatment 

plan must be completed by the fourth session. 

Nevertheless, it is usually a mistake to a 

session with filling out forms. Take some time 

at the very beginning just to listen to your client, 

to understand him, and enhance motivation for 

change. If one contact is all you get with this 

client, filling out a questionnaire alone is 

unlikely to help. Research shows that even a 

single session of motivational interviewing does 

make a difference. 

The rest of this chapter describes creative 

ways in which the motivational approaches 

described in this TIP have been implemented. 

In the Emergency Department 

One of the first demonstrations of the power of 

brief interventions was implemented in the 

emergency department at Massachusetts 

General Hospital in the late 1950s. Morris 

Chafetz was concerned that many of the patients 

treated in the emergency department were there 

because of health problems and injuries related 

to their drinking. Yet nothing was being done 

about it. A resident might shake a finger at the 

patient and say, ”You really have to quit 

drinking,” but never follow up. In fact, less than 

5 percent of these patients sought treatment for 

their alcohol problems. 

Chafetz wondered what would happen if an 

empathic counselor were present to listen to 

these patients after they had been treated 

medically, encouraging them to come back for 

treatment. Thus, he conducted two studies in 

which patients coming into the emergency 

department with alcohol-related medical 

problems were assigned, at random, to meet 

with a counselor for a short conversation (15 to 

20 minutes) following their medical treatment.

In both studies (Chafetz et al., 1962, 1964), 

patients were 12 times more likely to return for 

treatment of their alcohol problems if they had 

talked with an empathic counselor (65 and 78 

percent), compared with patients receiving only 

emergency department care (5 and 6 percent). 

At Boston Medical Center’s Emergency 

Department, doctors developed Project ASSERT 

(an acronym for Alcohol and Substance abuse 

Services and Educating providers to Refer 

patients to Treatment), originally funded by the 

Center for Substance Abuse Treatment. Project 

ASSERT employs health promotion advocates 

who screen emergency department patients for 

substance use, establish rapport, explore change 

issues, assess readiness to change using the 

readiness ruler, negotiate a plan, and facilitate 

access to the substance abuse treatment system. 

The program also trains and involves the 

residents in emergency medicine. Published 

followup data show a 45-percent reduction in 

severity of drug problems, a 56-percent 

reduction in alcohol use, and a 64-percent 

reduction in frequency of binge drinking. 

Additionally, 50 percent of the patients reported 

keeping an appointment for treatment 

(Bernstein et al., 1997a). 

In Obstetric Clinics 

Another example of an effective motivational 

intervention is the pilot study conducted by 

Nancy Handmaker with pregnant women who 

attended obstetric clinics. Women who reported 

some drinking in the past month underwent a 

structured assessment and were assigned to 

receive either a motivational intervention or 

written materials informing them of the risks of 

drinking during pregnancy. In the 

nonjudgmental personal interviews the women 

reported considerably more drinking than they 
did on screening questionnaires. Among 

women with higher estimated peak blood 

alcohol concentrations, motivational 

intervention was more effective in reducing 

consumption during the next 2 months of 

pregnancy (Handmaker et al., 1999). 

In Medical Settings 

Several studies have used motivational 

interventions in medical settings. Hospitalized 

teen smokers benefited from brief motivational 

interviews in their smoking dependence and 

number of days they smoked (Colby et al., 1998). 

Researchers determined the stage of change of 

patients in a primary care clinic who gave at 

least one positive response to the CAGE. 

Although the researchers had expected most of 

these individuals to be in the contemplation 

stage, the patients were found to be primarily in 

the action stage, and most were no longer using 

alcohol (Samet and O’Connor, 1998). This 

implies that primary care physicians can 

perhaps contribute best to their patients’ 

sobriety by providing positive feedback about 

remaining abstinent and using relapse 

prevention techniques. Primary care providers 

who received a brief training program on 

patient-centered alcohol counseling improved 

their counseling skills and were much better 

prepared to intervene with problem drinkers 

(Ockene et al., 1997). 

Motivational Interviewing and the 

Marijuana Checkup 

A study conducted at the University of 

Washington offered a two-session Marijuana 

Checkup, publicized through the local media 

with a telephone number for inquiries. In the 

initial weeks of the program, the staff noticed 

that 60 percent of eligible callers who scheduled 

an assessment session failed to keep their 

appointments. This rate was reduced by half 

when the initial telephone intake protocol was 

modified. The new approach involved a 3- to 5-

minute dialog during which the staff person 

asked a series of open-ended questions and, 

using reflective listening, discussed the caller’s 

reasons for being interested in the program. 

The Matrix Model for Drug Users 

In 1994, the National Institute on Drug Abuse 

funded the development of a model intensive 

outpatient treatment program that was to be 

constructed from research-supported elements 

(Rawson et al., 1995). The first version of this 

model, intended for persons with stimulant use 

disorders, contained specific instructions for 

therapists and an articulated philosophy of 

treatment that emphasized a motivational 

approach:

The therapist fosters a positive, healthy 

relationship with the patient and uses that 

relationship to reinforce positive behavior 

change. The interaction is realistic and direct 

but not confrontational or parental. Therapists 

are trained to view the treatment process as an 

exercise that will promote self-esteem, dignity, 

and self-worth. A positive relationship 

between patient and therapist is a critical 

element for patient retention. (p. 120) 

The basic motivation-enhancing philosophy 

that characterized the original Matrix model of 

outpatient treatment for stimulant users has 

since been broadened to include protocols for 

substances. The model continues to be 

evaluated and refined according to the results of 

ongoing outcome studies. 

Motivational Enhancement Therapy 

The Commonwealth of Virginia has developed 

and is using a multicomponent model that 

incorporates Motivational Enhancement 

Therapy (MET). The program is called SATOE 

for its origins in the Substance Abuse Treatment 

Outcome Evaluation work group—a statewide 

gathering of clients and representatives from 

Virginia’s local public substance abuse 

treatment agencies, universities, and the 

Department of Mental Health, Mental 

Retardation and Substance Abuse Services. 
The evolving elements of the SATOE model 

include

Assessments of clients 

Placements of clients in appropriate levels 

and types of services 

Utilization review and improvements of 

service delivery 

Treatment outcome evaluations 

The SATOE model currently consists of five 

primary components: 

Diagnoses of substance abuse disorders 

according to criteria in the 

, 4th 

Edition (DSM-IV) 

MET assessments and interventions 

Addiction Severity Index (ASI) evaluation 

Standardized client placement criteria, such 

as the Patient Placement Criteria of the 

American Society of Addiction Medicine 

Utilization review using treatment services 

review

In the SATOE model, clients are typically 

given the University of Rhode Island Change 

Assessment (URICA)—a 32-item, self-report 

questionnaire that assesses the client’s readiness 

to change problematic behaviors (see Chapter 8). 

URICA scores guide clinicians’ judgment 

regarding clients’ readiness for treatment. This 

instrument was selected because many public 

sector clients have diagnoses of a substance 

abuse disorder coexisting with mental health 

disorders, and this instrument allows 

respondents to specify the target problem, in 

contrast to other readiness instruments that are 

specific to substance use. 

In one implementation version of the model, 

clients identified as precontemplators (and 

sometimes contemplators) by URICA-supported 

clinical assessments are placed in a separate, 

time-limited (4 to 8 weeks) motivationally

oriented treatment track that uses MET 

principles and interventions. Although some 

clients find this course of MET-based treatment 

sufficient for them to make desired behavioral 

changes, the MET-based treatment is more 

typically expected to increase clients’ readiness 

for more traditional substance abuse treatment 

that also incorporates MET principles. Other 

approaches to implementing MET under the 

SATOE involve integrating MET principles 

throughout traditional outpatient and intensive 

outpatient models of treatment. 

After the client completes the brief course of 

MET-based treatment, the program calls for a 

reevaluation of the client using such behavioral 

indicators as treatment compliance or urinalysis 

results in addition to another URICA assessment 

or an informal clinical assessment of readiness 

for change. Based on the findings, the client can 

be discharged or a new treatment plan can be 

developed that involves additional 

motivationally oriented treatment, traditional 

substance abuse treatment, other services such 

as case management or individual therapy and, 

in the case of clients referred by the criminal 

justice system, referral to criminal justice 

agencies for graduated sanctions. Although the 

State expects to support all of SATOE’s 

components, initial emphasis has been placed on 

the readiness to change assessments and the 

ASI. A list of providers has been established to 

facilitate communication among users of the 

model or its components. In addition, a 

comprehensive evaluation of the 

implementation parameters and a cost-benefit 

analysis of the model are planned. 

To facilitate implementation of SATOE, the 

State undertook several important activities. 

The first was to develop a manual of MET 

principles and techniques. Because the bestknown protocol of MET for substance abuse 

treatment is the Project MATCH effort for brief 

treatment of clients, and 

treatment is the prevalent modality in Virginia’s 

public programs, the Virginia Addiction 

Technology Transfer Center developed a 

 model of MET treatment and produced a 
manual for this protocol (Ingersoll and Wagner, 

1997). This model has been demonstrated to be 

effective in increasing readiness to change 

(Wagner et al., 1998). The second activity is a 

large-scale training initiative in which 

administrative staff is introduced to basic MET 

principles and implications for program 

changes, while clinical staff is trained in MET 

principles and related clinical interventions.

Virginia expects the SATOE model to evolve 

over time in response to feedback from the field. 

Serious attention is now being given to 

alternatives within the model that will allow 

local agencies to adjust it to their priorities and 

limitations. For example, some treatment 

agencies in the State have chosen to integrate 

MET principles throughout their substance 

abuse disorder services continuum or in specific 

services such as intensive outpatient therapy, 

rather than to have a separate MET-based 

treatment track. Whereas the standard MET 

protocol involves four sessions, the SATOE 

model will explore longer term and even openended versions to accommodate the 

expectations of local criminal justice agencies. 

Implementation of the SATOE model 

represents a potential paradigmatic change for 

Virginia’s delivery system for substance abuse 

treatment. The bottom line in all SATOE-related 

efforts has been the development of 

methodologies that permit public-sector 

agencies to provide the most appropriate and 

cost-effective services. 

An African-Centered Application of 

Motivational Intervention 

In working with African-American clients, the 

application of motivational intervention with a 

culturally congruent manner can be very 

effective in eliciting increased self-disclosure, 

engagement in the treatment process, and 

positive treatment outcomes. For example, in 

the development of discrepancy, amplifying 

discrepancies between substance use behavior 

and the client’s perceived purpose, reason for 

being, or destiny in life creates significant 

dissonance and reflective pause. Other 

culturally significant discrepancies include the 

discrepancy between substance use and 

commitment to the well-being of the 

community; substance use and relationships 

with others; substance use and fulfillment of 

destiny; substance use and one’s spiritual 

development and hardiness; substance use and 

acting “out of character.” These discrepancies 

relate to culturally meaningful principles among 

African-Americans—cultural principles that 

reflect their African cultural heritage (Grills and 

Rowe, 1998; Longshore et al., 1998). These 

include principles of interconnectedness, 

responsibility to the community, the belief that 

the essential core that is the self is divine 

essence, the belief that each person has a Godgiven purpose in life, and the importance of 

developing good character. Additionally, a 

reframing of healing (recovery) from a process 

of just healing the personal self to a process that 

stimulates healing of the community engages 

the client more substantively in a consideration 

of his substance use. One’s own healing 

represents a healing of the community because 

of the essential interdependent nature of the 

African-American communities (Rowe and 

Grills, 1993). 

Finally, the application of motivational 

intervention with African-American clients has 

been enhanced through the contextualization of 

personal substance use within a historical and 

societal reality. Substance use is understood not 

solely as a function of attributes of the 

individual but also within the context of very 

real historical and systemic forces of oppression 

and racism in the United States that aggressively 

impinge upon the well-being and life-affirming 

practices of the individual, the family, and the 

community. The adverse effects of substance 

use are considered to erode life chances, family 
life, cultural traditions, and sense of community 

life for African-Americans (Goddard, 1992). 

This culturally congruent application of 

motivational intervention has been found 

effective in the movement of African-American 

clients from precontemplation to contemplation, 

contemplation to action, and from action to 

maintenance (Longshore et al., 1998). 

Adolescents with Multiple 

Drug Problems 

The adolescent treatment program at the 

University of New Mexico Center on 

Alcoholism, Substance Abuse, and Addictions 

works mostly with adolescents who have 

overwhelming problems. They use multiple 

drugs, are in trouble with the law, are failing in 

or have dropped out of school, have tumultuous 

and sometimes abusive family relationships, 

sometimes belong to gangs, and are engaged in 

many kinds of risky behavior. Almost none of 

them come for treatment of their own accord. 

They are sent by the courts, brought by a parent, 

or transported from a custodial setting. They 

are often angry, silent, brooding, 

confrontational, or defiant. They resent being 

told by adults that they should say no to drugs. 

Even with all the external pressure from 

courts and family, retention is a significant 

problem. The average adolescent client 

admitted to the program stays for five 

outpatient sessions. To address this problem, 

motivational interviewing was used at intake 

(Aubrey, 1998). Adolescents entering the 

program were randomly assigned to receive the 

usual intake interview or one motivational 

interview that included personal feedback from 

assessment. Aubrey found that her adolescent 

clients responded very well to motivational 

interviewing, a counseling style quite different 

from what they had expected. They also stayed 

in treatment longer. Those who had a 

motivational interview at intake stayed for an 

average of 17 sessions compared to 6 sessions 

for those receiving the regular intake procedure. 

Most important was the impact on adolescents’ 

substance use. At the 3-month followup, 

adolescents who received the motivational 

interview had a significantly higher rate of 

abstinence than the control group (70 percent 

versus 43 percent), paralleling previous findings 

with adult inpatient (Brown and Miller, 1993) 

and outpatient populations (Bien et al., 1993b). 

Women With Multiple 

Vulnerabilities 

Individuals with substance abuse problems are 

more likely to have an accompanying health, 

mental health, or social problem than the 

general population. Women are especially 

vulnerable; studies indicate higher rates of 

coexisting disorders for women than men 

(Helzer and Pryzbeck, 1988; Regier et al., 1990). 

Recognizing that women may have multiple 

problems and that they may be prepared to 

change one aspect of their lives but not another, 

researchers in California developed the Steps of 

Change model, based on the stages of change 

(Brown et al., in press; Melchior et al., in press). 

The Steps of Change assesses a woman’s 

readiness to enter treatment by examining four 

categories: (1) readiness to change substance use 

behavior, (2) readiness to change high-risk sex 

practices, (3) readiness to change a domestic 

violence situation, and (4) readiness to deal with 

emotional problems. This allows a woman to 

consider her multiple needs and enter into 

appropriate types of treatment or integrated 

treatment. Initial results from the study showed 

that the four levels of stage of change do not 

indicate a single underlying desire to change, 

thus supporting the use of the Steps of Change 

to evaluate readiness in various domains, and 

that those problems presenting the greatest 

potential for immediate harm to women 

typically induce the greatest willingness to 

change. These are important considerations 

when predicting treatment entry and outcome 
for women. Future studies will examine the 

retention of women in treatment for substance 

abuse based on the Steps of Change model. 

A Short-Term Residential 

Treatment Program 

In a Southwestern treatment program that 

serves a population that is 95 percent Native 

American, a number of motivational strategies 

are being used to enhance treatment outcome in 

the various program components of the 150-bed 

facility. For example, the facility’s clinical staff 

members wear name badges that identify more 

than the name and title of the clinician. Each 

clinician’s name badge includes reference to the 

ethnic group or family of origin—tribal 

members are identified by one of two dozen 

clans that comprise the tribal identity in the 

native language and non-Native Americans are 

identified by their ancestry (e.g., European, 

African). Clients entering the 161⁄2-day 

residential program are provided material to 

design their own individualized name badges 

that contain information regarding their families 

of origin. Clinicians are encouraged to integrate 

use of clan relationships in their individual and 

family interventions, so it is common to hear 

references to a client as younger brother, 

grandmother, or uncle. These references 

enhance the motivation of clients to participate 

in the treatment process and become engaged in 

the therapeutic dynamics of the Native 

American program. 

In a 6-month followup of three dozen former 

clients, this program found that 70 percent of 

those completing the residential program were 

still doing better than prior to admission; they 

had lower rates of alcohol consumption and 

improved quality of life and family interactions. 

Although opportunity for continued 

improvement in those areas of functioning 

remained, cases of significant client change 

occurred. There were followup reports of 

individuals establishing places of residence after 

a number of months or years of alcohol abuse 

during which these clients had become 

homeless. Some clients began to build on the 

basic cultural teachings to which they had been 

exposed. Clients also attempted to find mentors 

outside the treatment program from whom they 

could learn more about traditions, such as how 

to run a sweat lodge and how to facilitate these 

ceremonies for family or friends. The 

importance of including familial relationships as 

part of the therapeutic process was key in 

motivating clients to begin changing drinking 

behaviors that standard treatment programs had 

deemed very difficult, if not impossible, to 

change. 

One former client, a graduate of that 

followup cohort, left the region to enter a 

standard 30-day residential treatment program. 

After completing that 30-day program, the client 

was encouraged to volunteer and remain as a 

cultural advisor, as other members of the client’s 

tribe were being admitted. Two years later, that 

client and volunteer returned home and 

obtained employment as a Traditional 

Counselor in the 161⁄2-day program where he 

originally began recovery. 

Group Settings 

The current context of service delivery places 

heavy emphasis on group treatment. Many 

motivation-enhancing activities can take place in 

group therapy that cannot be done in individual 

treatment (e.g., clients can receive feedback from 

peers); however, several significant clinical 

issues arise in terms of conducting groups: 

attrition, structure of groups, group cohesion, 

and handling difficult clients (Dies, 1994). 

Conducting group therapy is considerably more 

complicated than conducting individual 

treatment, as it involves handling multiple 

clients simultaneously. Also, the use of 

behavioral materials and motivational strategies 

and techniques in groups must be done in such 

a way as to accomplish the same objectives as in 
Motivational Enhancement in Group Therapy 

Conducting motivational interventions in a group versus individual format is more difficult, more 

complex, and more challenging. Personally, however, I find it much more rewarding. In group 

therapy, particularly using motivational techniques and strategies, clients learn through the group. It 

is like a hall of mirrors; clients get the feel of how they come across. For me, when a client uses 

reflective listening with another client or points out another client’s ambivalence, the group is like a 

living, learning laboratory of experiences practiced first in a safe environment before being tried in the 

real world. In the end, what the members have is a common goal to reduce or stop substance abuse, 

and it is here that their mutual support and peer pressure is effective. 

Linda C. Sobell, Consensus Panel Member 

individual therapy. Therefore, being a good 

clinician in an individual setting does not 

qualify a therapist to conduct group sessions; 

rather, the clinician must possess an 

understanding of group dynamics and have the 

necessary skills to conduct group therapy. 

Efforts to date have yielded mixed results for 

motivational enhancement therapy in group 

settings. Some studies find that motivational 

interviewing in a group setting is less effective 

than in individual counseling; in one case, 

college students treated in a group actually 

fared slightly worse than those in a control 

group given no treatment (Walters et al., in 

press).

However, one team at the University of 

Washington found that heavy-drinking college 

students markedly reduced their drinking in 

response to a 6-week group program (Baer et al., 

1992). Favorable results were also obtained in a 

recent, randomized clinical trial evaluating a 

motivationally based cognitive–behavioral

intervention, Guided Self-Change (GSC) 

treatment. This trial demonstrated that 

motivationally based techniques and strategies 

were as successful in group format as in 

individual treatment for both alcohol and 

substance abuse (Sobell et al., 1995; Sobell and 

Sobell, 1998). Specifically, the results from this 

trial were (1) no evidence of differential attrition 

over the course of treatment as a result of 

random assignment to group or individual 

treatment, (2) very high group cohesion, 

considered essential to successful group 

outcomes (Cota et al., 1995; MacKenzie, 1983; 

Satterfield, 1994), based on client reports that 

they were able to respond with relative 

openness, (3) similar outcomes for 

motivationally based GSC group and levels of 

client satisfaction as for individually treated 

clients, (4) a significant decrease in drinking and 

drug use from pretreatment to treatment in both 

the group and individual formats, and changes 

maintained 1 year following treatment, and (5) a 

considerable cost reduction when providing 

motivationally based treatment in a group 

rather than an individual format—41.5 percent 

cost savings for the actual service provision, and 

an eightfold reduction in missed appointments 

in the group format compared to individual 

sessions. Additionally, 80 percent of all 

individual and group clients said they would 

recommend the GSC program to a friend. 

Because social support is intrinsic to group 

treatment, clients in a group can reinforce and 

help maintain each others’ changes. People start 

to open up over the course of treatment as they 

receive feedback and are reinforced for selfdisclosure—two important elements of group 

treatment and motivational interviewing. When 

using advice feedback materials in group, a 

“round robin” procedure can be used whereby 

clients engage in reflective listening and 

comment in a way that promotes discrepancy as 

well as points out observed ambivalence in their 

peers. In group therapy, all clients act as agents 
of change by helping each other, through a peerbased process, to strengthen their motivation 

and commitment to change. The group rather 

than the individual clinician is the agent of 

change (Dies, 1994). 

Although this study offers much promise, it 

is the first study to use a motivationally based 

intervention in a group format. It seems 

reasonable that motivational approaches could 

be adapted for use in groups to increase cost 

effectiveness, yet it is clear that some efforts at 

group motivational intervention have failed or 

even been detrimental. Until effective group 

treatment methods are clarified, it would be 

wise to evaluate new programs to make sure 

they are accomplishing what is intended. 

10 Directions for Future Research

Motivational intervention is a relatively 

new, but favorably received, 

approach to encouraging positive 

behavioral change. The approach is derived 

from a variety of sources, including clientcentered counseling, cognitive therapy, systems 

theory, and a transtheoretical model of change 

(Miller and Rollnick, 1991). To date, 

motivational interventions have been 

successfully used with a variety of problems, 

client populations, and settings (see Chapter 2), 

and the methodology appears to be generally 

applicable, although it was primarily developed 

for heavy alcohol drinkers and cigarette 

smokers. A number of controlled clinical trials 

of motivational interviewing and brief 

interventions that use a motivational approach 

have been conducted with promising results 

(Bien et al., 1993; Noonan and Moyers, 1997). 

As with many innovative treatment 

approaches, however, there are still many 

unanswered questions about motivational 

interventions—especially as the concept has 

evolved over its comparatively short lifespan. 

Many of these questions are issues for an 

ongoing and broad research agenda; others are 

more practical problems pertaining to clinical 

applications. Many of the questions are also 

complex and interrelated so that untangling 

answers presents a challenge. 

Some of the questions or issues that call for 

additional research include the following: 

What are the active ingredients of 

motivational interventions? Although there 

has been some attempt to identify the 

common elements of brief interventions and 

to add more fundamental elements to 

motivational approaches, no structured 

research has yet parceled out the separate 

elements and determined which are most 

critical or which combinations are most 

useful. Reflective listening, structured 

feedback, discrepancy development, and 

decisional balances, for example, have each 

assumed some prominence in discussions of 

the approach. This question probably does 

not have a simple answer because some 

types of clients are likely to respond better to 

one aspect of the model than another and at 

different points in the change process. 

Can motivational interventions be 

standardized? A corollary of the first 

question regarding active ingredients is 

whether motivational approaches can be 

successfully integrated into training manuals 

so that clinicians can be taught the basic 

elements and monitored to determine their 

adherence to the model. One example of 

such a program is already available, the 

Project MATCH manual published by the 

National Institute on Alcohol Abuse and 

Alcoholism (Miller et al., 1995c). 

What types of clients benefit most—and 

least—from motivatio nal interventions? 

There is a danger here that in the interest of 

health care cost containment, someone might 

conclude, “Why not give motivational 

interventions?” Far too little is known at this 
time about who does and who does not 

respond to brief motivational counseling— 

and why. About half the studies of brief 

motivational interventions have been of 

heavy drinkers in medical settings who were

seeking treatment for alcohol problems.

Other studies have shown that motivational 

intervention increases the effectiveness of 

subsequent treatment (Bien et al., 1993; 

Noonan and Moyers, 1997). Project MATCH 

tested a four-session motivational 

enhancement therapy against two 12-session 

outpatient treatment methods and found 

similar overall long-term outcomes, with 

some evidence that more severely dependent 

clients fared better in longer treatment 

(Project MATCH Research Group, 1997a). It 

is far too early to predict who needs only 

brief motivational counseling and who needs 

more intensive treatment. 

What standard outcomes for motivational 

interventions can be defined and 

measured? Motivational approaches have 

been used to influence a variety of factors, 

including substance consumption patterns, 

successful referrals, compliance with 

treatment, and successful completion of the 

prescribed regimen. Research evaluations 

must specify what outcomes are expected 

and how these will be measured. One issue 

with motivational interventions is the 

variable effect sizes in the studies to date 

(Noonan and Moyers, 1997). Similarly, 

where the intervention is targeted at 

compliance with medical or treatment advice 

(e.g., taking medications as prescribed, 

participating regularly in exercise or

rehabilitation programs), how large an effect 

is expected and how long will it last? 

Another related question is what, if any, 

proximal outcomes predict longer term 

outcomes.

What characteristics of clinicians influence 

the effectiveness of motivational 

interventions? Clinicians, as well as clients, 

have characteristics that negatively or 

positively influence how closely they can 

adhere to the model and what their 

expectancies are with regard to the potential 

effectiveness of motivational interventions. 

Clinicians who delivered brief advice with a 

medically authoritative voice or were not 

carefully trained may have compromised the 

 of motivational interviewing and 

negatively tainted research findings (Noonan 

and Moyers, 1997). Motivational 

interviewing is not an approach that is 

compatible with all clinicians. 

Are stage-matched interventions 

appropriate? Some evidence indicates that 

when clients are at early stages of readiness, 

they are most likely to respond favorably to a 

motivationally focused intervention rather 

than one that focuses on behavioral change 

(Heather et al., 1996b). This suggests that 

different treatment strategies may be optimal 

at different stages of change. A different 

question is whether certain motivational 

strategies are appropriate at certain 

stages of change (Perz et al., 1996), or with 

certain populations (Obert et al., 1997). Do 

action-oriented treatments work better for 

clients in the action stage? Two studies 

found that outcomes were similar for actionstage clients given motivational interviewing 

versus behavioral change treatment (Heather 

et al., 1996; Project MATCH Research Group, 

1997a;). Which interventions are better at 

which stages or with which populations? 

There is still much to learn. 

How effective and cost-efficient are 

motivational interve ntions in relation to 

other established and more extensive 

substance abuse treatments? At least one 

clinical trial has indicated that motivational 

interviewing was not inferior to a more 
Motivational Interviewing With Dually Diagnosed Inpatients 

I became interested in motivational interviewing (MI) when my team and I were trying to improve the 

rate of attendance at aftercare appointments for dually diagnosed patients discharged from our 

psychiatric units. I was surprised to see that little had been written about the efficacy of motivational 

interventions with this population. So, my team and I decided to conduct a study of MI’s effectiveness 

with dually diagnosed patients. We randomly assigned half of our patients to standard treatment (ST), 

in which they received standard inpatient psychiatric care, including standard discharge planning 

where the team would encourage and explain the importance of aftercare. The other half were 

assigned to ST but also received a motivational assessment, feedback on the results at admission, and a 

1-hour motivational interview just before discharge. 

We found that dually diagnosed patients in the MI group attended their first outpatient 

appointment at a rate that was two and a half times greater than the ST group (Swanson et al., in 

press), suggesting that MI, with virtually no modification, was effective. The intervention appeared to 

be particularly effective for patients with very low motivation. This could have been because these 

patients were more verbal about their ambivalence than others and because we viewed MI as a perfect 

way to resolve ambivalence. Another thing we learned was that asking patients about why they would 

attend aftercare had surprise value and greatly enhanced the rapport between therapist and 

patient. It appeared to let patients know that we were not only going to tell them about the importance 

of aftercare, but that we were actually willing to discuss their ambivalence about it. 

Patients were also surprised when we did not directly counter their reasons for not going to 

aftercare. For example, if a patient said, “I’m better now, I don’t need aftercare,” we would not say, 

“But in order to stay well, you need to continue your treatment.” Instead, we used 

(e.g., “What do you think helped you get better?” or simply, “Tell me more about that”) or 

 (e.g., “So, you’re saying you probably won’t need any other treatment ever again” or, for 

more fragile patients, “It’s hard for you to imagine a reason why you might continue to need 

treatment”). When patients offered specific disadvantages of pursuing aftercare, such as loss of time 

from work or negative reactions from family, we similarly responded with open-ended questions and 

reflective listening (e.g., “It sounds like your job is very important to you and that you wouldn’t want 

anything to get in the way of that”). Frequently such questions and reflections would lead a patient to 

counter his own initially resistant statements. It turned out that even difficult patients could sell 

themselves on the idea of aftercare better than we ever could, and MI gave us the perfect method for 

facilitating this process. What was most important, however, was what we did do, namely, argue 

with the patient or even attempt to therapeutically dispute his (sometimes) illogical ideas about 

aftercare. Instead, we waited for kernels of motivation and simply shaped them along until the patient 

finally heard himself arguing in favor of seeking further services. 

Michael V. Pantalon, Field Reviewer 

extended support group in helping adult 

marijuana users reduce use or achieve and 

maintain abstinence (Noonan and Moyers, 

1997). Similarly, in Project MATCH, a 

motivational enhancement approach yielded 

comparable overall outcomes at lower cost, 

compared with two longer treatment 

methods. Replications and refinements of 

this type of study must be conducted to 

ascertain whether motivational approaches 

are realistic and less costly alternative 

interventions for some clients. 
How do culture and context influence the 

effectiveness of motivational interventions? 

Project MATCH found no differences in the 

treatment response of African-American, 

Hispanic, and non-Hispanic white 

outpatients to motivational enhancement 

therapy and two other treatment approaches 

(Project MATCH Research Group, 1997a). 

Yet ethnicity was defined simplistically here, 

as in most studies, as a self-identified label. 

More sophisticated analyses of ethnic 

influences are needed, because within-group 

heterogeneity is missed by such crude 

categorization, also called “ethnic gloss” 

(Longshore and Grills, 1998). Levels of 

acculturation, language, and counselor–client 

match can influence the process and outcome 

of motivational interventions. 

What kinds of training and support are 

necessary to teach motivational 

interventions? The clinical approaches 

described in this TIP are more a motivational 

of counseling, than a set of tricks or 

techniques. Clinicians differ in their 

effectiveness with motivational counseling 

(Project MATCH Research Group, 1998b). 

As the need to teach motivational 

interventions increases, questions to be 

considered will include the following: What 

are the “technology transfer” aspects of 

teaching this motivational approach? What 

training formats are most effective in 

changing counselor practice behavior to 

influence clients’ responses during and after 

treatment? What aspects of motivational 

intervention are the most important to teach, 

and how is such teaching best done? It seems 

likely, though, that more than a single 

workshop presentation would be necessary 

to change established clinical practices. 

Perhaps most promising is the incorporation 

of this approach into the training of 

addiction professionals. 

Conclusion

Many different motivational approaches have 

been discussed in this TIP. Certainly, the 

evidence to date is very encouraging that even 

brief interventions can influence client 

motivation and trigger significant improvement. 

However, we are just beginning to understand 

how and why these approaches work, and how 

best to incorporate them into health care 

services with various populations. The use of 

these promising methods in the future will 

depend on the creativity of clinicians and 

researchers to adopt, adapt, and evaluate them 

to make them effective for clients. 
Appendix A 

Bibliography

Agency for Health Care Policy and Research. 

Number 18. Washington, DC: U.S. 

Government Printing Office, 1996. 

Alcoholics Anonymous. 

3rd

ed. New York: Alcoholics Anonymous 

World Services, 1976. 

Allen, J.P., and Columbus, M., eds. 

. Bethesda, MD: National Institute 

on Alcohol Abuse and Alcoholism, 1995. 

Allport, G.W.; Vernon, P.E.; and Lindzey, G. 

, 3rd ed. 

Boston: Houghton-Mifflin, 1960. 

Allsop, S.; Saunders, B.; Phillips, M.; and Carr, 

A. A trial of relapse prevention with 

severely dependent male problem drinkers. 

 92:61–73, 1997. 

Alterman, A.I.; Kampman, K.; Boardman, C.R.; 

Cacciola, J.S.; Rutherford, M.J.; McKay, J.R.; 

and Maany, I. A cocaine-positive baseline 

urine predicts outpatient treatment attrition 

and failure to attain initial abstinence. 

 46:79–85, 1997. 

Alterman, A.I.; McKay, J.R.; Mulvaney, F.D.; and 

McLellan, A.T. Prediction of attrition from 

day hospital treatment in lower 

socioeconomic cocaine-dependent men. 

 40:227–233, 

1996.

American Psychiatric Association. 

, 4th 

ed. Washington, DC: American Psychiatric 

Association, 1994. 

American Psychiatric Association. Practice 

guidelines for the treatment of substance use 

disorders: Alcohol, cocaine, opioids. 

152(11 

Suppl.):1–59, 1995. 

American Society of Addiction Medicine. 

 2nd ed

Washington, DC: American Society of 

Addiction Medicine, 1996. 

Anderson, P., and Scott, E. The effect of general 

practitioners’ advice to heavy drinking men. 

 87:891–900, 1992. 

Anglin, M.D.; Hser, Y.; Crits-Cristoph, P.; 

Cummings, L.; Hall, S.; Kosten, T.R.; and 

Martin, W.R. Treatment research: 1989–1991. 

In:

Rockville, MD: National Institute on 

Drug Abuse, 1992 (unpublished). 
Annis, H.M., and Davis, C.S. Self-efficacy and 

the prevention of alcoholic relapse: Initial 

findings from a treatment trial. In: Baker, T., 

and Cannon, D., eds. 

New York: 

Praeger, 1988. pp. 88–112. 

Annis, H.M., and Davis, C.S. Relapse 

prevention.

15:204–212, 1991. 

Annis, H.M., and Graham, J.M. 

 Toronto, ON: Addiction Research 

Foundation, 1988. 

Annis, H.M., and Graham, J.M. 

 Toronto, ON: 

Addiction Research Foundation, 1990. 

Annis, H.M., and Graham, J.M. Profile types on 

the Inventory of Drinking Situations: 

Implications for relapse prevention 

counseling. 

9:176–182, 1995. 

Appelbaum, A. A critical re-examination of the 

concept of “motivation for change” in 

psychoanalytic treatment. 

 53:51–59, 1972. 

Aubrey, L.L. “Motivational interviewing with 

adolescents presenting for outpatient 

substance abuse treatment.” Ph.D. diss., 

University of New Mexico. 

, 59-03B, 1357, 1998. 

Azrin, N.H., and Besalel, V.A

 Baltimore, MD: 

University Park Press, 1980. 

Azrin, N.H., and Besalel, V.A. .

Berkeley, CA: Ten Speed Press, 1982. 

Azrin, N.H.; Sisson, R.W.; Meyers, R.J.; and 

Godley, M.D. Alcoholism treatment by 

disulfiram and community reinforcement 

therapy.

13(2):105–112, 1982. 

Babor, T.F., and Grant, M., eds. 

. Geneva, Switzerland: 

World Health Organization, 1992. 

Baer, J.S.; Marlatt, G.A.; Kivlahan, D.R.; 

Fromme, K.; Larimer, M.E.; and Williams, E. 

Experimental test of three methods of alcohol 

risk reduction with young adults. 

60(6):974– 

979, 1992. 

Bandura, A. Human agency in social cognitive 

theory. 44:1175–1184, 

1989.

Bandura, A. 

New York: W.H. Freeman, 1997. 

Baumeister, R.F. The crystallization of 

discontent in the process of major life change. 

In: Heatherton, T.F., and Weinberger, J.L., 

eds. Washington, 

DC: American Psychological Association, 

1994. pp. 281–294. 

Beck, A.T.; Wright, F.D.; Newman, C.F.; and 

Liese, B.S. 

New York: Guilford Press, 1993. 

Beckman, L.J. An attributional analysis of 

Alcoholics Anonymous. 

41:714–726, 1980. 

Bernstein E.; Bernstein, J.; and Levenson, S. 

Project ASSERT: An ED-based intervention 

to increase access to primary care, preventive 

services, and the substance abuse treatment 

system

30(2):181–197, 1997a. 

Bernstein, E.; Bernstein, J.; Schulz, C.; and 

Shepard, D.S. 

. Waltham, MA: 

Institute for Health Policy, Brandeis 

University, 1997b. 
Bien, T.H. “Motivational intervention with 

alcohol outpatients.” Ph.D. diss., University 

of New Mexico, 1992. 

Bien, T.H.; Miller, W.R.; and Boroughs, J.M. 

Motivational interviewing with alcohol 

outpatients.

 21:347–356, 1993a. 

Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief 

interventions for alcohol problems: A review. 

 88:315–336, 1993b. 

Blomqvist, J. Paths to recovery from substance 

misuse: Change of lifestyle and the role of 

treatment.

31(13):1807–1852, 1996. 

Borysenko, J., and Borysenko, M. 

 Carson, CA: Hay House, 1995. 

Brecht, M.L., and Anglin, M.D. Conditional 

factors of maturing out: Legal supervision 

and treatment.

25:395–407, 1990. 

Brehm, S.S., and Brehm, J.W. 

New York: Academic Press, 1981. 

Breslin, F.C.; Sobell, L.C.; Sobell, M.B.; and 

Buchan, G. “A comparison of a brief and 

long format for the Situational Confidence 

Questionnaire.” Poster presented at the 31st 

Annual Meeting of the Association for 

Advancement of Behavior Therapy. Miami 

Beach, FL. November 1997. 

Brown, J.M., and Miller, W.R. Impact of 

motivational interviewing on participation in 

residential alcoholism treatment. 

 7:211–218, 1993. 

Brown, S.A. Drug effect expectancies and 

addictive behavior change. 

1 55–67, 1993. 

Brown, S.A.; Christiansen, B.A.; and Goldman, 

M.S. The Alcohol Expectancy Questionnaire: 

An instrument for the assessment of 

adolescent and adult alcohol expectancies. 

 48:483–491, 1987. 

Brown, V.B.; Huba, G.J.; and Melchior, L.A. 

Level of burden: Women with more than one 

co-occurring disorder. 

27(4):339–346, 1995. 

Brown, V.B.; Melchior, L.A.; and Huba, G.J. 

Level of burden among women diagnosed 

with severe mental illness and substance 

abuse.

31(1):31−40, 1999. 

Brown, V.B.; Melchior, L.A.; Panter, A.T.; 

Slaughter, R.; and Huba, G.J. Women’s steps 

of change and entry into drug abuse 

treatment: A multidimensional stages of 

change model. 

, in press. 

Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E.; 

and Wilson, G.T. Understanding and 

preventing relapse. 

41:765–782, 1986. 

Budman, S., and Gurman, A. 

. New York: Guilford Press, 

1988.

Budney, A.J., and Higgins, S.T. 

HHS Pub. No. 98-4309, 

Washington, DC: U.S. Government Printing 

Office, 1998. 

Carey, K.B. Substance use reduction in the 

context of outpatient psychiatric treatment: A 

collaborative, motivational, harm reduction 

approach.

32:291–306, 1996. 
Carpenter, R.A.; Lyons, C.A.; and Miller, W.R. 

Peer-managed self-control program for 

prevention of alcohol abuse in American 

Indian high school students: A pilot 

evaluation study

20:299–310, 1985. 

Carroll, M.E. The economic context of drug and 

non-drug reinforcers affects acquisition and 

maintenance of drug-reinforced behavior 

and withdrawal effects. 

33:201–210, 1993. 

Center for Substance Abuse Treatment. 

 Treatment Improvement 

Protocol (TIP) Series, Number 7. HHS Pub. 

No. (SMA) 94-2076. Washington, DC: U.S. 

Government Printing Office, 1994a. 

Center for Substance Abuse Treatment. 

Treatment Improvement 

Protocol (TIP) Series, Number 9. HHS Pub. 

No. (SMA) 94-2078. Washington, DC: U.S. 

Government Printing Office, 1994b. 

Center for Substance Abuse Treatment. 

Treatment Improvement 

Protocol (TIP) Series, Number 10. HHS 

Pub. No. (SMA) 94-3003, Washington, DC: 

U.S. Government Printing Office, 1994c. 

Center for Substance Abuse Treatment. 

Treatment Improvement Protocol (TIP) 

Series, Number 11. HHS Pub. No. (SMA) 

94-2094. Washington, DC: U.S. Government 

Printing Office, 1994d. 

Center for Substance Abuse Treatment. 

Treatment

Improvement Protocol (TIP) Series, Number 

12. HHS Pub. No. (SMA) 94-3004. 

Washington, DC: U.S. Government Printing 

Office, 1994e. 

Center for Substance Abuse Treatment. 

Treatment Improvement Protocol (TIP) 

Series, Number 13. HHS Pub. No. (SMA) 

95-3021. Washington, DC: U.S. Government 

Printing Office, 1995a. 

Center for Substance Abuse Treatment. 

 Treatment Improvement Protocol 

(TIP) Series, Number 17. HHS Pub. No. 

(SMA) 95-3039. Washington, DC: U.S. 

Government Printing Office, 1995b. 

Center for Substance Abuse Treatment. 

 Treatment 

Improvement Protocol (TIP) Series, Number 

20. HHS Pub. No. (SMA) 95-3049. 

Washington, DC: U.S. Government Printing 

Office, 1995c. 

Center for Substance Abuse Treatment. 

. Treatment Improvement Protocol 

(TIP) Series, Number 24. HHS Pub. No. 

(SMA) 97-3139. Washington, DC: U.S. 

Government Printing Office, 1997. 

Center for Substance Abuse Treatment. 

.

Treatment Improvement Protocol (TIP) 

Series, Number 29. HHS Pub. No. (SMA) 

98-3249. Washington, DC: U.S. Government 

Printing Office, 1998a. 
Center for Substance Abuse Treatment. 

.

Treatment Improvement Protocol (TIP) 

Series, Number 30. HHS Pub. No. (SMA) 

98-3245. Washington, DC: U.S. Government 

Printing Office, 1998b. 

Center for Substance Abuse Treatment. 

. Treatment Improvement Protocol 

(TIP) Series. HHS Pub. No. (SMA) 99-3353. 

Washington, DC: U.S. Government Printing 

Office, in press (a). 

Center for Substance Abuse Treatment. 

. Treatment 

Improvement Protocol (TIP) Series. 

Washington, DC: U.S. Government Printing 

Office, in press (b). 

Chafetz, M.E.; Blane, H.T.; Abram, H.S.; Clark, 

E.; Golner, J.; Hastie, E.L.; and McCourt, W.F. 

Establishing treatment relations with 

alcoholics: A supplementary report. 

138:390–393,

1964.

Chafetz, M.E.; Blane, H.T.; Abram, H.S.; Golner, 

J.; Lacy, E.; McCourt, W.F.; Clark, E.; and 

Meyers, W. Establishing treatment relations 

with alcoholics. 

134:395–409, 1962. 

Chamberlain, P.; Patterson, G.; Reid, J.; 

Kavanaugh, K.; and Forgatch, M. 

Observation of client resistance. 

 15:144–155, 1984. 

Chapman, P.L.H., and Huygens, I. An 

evaluation of three treatment programmes 

for alcoholism: An experimental study with 

6- and 18-month follow-up. 

 83:67–81, 1988. 

Chen, K., and Kandel, D.B. The natural history 

of drug use from adolescence to mid-thirties 

in a general population sample. 

 85(1):41–47, 1995. 

Chick, J.; Lloyd, G.; and Crombie, E. 

Counselling problem drinkers in medical 

wards: A controlled study. 

 290:965–967, 1985. 

Chick, J.; Ritson, B.; Connaughton, J.; Stewart, A; 

and Chick, J. Advice versus extended 

treatment for alcoholism: A controlled study. 

 83:159–170, 1988. 

Christiansen, B.A.; Goldman, M.S.; and Inn, A. 

Development of alcohol-related expectancies 

in adolescents: Separating pharmacological 

from social learning influences. 

50:336–344.

1982.

Colby, S.M.; Monti, P.M.; Barnett, N.P.; 

Rohsenow, D.J.; Weissman, K.; Spirito, A.; 

Woolard, R.H.; and Lewander, W.J. Brief 

motivational interviewing in a hospital 

setting for adolescent smoking: A 

preliminary study. 

 66:574–578, 1998. 

Collins, R.L.; Lapp, W.M.; Emmons, K.M.; and 

Isaac, L.M. Endorsement and strength of 

alcohol expectancies. 

51(4):336–342, 1990. 

Colten, M.E., and Janis, I.L. Effects of moderate 

self-disclosure and the balance sheet 

procedure. In: Janis, I.L., ed. 

. New Haven, 

CT: Yale University Press, 1982. pp. 159–171. 

Connors, G.J., and Maisto, S.A. Alcohol 

expectancy construct: Overview and clinical 

applications. 

12:487–504, 1988. 

Connors, G.J.; O’Farrell, T.J.; Cutter, H.S.G.; and 

Thompson, D.L. Dose-related effects of 

alcohol among male alcoholics, problem 

drinkers, and nonproblem drinkers. 

48:461–466, 1987. 
Costello, R.M. Alcoholism treatment and 

evaluation: In search of methods. II. 

Collation of two-year follow-up studies. 

10:857– 

867, 1975. 

Cota, A.A.; Longman, R.S.; Evans, C.R.; Dion, 

K.L.; and Kilik, L. Using and misusing factor 

analysis to explore group cohesion. 

 51:308–316, 1995. 

Cox, W.M.; Klinger, E.; and Blount, J.P. Alcohol 

use and goal hierarchies: Systematic 

motivational counseling for alcoholics. In: 

Miller, W.R., and Rollnick, S., eds

New York: 

Guilford Press, 1993. pp. 260–271. 

Cummings, C.; Gordon, J.R.; and Marlatt, G.A. 

Relapse: Prevention and prediction. In: 

Miller, W.R., ed. 

 Oxford: Pergamon Press, 1980. 

pp. 291–321. 

Cunningham, J.A.; Sobell, L.C.; Gavin, D.R.; 

Sobell, M.B.; and Breslin, F.C. Assessing 

motivation for change: Preliminary 

development and evaluation of a scale 

measuring the costs and benefits of alcohol 

or drug use. 

11(2):107–114, 1997. 

Cunningham, J.A.; Sobell, M.B.; Sobell, L.C.; 

Gavin, D.R.; and Annis, H.M. Heavy 

drinking and negative affective situations in 

a general population and a treatment sample: 

Alternative explanations. 

 9:123–127, 1995. 

Daley, D.C.; Salloum, I.M.; Zuckoff, A.; Kiricsi, 

L.; and Thase, M.E. Increasing treatment 

adherence among outpatients with 

depression and cocaine dependence: Results 

of a pilot study. 

 155:1611–1613, 1998. 

Daniels, V.; Somers, M.; and Orford, J. How can 

risk drinking amongst medical patients be 

modified? The effects of computer screening 

and advice and a self-help manual. 

 20:47–60, 1992. 

Davidson, R. Can psychology make sense of 

change? In: Edwards, G., and Lader, M., eds. 

Society for the 

Study of Addiction Monograph No. 3. New 

York: Oxford University Press, 1994. pp. 51– 

78.

Deci, E.L. . New York: 

Plenum Press, 1975. 

Deci, E.L. .

Lexington, MA: Lexington Books, 1980. 

De Leon, G.; Melnick, G.; Kressel, D.; and 

Jainchill, N. Circumstances, motivation, 

readiness, and suitability (the CMRS Scales): 

Predicting retention in therapeutic 

community treatment.

 20(4):495–515, 1994. 

DiClemente, C.C. Motivational interviewing 

and the stages of change. In: Miller, W.R., 

and Rollnick, S., eds. 

. New York: Guilford 

Press, 1991. pp. 191–202. 

DiClemente, C.C.; Carbonari, J.P.; Montgomery, 

R.P.G.; and Hughes, S.O. The Alcohol 

Abstinence Self-Efficacy Scale.

 55(2):141–148, 1994. 

DiClemente, C.C., and Prochaska, J.O. Processes 

and stages of self-change: Coping and 

competence in smoking behavior change. In: 

Shiffman, S., and Wills, T.A., eds. 

. New York: Academic Press, 

1985. pp. 319–343. 

DiClemente, C.C., and Prochaska, J.O. Toward a 

comprehensive transtheoretical model of 

change: Stages of change and addictive 

behaviors. In: Miller, W.R., and Heather, N., 

eds. 2nd ed. 

New York: Plenum Press, 1998. 
DiClemente, C.C., and Scott, C.W. Stages of 

change: Interactions with treatment 

compliance and involvement. In: Onken, 

L.S.; Blaine, J.D.; and Boren, J.J., eds. 

. NIDA 

Research Monograph Series, Number 165. 

HHS Pub. No. (ADM) 97-4142. Rockville, 

MD: National Institute on Drug Abuse, 1997. 

pp. 131–156. 

Dies, R.R., ed. 

. New York: Guilford Press, 1994. 

D’Onofrio, G.; Bernstein, E.; Bernstein, J.; 

Woolard, R.H.; Brewer, P.A.; Craig, S.A.; and 

Zink, B.J. Patients with alcohol problems in 

the emergency department, Part 2: 

Intervention and referral. 

5:1210−1217, 1998. 

Drummond, D.C. Alcohol interventions: Do the 

best things come in small packages? 

 92(4):375–379, 1997. 

Drummond, D.C.; Thom, B.; Brown, C.; 

Edwards, G.; and Mullan, M.J. Specialist 

versus general practitioner treatment of 

problem drinkers. 336:915–918, 1990. 

Eastwood, G.L., and Avunduk, C. 

, 2nd 

ed. New York: Little, Brown and Company, 

1994.

Edwards, G.; Orford, J.; Egert, S.; Guthrie, S.; 

Hawken, A.; Hensman, C.; Mitcheson, M.; 

Oppenheimer, E.; and Taylor, C. Alcoholism: 

A controlled trial of “treatment” and 

“advice.” 

38:1004–1031, 1977. 

Ellis, A., and Velten, E. 

Fort Lee, NJ: Barricade Books, 1992. 

Elvy, G.A.; Wells, J.E.; and Baird, K.A. 

Attempted referral as intervention for 

problem drinking in the general hospital. 

83:83–89, 1988. 

Fleming, M.F.; Barry, K.L.; Manwell, L.B.; 

Johnson, K.; and London, R. Brief physician 

advice for problem alcohol drinkers: A 

randomized controlled trial in communitybased primary care practices

277(13):1039–1045, 1997. 

Fosnocht, K.M. Cost-effectiveness of the 

AHCPR guidelines for smoking. 

279(11):837, 1998. 

Galanter, M.; Keller, D.S.; and Dermatis, H. 

Network Therapy for addiction: Assessment 

of the clinical outcome of training. 

23:355–367,

1997.

Gavin, D.R.; Sobell, L.C.; and Sobell, M.B. 

Evaluation of the Readiness to Change 

Questionnaire with problem drinkers in 

treatment. 10:53–

58, 1998. 

Goddard, L., ed. 

 Washington, DC: U.S. Government 

Printing Office, 1992. 

Gordon, T. 

New York: Wyden, 1970. 

Grills, C., and Rowe, D. African traditional 

medicine: Implications for African centered 

approaches to healing. In: Jones, R., ed. 

. Hampton, 

VA: Cobb and Henry, 1998. 

Handmaker, N.S.; Miller, W.R.; and Manicke, M. 

Findings of a pilot study of motivational 

interviewing with pregnant drinkers.

 60(2):285–287, 1999. 

Harris, K.B., and Miller, W.R. Behavioral selfcontrol training for problem drinkers: 

Components of efficacy. 

4:82–90, 1990. 
Appendix A 

Heather, N. Interpreting the evidence on brief 

interventions for excessive drinkers: The 

need for caution. Alcohol and Alcoholism 

30(3):287–296, 1995.

Heather, N.; Kissoon-Singh, J.; and Fenton, G.W.

Assisted natural recovery from alcohol 

problems: Effects of a self-help manual with

and without supplementary telephone 

contact. British Journal of Addiction 85:1177– 

1185, 1990.

Heather, N.; Luce, A.; Peck, D.; and Dunbar, B.

“Development of the Readiness to Change 

Questionnaire (Treatment Version).” Report 

to the Northern and Yorkshire R&D 

Directorate, 1996a.

Heather, N.; Luce, A.; Peck, D.; Dunbar, B.; and 

James, I. Development of a Treatment 

Version of the Readiness to Change 

Questionnaire. Addiction Research 7(1):63–83,

1999c.

Heather N.; Robertson, I.; MacPherson, B.;

Allsop, S.; and Fulton, A. Effectiveness of a 

controlled drinking self-help manual: One 

year follow-up results. British Journal of 

Clinical Psychology 26:279–287, 1987.

Heather, N.; Rollnick, S.; and Bell, A. Predictive

validity of the Readiness to Change 

Questionnaire. Addiction 88:1667–1677, 1993.

Heather, N.; Rollnick, S.; Bell, A.; and 

Richmond, R. Effects of brief counseling

among male heavy drinkers identified on 

general hospital wards. Drug and Alcohol 

Review 15:29–38, 1996b.

Heather, N.; Whitton, B.; and Robertson, I.

Evaluation of a self-help manual for mediarecruited problem drinkers: Six month 

follow-up results. British Journal of Clinical 

Psychology 25:19–34, 1986.

Helzer, J.E., and Pryzbeck, T.R. Co-occurrence 

of alcoholism with other psychiatric

disorders in the general population and its

impact on treatment. Journal of Studies on 

Alcohol 49:219–224, 1988.

Higgins, S.T.; Bickel, W.K.; and Hughes, J.R.

Influence of an alternative reinforcer on 

human cocaine self-administration. Life 

Sciences 55:179–187, 1994a.

Higgins, S.T., and Budney, A.J. Treatment of 

cocaine dependence through the principles of 

behavior analysis and behavioral

pharmacology. In: Onken, L.S.; Blaine, J.D.;

and Boren, J.J., eds. Behavioral Treatments for 

Drug Abuse and Dependence. Rockville, MD: 

National Institute on Drug Abuse, 1993.

pp. 97–121.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Badger, 

G.J.; Foerg, F.E.; and Ogden, D. Outpatient

behavioral treatment for cocaine dependence: 

One-year outcome. Experimental and Clinical 

Psychopharmacology 3:20 5–212, 1995.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, 

F.; Donham, R.; and Badger, M.S. Incentives

improve outcome in outpatient behavioral 

treatment of cocaine dependence. Archives of 

General Psychiatry 51:568–576, 1994b.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.;

Hughes, J.R.; Foerg, F.; and Badger, G.

Achieving cocaine abstinence with a 

behavioral approach. American Journal of 

Psychiatry 150:763–769, 1993.

Higgins, S.T., and Silverman, K. Motivating 

Behavior Change Among Illicit Drug Abusers: 

Research on Contingency Management 

Interventions. Washington, DC: American

Psychological Association, 1999.

Holder, H.; Longabaugh, R.; Miller, W.R.; and 

Rubonis, A.V. The cost effectiveness of 

treatment for alcoholism: A first

approximation. Journal of Studies on Alcohol 

52(6):517–540, 1991.

Hunt, G.M., and Azrin, N.H. A communityreinforcement approach to alcoholism.

Behavioral Research and Therapy 11(1):91–104, 

1973.

170 
Bibliography 

Hurt, R.D.; Offord, K.P.; Croghan, I.T.; GomezDahl, L.; Kottke, T.E.; Morse, R.M.; and 

Melton, J. Mortality following inpatient 

addictions treatment: Role of tobacco use in a 

community-based cohort. JAMA 25:1097– 

1103, 1996.

Inciardi, J.A; Tims, F.M.; and Fletcher, B.

Innovative Approaches to the Treatment of Drug 

Abuse: Program Models and Strategies. 

Westport, CT: Greenwood, 1993.

Ingersoll, K.S., and Wagner, C.C. Motivational 

Enhancement Groups for the Virginia Substance 

Abuse Treatment Outcomes Evaluation 

(SATOE) Model: Theoretical Background and 

Clinical Guidelines. Richmond, VA: Office of 

Mental Health Services, Department of 

Mental Health, Mental Retardation and 

Substance Abuse Services, 1997.

Institute of Medicine. Broadening the Base of 

Treatment for Alcohol Problems. Report of a 

Study by a Committee of the Institute of 

Medicine, Division of Mental Health and 

Behavioral Medicine. Washington, DC: 

National Academy Press, 1990a.

Institute of Medicine. Treating Drug Problems. 

Washington, DC: National Academy Press, 

1990b.

Intagliata, J. A telephone follow-up procedure 

for increasing the effectiveness of a treatment 

program for alcoholics. Journal of Studies on 

Alcohol 37:1330–1335, 1976.

Ivey, A.E.; Gluckstern, N.B.; and Ivey, M.B.

Basic Influencing Skills. 3rd ed. North 

Amherst, MA: Microtraining Associates,

1997.

Jaffee, J.H. The swinging pendulum: The 

treatment of drug users in America. In: 

Dupont, R.L.; Goldstein, A.; O’Donnell, J.;

and Brown, B., eds. Handbook on Drug Abuse.

Rockville, MD: National Institute on Drug 

Abuse, 1979. pp. 3–16.

Janis, I.L., and Mann, L. Decision Making: A 

Psychological Analysis of Conflict, Choice, and 

Commitment. London: Cassel and Collier

Macmillan, 1977.

Johnson, V.E. I’ll Quit Tomorrow. New York: 

Harper & Row, 1973.

Jones, R.A. Self-Fulfilling Prophecies: Social, 

Psychological, and Physiological Effects of 

Expectancies. Hillsdale, NJ: L. Erlbaum, 1977.

Kahan, M.; Wilson, L.; and Becker, L.

Effectiveness of physician-based 

interventions with problem drinkers: A 

review. Canadian Medical Association Journal 

152(6):851–859, 1995.

Kanfer, F.H. Self-regulation: Research, issues, 

and speculations. In: Neuringer, C., and 

Michael, J.L., eds. Behavior Modification in 

Clinical Psychology. New York: AppletonCentury-Crofts, 1970. pp. 178–220.

Kanfer, F.H., and Schefft, B.K. Guiding the 

Process of Therapeutic Change. Champaign, IL: 

Research Press, 1988.

Keller, D.S.; Galanter, M.; and Weinberg, S.

Validation of a scale for network therapy: A 

technique for systematic use of peer and 

family support in addiction treatment.

American Journal of Drug and Alcohol Abuse 

23:115–127, 1997.

Kent, R. Motivational interviewing and the 

maintenance of change. In: Miller, W.R., and 

Rollnick, S., eds. Motivational Interviewing: 

Preparing People To Change Addictive Behavior.

New York: Guilford Press, 1991. pp. 191– 

202.

Khantzian, E.J. An ego/self theory of substance 

dependence: A contemporary psychoanalytic

perspective. In: Lettieri, D.J.; Sayers, M.; and 

Pearson, H.W., eds. Theories on Drug Abuse: 

Selected Contemporary Perspectives. NIDA 

Research Monograph Series, Number 30.

HHS Publication No. (ADM) 80-967. 

Washington, DC: U.S. Government Printing

Office, 1980. pp. 29–33.

171 
Appendix A 

Khantzian, E.J.; Halliday, K.S.; and McAuliffe, 

W.E. Addiction and the Vulnerable Self: 

Modified Dynamic Group Therapy for Substance 

Abusers. New York: Guilford Press, 1990.

Kilpatrick, D.G.; Roitzsch, J.C.; Best, C.L.; 

McAlhany, D.A.; Sturgis, E.T.; and Miller, 

W.C. Treatment goal preference and 

problem perception of chronic alcoholics: 

Behavioral and personality correlates.

Addictive Behaviors 3:107–116, 1978.

Klingemann, H.K. The motivation for change 

from problem alcohol and heroin use. British 

Journal of Addiction 86:727–744, 1991.

Kolden, G.G.; Howard, K.I.; Bankoff, E.A.; 

Maling, M.S.; and Martinovich, Z. Factors 

associated with treatment continuation: 

Implications for the treatment of drug 

dependence. In: Onken, L.S.; Blaine, J.D.; 

and Boren, J.J., eds. Beyond the Therapeutic 

Alliance: Keeping the Drug-Dependent 

Individual in Treatment. NIDA Research 

Monograph Series, Number 165. HHS Pub. 

No. (ADM) 97-4142. Rockville, MD: National 

Institute on Drug Abuse, 1997. pp. 110–130.

Kopel, S., and Arkowitz, H. The role of 

attribution and self-perception in behavior 

change: Implications for behavior therapy. 

Genetic Psychology Monographs 92:175–212, 

1975.

Koumans, A.J.R., and Muller, J.J. Use of letters 

to increase motivation in alcoholics.

Psychology Reports 16:1152, 1965.

Kris, A.O. The conflict of ambivalence.

Psychoanalytical Study of the Child 39:213–234, 

1984.

Kristenson, H.; Öhlin, H.; Hultén-Nosslin, M.B.; 

Trell, E.; and Hood, B. Identification and 

intervention of heavy drinking in middleaged men: Results and follow-up of 24–60 

months of long-term study with randomized 

controls. Alcoholism: Clinical and 

Experimental Research 7:203–209, 1983.

Kuchipudi, V.; Hobein, K.; Flickinger, A.; and 

Iber, F.L. Failure of a 2-hour motivational 

intervention to alter recurrent drinking 

behavior in alcoholics with gastrointestinal 

disease. Journal of Studies on Alcohol 

51:356–360, 1990.

Landry, M.J. Overview of Addiction Treatment 

Effectiveness. HHS Pub. No. (SMA) 96-

3081. Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 

Office of Applied Studies, 1996.

Landry, M.J.; Smith, D.E.; and Steinberg, J.R. 

Anxiety, depression, and substance use 

disorders: Diagnosis, treatment, and 

prescribing practices. Journal of 

Psychoactive Drugs 23(4):397–416, 1991.

Leake, G.J., and King, S.A. Effect of counselor 

expectations on alcoholic recovery. Alcohol 

Health and Research World 11(3):16–22, 

1977.

Leigh, B.C. Confirmatory factor analysis of 

alcohol expectancy scales. Journal of Studies 

on Alcohol 50:268–277, 1989a.

Leigh, B.C. In search of the seven dwarves: 

Issues of measurement and meaning in 

alcohol expectancy research. Psychological 

Bulletin 105:361–373, 1989b.

Leukefeld, C.G., and Tims, F.M. Compulsory 

treatment: A review of findings. In: 

Leukefeld, C.G., and Tims, F.M., eds.

Compulsory Treatment of Drug Abuse: 

Research and Clinical Practice. NIDA 

Research Monograph Series, Number 86. 

HHS Pub. No. (ADM) 88-1578. Rockville, 

MD: National Institute on Drug Abuse, 1988. 

pp. 236–251.

Leventhal, H. Fear appeals and persuasion: The 

differentiation of a motivational construct. 

American Journal of Public Health 61:1208– 

1224, 1971.

172 
Liepman, M.R.; Nirenberg, T.D.; and Begin, 

A.M. Evaluation of a program designed to 

help family and significant others to 

motivate resistant alcoholics into recovery.

15(2):209–221, 1989. 

Løberg, T., and Miller, W.R. Personality, 

cognitive, and neuropsychological correlates 

of harmful alcohol consumption: A crossnational comparison of clinical samples. 

472:75–97, 1986. 

Loneck, B.; Garrett, J.A.; and Banks, S.M. A 

comparison of the Johnson intervention with 

four other methods of referral to outpatient 

treatment.

22(2):233–246, 1996a. 

Loneck, B.; Garrett, J.A.; and Banks, S.M. The 

Johnson intervention and relapse during 

outpatient treatment.

 22(3):363–375, 1996b. 

Longabaugh, R.; Beattie, M.; Noel, N.; Stout, R.; 

and Malloy, P. The effect of social 

investment on treatment outcome. 

 54(4):465–478, 1993. 

Longshore, D., and Grills, C. Drug problem 

recognition among African American drugusing arrestees. 

23(2):275–279, 1998. 

Longshore, D.; Grills, C.; Anglin, D.; and Annon, 

K. Treatment motivation among AfricanAmerican drug using arrestees. 

24(2):126–144, 1998. 

Luborsky, L.; McLellan, A.T.; Woody, G.E.; 

O’Brien, C.P.; and Auerbach, A. Therapist 

success and its determinants. 

 42:602–611, 1985. 

Luke, D. “Teens’ images of smoking and 

smokers.” Paper presented at the annual 

meeting of the Society for Research on 

Nicotine and Tobacco, New Orleans, LA, 

1998.

MacKenzie, K.R., ed. 

. New York: 

International Universities Press, 1983. 

Marlatt, G.A.; Baer, J.S.; Kivlahan, D.R.; Dimeff, 

L.A., Larimer, M.E., Quigley, L.A.; Somers, 

J.M.; and Williams, E. Screening and brief 

intervention for high-risk college student 

drinkers: Results from a 2-year follow-up 

assessment.

 66:604–615, 1998. 

Marlatt, G.A., and George, W.H. Relapse 

prevention: Introduction and overview of the 

model. 79:261– 

273, 1984. 

Marlatt, G.A., and Gordon, J.R., eds. 

. New York: 

Guilford Press, 1985. 

Marlatt, G.A., and Kristeller, J. Mindfulness and 

meditation. In: Miller, W.R., ed. 

. Washington, DC: American 

Psychological Association, 1999. 

Mattick, R.P., and Jarvis, T. Brief or minimal 

intervention for ‘alcoholics’? The evidence 

suggests otherwise. 

13:137–144, 1994. 

McAuliffe, W.E., and Gordon, R.A. 

Reinforcement and the combination of 

effects: Summary of a theory of opiate 

addiction. In: Lettieri, D.J.; Sayers, M.; and 

Wallenstein-Pearson, H., eds. 

. NIDA Research Monograph 

Series, Number 30. HHS Pub. No. (ADM)

80-967. Washington, DC: U.S. Government 

Printing Office, 1980. pp. 137–141. 
McCaul, M.E., and Svikis, D.S. Improving client 

compliance in outpatient treatment: 

Counselor-targeted interventions. In: 

Pickens, R.W.; Leukefeld, C.G.; and Schuster, 

C.R. . NIDA 

Research Monograph Series, Number 106. 

Rockville, MD: National Institute on Drug 

Abuse, 1991. pp. 204–217.

McConnaughy, E.A.; Prochaska, J.O.; and 

Velicer, W.F. Stages of change in 

psychotherapy: Measurement and sample 

profiles.

20:368–375, 1983. 

McLellan, A.T.; Alterman, A.I.; Metzger, D.S.; 

Grisson, G.R.; Woody, G.E.; Luborsky, L.; 

and O’Brien, C.P. Similarity of outcome 

predictors across opiate, cocaine, and alcohol 

treatments: Role of treatment services. 

62(6):1141–1158, 1994. 

Melchior, L.A.; Huba, G.J.; Brown, V.B.; and 

Slaughter, R. Evaluation of the effects of 

outreach to women with multiple 

vulnerabilities on entry into substance abuse 

treatment. ,

in press. 

Meyers, R.J., and Smith, J.E. 

New York: Guilford 

Press, 1995. 

Meyers, R.J., and Smith, J.E. Getting off the 

fence: Procedures to engage treatmentresistant drinkers. 

14(5):467–472, 1997. 

Miller, L. Neuropsychological assessment of 

substance abusers: Review and 

recommendations. 

 2(1):5–17, 1985a. 

Miller, W.R. Alcoholism scales and objective 

assessment methods: A review. 

 98:84–107, 1976. 

Miller, W.R. Motivational interviewing with 

problem drinkers. 

11:147–172, 1983. 

Miller, W.R. Motivation for treatment: A review 

with special emphasis on alcoholism. 

 98(1):84–107, 1985b. 

Miller, W.R. Increasing motivation for change. 

In: Hester, R.K., and Miller, W.R., eds. 

2nd ed. Boston: Allyn & 

Bacon, 1995. pp. 89–104. 

Miller, W.R. What is a relapse? Fifty ways to 

leave the wagon. 91(Suppl.):S15–

S27, 1996. 

Miller, W.R.; Andrews, N.R.; Wilbourne, P.; and 

Bennett, M.E. A wealth of alternatives: 

Effective treatments for alcohol problems. In: 

Miller, W.R., and Heather, N., eds. 

, 2nd 

ed. New York: Plenum Press, 1998. pp. 203– 

216. 

Miller, W.R., and Baca, L.M. Two-year followup of bibliotherapy and therapist-directed 

controlled drinking training for problem 

drinkers. 14:441–448, 1983. 

Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. 

Enhancing motivation for change in problem 

drinking: A controlled comparison of two 

therapist styles. 

61(3):455–461, 1993. 

Miller, W.R.; Brown, J.M.; Simpson, T.L.; 

Handmaker, N.S.; Bien, T.H.; Luckie, L.F.; 

Montgomery, H.A.; Hester, R.K.; and 

Tonigan, J.S. What works? A 

methodological analysis of the alcohol 

treatment outcome literature. In: Hester, 

R.K., and Miller, W.R., eds. 

, 2nd ed. Boston: Allyn & Bacon, 

1995a. pp. 12–44. 
Miller, W.R., and C’de Baca, J. Quantum 

change: Toward a psychology of 

transformation. In: Heatherton, T., and 

Weinberger, J., eds. 

Washington, DC: American Psychological 

Association, 1994. pp. 253–280 

Miller, W.R.; Gribskov, C.J.; and Mortell, R.L 

Effectiveness of a self-control manual for 

problem drinkers with and without therapist 

contact.

16:1247–1254, 1981. 

Miller, W.R., and Heather, N., eds. 

, 2nd ed. New York: 

Plenum Press, 1998. 

Miller, W.R., and Kurtz, E. Models of 

alcoholism used in treatment: Contrasting 

AA and other perspectives with which it is 

often confused. 

55:159–166, 1994. 

Miller, W.R.; Leckman, A.L; Delaney, H.D.; and 

Tinkcom, M. Long-term follow-up of 

behavioral self-control training. 

 53(3):249–261, 1992. 

Miller, W.R., and Meyers, R.J. Engaging 

unmotivated individuals in treatment for 

alcohol problems: A comparison of three 

intervention strategies. 

, in press. 

Miller, W.R., and Page, A.C. Warm turkey: 

Other routes to abstinence

 8:227–232, 1991. 

Miller, W.R., and Pechacek, T.F. New roads: 

Assessing and treating psychological 

dependence.

 4:73–77, 1987. 

Miller, W.R., and Rollnick, S. 

 New York: Guilford 

Press, 1991. 

Miller, W.R., and Sanchez, V.C. Motivating 

young adults for treatment and lifestyle 

change. In: Howard, G., and Nathan, P.E., 

eds.

Notre Dame, IN: University of Notre Dame 

Press, 1994. 

Miller, W.R., and Saucedo, C.F. Assessment of 

neuropsychological impairment and brain 

damage in problem drinkers. In: Golden, 

C.J.; Moses, J.A., Jr.; Coffman, J.A.; Miller, 

W.R.; and Strider, F.D., eds. 

. New York: Grune & 

Stratton, 1983. pp. 141–195. 

Miller, W.R., and Sovereign, R.G. The check-up: 

A model for early intervention in addictive 

behaviors. In: Løberg, T.; Miller, W.R.; 

Nathan, P.E.; and Marlatt, G.A., eds

Amsterdam: Swets & Zeitlinger, 

1989. pp. 219–231. 

Miller, W.R.; Sovereign, R.G.; and Krege, B. 

Motivational interviewing with problem 

drinkers: II. The Drinker’s Check-up as a 

preventive intervention. 

 16:251–268, 1988. 

Miller, W.R., and Taylor, C.A. Relative 

effectiveness of bibliotherapy, individual and 

group self-control training in the treatment of 

problem drinkers. 5:13– 

24, 1980. 

Miller, W.R.; Taylor, C.A.; and West, J.C. 

Focused versus broad-spectrum behavior 

therapy for problem drinkers. 

48:590–601,

1980.

Miller, W.R., and Tonigan, J.S. Assessing 

drinkers’ motivation for change: The Stages 

of Change Readiness and Treatment 

Eagerness Scale (SOCRATES).

10(2):81–89, 1996. 
Miller, W.R.; Westerberg, V.S.; and Waldron, 

H.B. Evaluating alcohol problems. In: 

Hester, R.K., and Miller, W.R., eds. 

, 2nd ed. Boston: Allyn & Bacon, 

1995b. pp. 61–88. 

Miller, W.R.; Zweben, A.; DiClemente, C.C.; and 

Rychtarik, R.G. 

. Project MATCH 

Monograph Series, Vol. 2. NIH Pub. No. 94-

3723. Rockville, MD: National Institute on 

Alcohol Abuse and Alcoholism, 1995c. 

Moos, R.H.; Brennan, P.L.; Fondacaro, M.R.; and 

Moos, B.S. Approach and avoidance coping 

responses among older problem and 

nonproblem drinkers. 

5(1):31–40, 1990. 

Najavits, L.M., and Weiss, R.D. Variations in 

therapist effectiveness in the treatment of 

patients with substance use disorders: An 

empirical review. 89(6):679–688, 

1994.

Nir, Y., and Cutler, R. The unmotivated patient 

syndrome: Survey of therapeutic 

interventions.

135:442–447, 1978. 

Nirenberg, T.D.; Sobell, L.C.; and Sobell, M.B. 

Effective and inexpensive procedures for 

decreasing client attrition in an outpatient 

alcohol treatment program.

 7:73–82, 1980. 

Noonan, W.C., and Moyers, T.B. Motivational 

interviewing. 

2:8–16, 1997. 

Obert, J.L.; Rawson, R.A.; and Miotto, K. 

Substance abuse treatment for “hazardous 

users”: An early intervention. 

29(3):291–298, 1997. 

Ockene, J.K.; Wheeler, E.V.; Adams, A.; Hurley, 

T.G.; and Hebert, J. Provider training for 

patient-centered alcohol counseling in a 

primary care setting. 

157(20):2334–2341, 1997.

O’Farrell, T.J., ed.

. New York: 

Guilford Press, 1993. 

Orford, J. 

New York: John Wiley 

and Sons, 1985. 

Orford, J. Empowering family and friends: A 

new approach to the secondary prevention of 

addiction. 13:417–

429, 1994. 

Orleans, C.T.; Schoenbach, V.J.; Wagner, E.H.; 

Quade, D.; Salmon, M.A.; Pearson, D.C.; 

Fiedler, J.; Porter, C.Q.; and Kaplan, B.H. 

Self-help quit smoking interventions: Effects 

of self-help materials, social support 

instructions, and telephone counseling. 

59:439–448, 1991. 

Panepinto, W.C., and Higgins, M.J. Keeping 

alcoholics in treatment: Effective followthrough procedures. 

 30:414–419, 1969. 

Parker, M.W.; Winstead, D.K.; and Willi, F.J. 

Patient autonomy in alcohol rehabilitation: I. 

Literature review. 

 14:1015–1022, 1979. 

Pattison, E.M.; Sobell, M.B.; and Sobell, L.C. 

New York: Springer, 1977. 

Persson, J., and Magnusson, P.H. Early 

intervention in patients with excessive 

consumption of alcohol: A controlled study. 

6:403–408, 1989. 
Perz, C.A.; DiClemente, C.C.; and Carbonari, J.P. 

Doing the right thing at the right time? The 

interaction of stages and processes of change 

in successful smoking cessation. 

 15:462–468, 1996. 

Peterson, L.; Gable, S.; and Saldana, L. 

Treatment of maternal addiction to prevent 

child abuse and neglect. 

21: 789–801, 1996. 

Pickens, R.W., and Fletcher, B.W. Overview of 

treatment issues. In: Pickens, R.W.; 

Leukefeld, C.G.; and Schuster, C.R., eds. 

NIDA 

Research Monograph Series, Number 106. 

HHS Pub. No. (ADM) 91-1754. Rockville,

MD: National Institute on Drug Abuse, 1991. 

pp. 1–19. 

Polich, J.M.; Armor, D.J.; and Braiker, H.B. 

New York: John Wiley and Sons, 

1981.

Prochaska, J.O. 

. Homewood, IL: 

Dorsey Press, 1979. 

Prochaska, J.O., and DiClemente, C.C. Stages 

and processes of self-change of smoking: 

Toward an integrated model of change. 

51:390–395, 1983. 

Prochaska, J.O., and DiClemente, C.C. 

. Homewood, IL: Dow 

Jones-Irwin, 1984. 

Prochaska, J.O., and DiClemente, C.C. Stages of 

change in the modification of problem 

behaviors. In: Hersen, M.; Eisler, R.M.; and 

Miller, P.M., eds. 

Sycamore, IL: Sycamore 

Publishing Company, 1992. pp. 184–214. 

Prochaska, J.O; DiClemente, C.C.; and Norcross, 

J.C. Changing: Process approaches to 

initiation and maintenance of changes. In: 

Klar, Y.; Fisher, J.D.; Chinsky, J.M.; and 

Nadler, A., eds. 

New

York: Springer-Verlag, 1992a. pp. 87–114. 

Prochaska, J.O.; DiClemente, C.C.; and Norcross, 

J.C. In search of how people change: 

Applications to addictive behaviors. 

 47:1102–1114, 1992b. 

Prochaska, J.O., and Goldstein, M.G. Process of 

smoking cessation: Implications for 

clinicians. 12:727–735,

1991.

Prochaska, J.O.; Velicer, W.F.; Rossi, J.S.; 

Goldstein, M.G.; Marcus, B.H.; Rakowski, W.; 

Fiore, C.; Harlow, L.L.; Redding, C.A., 

Rosenbloom, D.; and Rossi, S.R. Stages of 

change and decisional balance for 12 

problem behaviors. 

13(1):39–46, 1994. 

Project MATCH Research Group. Matching 

alcoholism treatments to client heterogeneity: 

Project MATCH posttreatment drinking 

outcomes. 58:7– 

29, 1997a. 

Project MATCH Research Group. Matching 

alcoholism treatments to client heterogeneity: 

Project MATCH three-year drinking 

outcomes.

 22:1300–1311, 1998a. 

Project MATCH Research Group. Project 

MATCH secondary a priori hypotheses. 

92:1671–1698, 1997b. 

Project MATCH Research Group. Therapist 

effects in three treatments for alcohol 

problems 8(4):455– 

474, 1998b. 

Rawson, R.A.; Obert, J.L.; McCann, M.J.; Smith, 

D.P.; and Scheffey, E.H. 

Beverly Hills, CA: Matrix, 

1989.
Rawson, R.A.; Shoptaw, S.J.; Obert, J.L.; 

McCann, M.J.; Hasson, A.L.; Marinelli-Casey, 

P.J.; Brethen, P.R.; and Ling, W. An intensive 

outpatient approach for cocaine abuse 

treatment: The Matrix model. 

 12(2):117–127, 

1995.

Regier, D.A.; Farmer, M.E.; Rae, D.S.; Locke, 

B Z.; Keith, S.J.; Judd, L.L.; and Goodwin, 

F.K. Comorbidity of mental disorders with 

alcohol and other drug abuse. 

264:2511–2518, 1990. 

Richmond, R.L.; Kehoe, L.A.; and Webster, I.W. 

Multivariate models for predicting 

abstention following interventions to stop 

smoking by general practitioners. 

88:1127–1135, 1993. 

Robertson, I.; Heather, N.; Dzialdowski, A.; 

Crawford, J.; and Winton, M. Comparison of 

minimal versus intensive controlled drinking 

treatment interventions for problem 

drinkers.

25:185–194, 1986. 

Robins, L.N.; Davis, D.H.; and Goodwin, D.W. 

Drug use by U.S. Army enlisted men in 

Vietnam: A follow-up on their return home. 

99:235–249, 

1974.

Rogers, C.R. A theory of therapy, personality, 

and interpersonal relationships as developed 

in the client-centered framework. In: Koch, 

S., ed. Vol. 3, 

. New York: McGraw-Hill, 1959. pp. 

184–256.

Rogers, R.W.; Deckner, C.W.; and Mewborn, 

C.R. An expectancy-value theory approach 

to the long-term modification of smoking 

behavior.

34:562–566, 1978. 

Rokeach, M. . New 

York: Free Press, 1973. 

Rokeach, M. . Palo Alto, 

CA: Consulting Psychologists Press, 1983. 

Rollnick, S.; Heather, N.; and Bell, A. 

Negotiating behavior change in medical 

settings: The development of brief 

motivational interviewing.

 1:25–37, 1992a. 

Rollnick, S.; Heather, N.; Gold, R.; and Hall, W. 

Development of a short “readiness to 

change” questionnaire for use in brief, 

opportunistic interventions among excessive 

drinkers. 87:743– 

754, 1992b. 

Rollnick, S., and Miller, W.R. What is 

motivational interviewing? 

23:325–334, 1995. 

Romelsjo, A.; Andersson, L.; Barrner, H.; Borg, 

S.; Granstrand, C.; Hultman, O.; Hassler, A.; 

Kallqvist, A.; Magnusson, P.; Morgell, R.; 

Hyman, K.; Olofsson, A.; Olsson, E.; Rhedin, 

A.; and Wikblad, O. Randomized study of 

secondary prevention of early stage problem 

drinkers in primary health care. 

 84:1319–1327, 1989. 

Rowe, D., and Grills, C. African-centered drug 

treatment: An alternative conceptual 

paradigm for drug counseling with AfricanAmerican clients. 

 25:21–33, 1993. 

Ryan, R.M.; Plant, R.W.; and O’Malley, S. Initial 

motivations for alcohol treatment: Relations 

with patient characteristics, treatment 

involvement, and dropout. 

 20(3):279–297, 1995. 

Samet, J.H., and O’Connor, P.G. Alcohol 

abusers in primary care: Readiness to change 

behavior.

105:302–306, 1998. 

Samet, J.H.; Rollnick, S.; and Barnes, H. Beyond 

CAGE: A brief clinical approach after 

detection of substance abuse. 

 156:2287–2293, 1996. 
Sannibale, C. The differential effect of a set of 

brief interventions on the functioning of a 

group of “early-stage” problem drinkers. 

7:147–155,

1988.

Satterfield, J.M. Integrating group dynamics 

and cognitive-behavioral groups: A hybrid 

model.

1:185–196, 1994. 

Saunders, B.; Wilkinson, C.; and Allsop, S. 

Motivational intervention with heroin users 

attending a methadone clinic. In: Miller, 

W.R., and Rollnick, S., eds. 

 New York: Guilford 

Press, 1991. pp. 279–292. 

Saunders, B.; Wilkinson, C.; and Phillips, M. 

The impact of a brief motivational 

intervention with opiate users attending a 

methadone programme. 90(3):415– 

424, 1995. 

Scales, R. “Motivational interviewing and skillsbased counseling in cardiac rehabilitation: 

The Cardiovascular Health Initiative and 

Lifestyle Intervention (CHILE) Study.” Ph.D. 

diss., University of New Mexico. 

, 59-03A, 0741, 1998. 

Schafer, J., and Brown, S.A. Marijuana and 

cocaine effect expectancies and drug use 

patterns.

 59:558–565, 1991. 

Senft, R.A.; Polen, M.R.; Freeborn, D.K.; and 

Hollis, J.F. Brief intervention in a primary 

care setting for hazardous drinkers. 

13:464–470, 1997. 

Silverman, K.; Chutuape, M.D.; Bigelow, G.E.; 

and Stitzer, M.L. Reinforcement of cocaine 

abstinence in treatment-resistant patients: 

Effects of reinforcer magnitude. In: Harris, 

L.S., ed .

NIDA Research Monograph Series, Number 

174. HHS Pub. No. (ADM) 97-4236,

Rockville, MD: National Institute on Drug 

Abuse, 1997. p. 74. 

Silverman, K.; Higgins, S.T.; Brooner, R.K.; 

Montoya, I.D.; Cone, E.J.; Schuster, C.R.; and 

Preston, K.L. Sustained cocaine abstinence in 

methadone maintenance patients through 

voucher-based reinforcement therapy. 

53:409–415, 

1996.

Simpson, D.D., and Joe, G.W. Motivation as a 

predictor of early dropout from drug abuse 

treatment. 30(2):357–368, 1993. 

Simpson, D.D.; Joe, G.W.; and Brown, B.S. 

Treatment retention and follow-up outcomes 

in the Drug Abuse Treatment Outcome 

Study (DATOS). 

 11:294–307, 1997. 

Sisson, R.W., and Azrin, N.H. Family member 

involvement to initiate and promote 

treatment of problem drinkers. 

17(1):15–21, 1986. 

Sklar, S.M.; Annis, H.M.; and Turner, N.E. 

Development and validation of the DrugTaking Confidence Questionnaire: A 

measure of coping self-efficacy. 

22:655–670,

1997.

Skutle, A., and Berg, G. Training in controlled 

drinking for early-stage problem drinkers. 

 82:493–501, 1987. 
Smith, D.E.; Heckemeyer, C.M.; Kratt, P.P.; and 

Mason, D.A. Motivational interviewing to 

improve adherence to a behavioral weightcontrol program for older obese women with 

NIDDM: A pilot study. 20:53–

54, 1997. 

Sobell, L.C. Bridging the gap between science 

and practitioners: The challenge before us. 

 27:297–320, 1996. 

Sobell, L.C.; Breslin, F.C.; and Sobell, M.B. 

Substance-related disorders (alcohol). In: 

Turner, S., and Hersen, M., eds. 

, 3rd ed. 

New York: John Wiley and Sons, 1997. pp. 

128–159.

Sobell, L.C.; Cunningham, J.A.; and Sobell, M.B. 

Recovery from alcohol problems with and 

without treatment: Prevalence in two 

population surveys. 

 86:966–972, 1996a. 

Sobell, L.C.; Cunningham, J.A.; Sobell, M.B.; 

Agrawal, S.; Gavin, D.R.; Leo, G.I.; and 

Singh, K.N. Fostering self-change among 

problem drinkers: A proactive community 

intervention. 21(6):817– 

833, 1996b. 

Sobell, L.C., and Sobell, M.B, eds. Alcohol 

consumption measures In: Allen, J.P., and 

Columbus, M., eds. 

Treatment Handbook Series 4. 

Bethesda, MD: National Institute on Alcohol 

Abuse and Alcoholism, 1995a. pp. 55–74. 

Sobell, L.C., and Sobell, M.B. 

. Toronto, ON: Addiction 

Research Foundation, 1996. 

Sobell, L.C.; Sobell, M.B.; Brown, J.; and Cleland, 

P.A. “A randomized trial comparing group 

versus individual guided self-change 

treatment for alcohol and drug abusers.” 

Poster presented at the 29th Annual Meeting 

of the Association for Advancement of 

Behavior Therapy, Washington, DC, 1995. 

Sobell, L.C.; Sobell, M.B.; and Leo, G.I. “Spousal 

social support: A motivational intervention 

for alcohol abusers.” Poster presented at the 

annual meeting of the Association for the 

Advancement of Behavior Therapy, Atlanta, 

GA, 1993a. 

Sobell, L.C.; Sobell, M.B.; Toneatto, T.; and Leo, 

G.I. What triggers the resolution of alcohol 

problems without treatment?

17:217–224.

1993b.

Sobell, L.C.; Toneatto, T.; and Sobell, M.B. 

Behavioral assessment and treatment 

planning for alcohol, tobacco, and other drug 

problems: Current status with an emphasis 

on clinical applications

25:533–580, 1994. 

Sobell, M.B.; Buchan, G.; and Sobell, L.C. 

“Relationship of goal choices by substance 

abusers in guided self-change treatment to 

subject characteristics and treatment 

outcome.” Poster presented at the annual 

meeting of the Association for Advancement 

of Behavior Therapy, New York, 1996c. 

Sobell, M.B., and Sobell, L.C. 

 New York: 

Guilford Press, 1993. 

Sobell, M.B., and Sobell, L.C. “Group versus 

individual guided self-change treatment for 

problem drinkers.” Paper presented at the 

World Congress on Behavioral and Cognitive 

Therapies, Copenhagen, Denmark, 1995b. 

Sobell, M.B., and Sobell, L.C. Guiding selfchange. In: Miller, W.R., and Heather, N., 

eds. 2nd ed. 

New York: Plenum, 1998. pp. 189–202. 
Sobell, M.B., and Sobell, L.C. Stepped care for 

alcohol problems: An efficient method for 

planning and delivering clinical services. In: 

Tucker, J.A.; Donovan, D.M.; and Marlatt, 

G.A., eds. 

New York: Guilford Press, 1999. pp. 331– 

343. 

Southwick, L.; Steele, C.; Marlatt, A.; and 

Lindell, M. Alcohol-related expectancies: 

Defined by phase of intoxication and 

drinking experience. 

49:713–721, 1981. 

Stanton, M.D. The role of family and significant 

others in the engagement and retention of 

drug-dependent individuals. In: Onken, L.S.; 

Blaine, J.D.; and Boren, J.J., eds.

. NIDA 

Research Monograph Series, Number 165. 

HHS Pub. No. (ADM) 97-4142. Rockville,

MD: National Institute on Drug Abuse, 1997. 

pp. 157–180. 

Stephens, R.S.; Roffman, R.A.; Cleaveland, B.L.; 

Curtin, L.; and Wertz, J. “Extended versus 

minimal intervention with marijuanadependent adults.” Paper presented at the 

annual meeting of the Association for 

Advancement of Behavior Therapy, San 

Diego, CA, 1994. 

Strang, J.; Bacchus, L.; Howes, S.; and Watson, P. 

Turned away from treatment: Maintenanceseeking opiate addicts at two-year follow-up. 

6:71–81, 1997. 

Sutton, S. Can stages of change provide 

guidelines in the treatment of addictions? In: 

Edwards, G., and Dare, C., eds. 

 New York: Cambridge University 

Press, 1996. 

Swanson, A.J.; Pantalon, M.V.; and Cohen, K.R. 

Motivational interviewing and treatment 

adherence among psychiatric and duallydiagnosed patients.

, in press. 

Taleff, M.J. 

. Dubuque, 

IA: Kendall/Hunt, 1997. 

Thomas, E.J., and Ager, R.D. Unilateral family 

therapy with spouses of uncooperative 

alcohol abusers. In: O’Farrell, T.J., ed. 

New York: Guilford Press, 

1993. pp. 3–33. 

Thombs, D.L. .

New York: Guilford Press, 1994. 

Tonigan, J.S.; Toscova, R.T.; and Connors, G.J. 

Spirituality and the 12-Step programs: A 

guide for clinicians. In: Miller, W.R., ed. 

. Washington, DC: 

American Psychological Association, 1999. 

Trigwell, P.; Grant, P.J.; and House, A. 

Motivation and glycemic control in diabetes 

mellitus.

43:307–315, 1997. 

Truax, C.B., and Carkhuff, R.R. 

. Chicago: 

Aldine, 1967. 

Tuchfield, B. Spontaneous remission in 

alcoholics: Empirical observations and 

theoretical implications. 

42:626–641, 1981. 

Tucker, J.A. Predictors of help-seeking and the 

temporal relationship of help to recovery 

among treated and untreated recovered 

problem drinkers. 90(6):805–809,

1995.

Tucker, J.A.; Vuchinich, R.E.; and Gladsjo, J.A. 

Environmental events surrounding natural 

recovery from alcohol-related problems. 

 55:401–411, 1994. 
Tucker, J.A.; Vuchinich, R.E.; and Pukish, M.M. 

Molar environmental contexts surrounding 

recovery from alcohol problems by treated 

and untreated problem drinkers. In: Marlatt, 

G.A., and Vanden Bos, G.R., eds.

Washington, DC: American 

Psychological Association, 1997. pp. 581– 

601. 

Vaillant, G.E. 

 Cambridge, MA: Harvard 

University Press, 1995. 

Van Bilsen, H.P. Motivational interviewing: 

perspectives from the Netherlands with 

particular emphasis on heroin-dependent 

clients. In: Miller, W.R., and Rollnick, S. 

. New York: 

Guilford Press, 1991. pp. 214–235. 

Van Bremen, J.R., and Chasnoff, I.J. Policy 

issues for integrating parenting interventions 

and addiction treatment for women. 

14:254– 

274, 1994. 

Varney, S.M.; Rohsenow, D.J.; Dey, A.N.; Myers, 

M.G.; Zwick, W.R.; and Monti, P.M. Factors 

associated with help seeking and perceived 

dependence among cocaine users. 

 21(1): 81– 

91, 1995. 

Victorio-Estrada, A., and Mucha, R.F. The 

Inventory of Drinking Situations (IDS) in 

current drinkers with different degrees of 

alcohol problems. 

22 557–565, 1997. 

Wagner, C.C.; Ingersoll, K.S.; Horvatich, P.; 

May, J.; Fornili, K.; and Gharib, S. 

. Scottsdale, AZ: College on 

Problems of Drug Dependence, 1998. 

Wahlberg, J. Personal growth and self-esteem 

through cultural spiritualism: A NativeAmerican experience. In: Rivas, R.F., and 

Hull, G.H., eds. 

. Belmont, CA: Wadsworth, 1996. pp. 

65–71.

Wallace, J. The new disease model of 

alcoholism. 

152(5):502–505, 1990. 

Wallace, P.; Cutler, S.; and Haines, A. 

Randomized controlled trial of general 

practitioner intervention in patients with 

excessive alcohol consumption. 

 297:663–668, 1988. 

Walters, S.T.; Bennett, M.E.; and Miller, J.E. 

Reducing alcohol use in college students: A 

controlled trial of two brief interventions.

 in press. 

Watson, A.L., and Sher, K.J. Resolution of 

alcohol problems without treatment: 

Methodological issues and future directions 

of natural recovery research. 

5:1–18, 1998. 

Wetter, D.W.; Fiore, M.C.; Gritz, E.R.; Lando, 

H.A.; Stitzer, M.L.; Hasselblad, V.; and Baker, 

T.B. The Agency for Health Care Policy and 

Research: Smoking cessation clinical practice 

guideline—Findings and implications for 

psychologists. 53:657– 

669, 1998. 

Wilbanks, W.L. Drug addiction should be 

treated as a lack of self-discipline. In: Leone, 

B., ed. 

San Diego, CA: Greenhaven, 

1989.

Wilk, A.I.; Jensen, N.M.; and Havighurst, T.C. 

Meta-analysis of randomized control trials 

addressing brief interventions in heavy 

alcohol drinkers. 

 12(5):274–283, 1997. 
Williams, R., and Williams, V. 

. New York: 

HarperCollins, 1994. 

Yahne, C.E., and Miller, W.R. Evoking hope. In: 

Miller, W.R., ed. 

Washington, DC: American Psychological 

Association, 1999. 

Zacny, J.P.; Divane, W.T.; and de Wit, H. 

Assessment of magnitude and availability of 

a non-drug reinforcer on preference for a 

drug reinforcer. 

7:281–286, 1992. 

Ziedonis, D., and Fisher, W. Motivation-based 

assessment and treatment of substance abuse 

in patients with schizophrenia.

 16(11):1–8, 1996. 

Zweben, A., and Barrett, D. Brief couples 

treatment for alcohol problems. In: O’Farrell, 

T.J., ed.

. New York: Guilford 

Press, 1993. pp. 353–380. 

Zweben, A.; Bonner, M.; Chaim, G.; and Santon, 

P. Facilitative strategies for retaining the 

alcohol-dependent client in outpatient 

treatment.

5:3–24, 1988. 

Zweben, A., and Fleming, M.F. Brief 

interventions for alcohol and drug problems. 

In: Tucker, J.A.; Donovan, D.M.; and Marlatt, 

G.A., eds. New 

York: Guilford Press, in press. 

Zweben, A., and Li, S. Efficacy of role induction 

in preventing early dropout from outpatient 

treatment of drug dependency. 

8:171–183, 

1981.

Zweben, A.; Pearlman, S.; and Li, S. A 

comparison of brief advice and conjoint 

therapy in the treatment of alcohol abuse: 

The results of the Marital Systems Study. 

83(8):899–916,

1988.

Zweben, J.E. Counseling issues in methadone 

maintenance treatment. 

23(2):177–190, 1991. 

? 

Appendix B 

Screening and Assessment 

Instruments

This appendix includes 

Alcohol and Drug Consequences Questionnaire (ADCQ) 

Alcohol (and Illegal Drugs) Decisional Balance Scale 

Alcohol Effects Questionnaire 

Alcohol Expectancy Questionnaire—III (Adult) 

Alcohol Use Disorders Identification Test (AUDIT) 

Brief Situational Confidence Questionnaire (BSCQ) 

Personal Feedback Report 

Understanding Your Personal Feedback Report 

Readiness To Change Questionnaire (Treatment Version) (RCQ-TV) 

Situational Confidence Questionnaire (SCQ-39) 

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES 8A, 8D) 

University of Rhode Island Change Assessment Scale (URICA) 

What I Want From Treatment 

Ordering information for these instruments, along with other resources, appears in Appendix C. 
Alcohol and Drug Consequences Questionnaire (ADCQ) 

There can be good and bad consequences to any change. These consequences may not be the same for 

everyone. In thinking about your decision to change your alcohol or drug use, we would like to know 

what consequences are important to you. This is not a test: There are no right or wrong answers. We 

simply want to know what you think. 

 stopping or cutting down important to me

“IF I STOP OR CUT DOWN . . . . “

Not Slightly Moderately Very Extremely Not

Important Important Important Important Important Applicable 

1. I will feel better 1 2 3 4 5 0

physically. 

2. I will have difficulty 1 2 3 4 5 0

relaxing. 

3. I will change a lifestyle I 1 2 3 4 5 0

enjoy.

4. I will have fewer problems 1 2 3 4 5 0

with my family. 

5. I will feel frustrated and 1 2 3 4 5 0

anxious. 

6. I will have more money to 1 2 3 4 5 0

do other things with. 

7. I will be more active and 1 2 3 4 5 0

alert. 

8. I will get depressed. 1 2 3 4 5 0

9. I will have fewer problems 1 2 3 4 5 0

with friends. 
Not

Important

Slightly

Important

Moderately

Important

Very

Important

Extremely

Important

Not

Applicable

10. I will feel better about 1 2 3 4 5 0

myself.

11. I will regain some self- 1 2 3 4 5 0

respect.

12. I will accomplish more of 1 2 3 4 5 0

the things I want to get 

done.

13. I will have a better 1 2 3 4 5 0

relationship with my 

family. 

14. I will have difficulty 1 2 3 4 5 0

coping with my problems. 

15. I will feel withdrawal or 1 2 3 4 5 0

craving. 

16. I will have too much time 1 2 3 4 5 0

on my hands. 

17. I will have difficulty not 1 2 3 4 5 0

drinking or using drugs. 

18. My health will improve. 1 2 3 4 5 0

19. I will live longer. 1 2 3 4 5 0

20. I will be more in control of 1 2 3 4 5 0

life.

21. I will feel bored. 1 2 3 4 5 0

22. I will be irritable. 1 2 3 4 5 0

23. I will be more financially 1 2 3 4 5 0

stable. 

24. I will miss the taste. 1 2 3 4 5 0
Not Slightly Moderately Very Extremely Not

Important Important Important Important Important Applicable 

25. I will have a better 1 2 3 4 5 0

relationship with my 

friends. 

26. I will feel stressed out. 1 2 3 4 5 0

27. I will save more money. 1 2 3 4 5 0

28. I will miss the feeling of 1 2 3 4 5 0

being high. 
PLEASE READ EACH STATEMENT AND CIRCLE THE NUMBER ON THE RIGHT TO INDICATE 

STATEMENT IS TO YOU AT THE PRESENT TIME IN RELATION TO MAKING A DECISION 

HOW YOU RATE ITS LEVEL OF IMPORTANCE AS IT RELATES TO YOUR MAKI

Alcohol (and Illegal Drugs) Decisional Balance Scale 

Client ID#_________________ 

Date: ______/______/______ 

Assessment Point: _____________

THE FOLLOWING STATEMENTS MAY PLAY A PART IN MAKING A DECISION ABOUT USING 

ALCOHOL (AND DRUGS). WE WOULD LIKE TO KNOW HOW IMPORTANT EACH 

ABOUT YOUR USING ALCOHOL (AND DRUGS). PLEASE RATE THE LEVEL OF IMPORTANCE 

TO EACH STATEMENT ON THE FOLLOWING 5 POINTS: 

1 = Not important at all 

2 = Slightly important 

3 = Moderately important 

4 = Very important 

5 = Extremely important 

NG A 

DECISION ABOUT WHETHER TO DRINK (OR USE DRUGS) AT THE PRESENT TIME. 

How important is this to me? Importance in making a decision about drinking: 

Not At All Slightly Moderately Very Extremely 

1. My drinking (drug use) causes 

problems with others. 

1 2 3 4 5

2. I like myself better when I am drinking 

(using drugs). 

1 2 3 4 5

3. Because I continue to drink (use drugs) 

some people think I lack the character 

to quit. 

1 2 3 4 5

4. Drinking (drug use) helps me deal 

with problems. 

1 2 3 4 5

5. Having to lie to others about my 

drinking (drug use) bothers me. 

1 2 3 4 5

6. Some people try to avoid me when I 

drink (use drugs). 

1 2 3 4 5
How important is this to me? Importance in making a decision about drinking: 

Not At All Slightly Moderately Very Extremely 

7. Drinking (drug use) helps me to have 1 2 3 4 5

fun and socialize. 

8. Drinking (drug use) interferes with my 1 2 3 4 5

functioning at home or/and at work. 

9. Drinking (drug use) makes me more of 1 2 3 4 5

a fun person. 

10. Some people close to me are 1 2 3 4 5

disappointed in me because of my 

drinking (drug use). 

11. Drinking (drug use) helps me to loosen 1 2 3 4 5

up and express myself. 

12. I seem to get myself into trouble when 1 2 3 4 5

drinking (using drugs). 

13. I could accidentally hurt someone 1 2 3 4 5

because of my drinking (drug use). 

14. Not drinking (using drugs) at a social 1 2 3 4 5

gathering would make me feel too 

different.

15. I am losing the trust and respect of my 1 2 3 4 5

coworkers and/or spouse because of 

my drinking (drug use). 

16. My drinking (drug use) helps give me 1 2 3 4 5

energy and keeps me going. 

17. I am more sure of myself when I am 1 2 3 4 5

drinking (using drugs). 

18. I am setting a bad example for others 1 2 3 4 5

with my drinking (drug use). 
How important is this to me? Importance in making a decision about drinking: 

Not At All Slightly Moderately Very Extremely 

19. Without alcohol (illegal drugs), my life 1 2 3 4 5

would be dull and boring. 

20. People seem to like me better when I 1 2 3 4 5

am drinking (using drugs). 

Scoring:

Pros of drinking (drug use) are items: 2, 4, 7, 9, 11, 14, 16, 17, 19, 20. 

Cons of drinking (drug use) are items: 1, 3, 5, 6, 8, 10, 12, 13, 15, 18. 

To get the average number of pros endorsed, add up the total number of points from the items and divide 

by 10. Example: Pros of drinking (drug use) = Sum of items (2+4+7+9+11+14+16+17+19+20) 

10

To get the average number of cons endorsed, add up the total number of points from the items and 

divide by 10. Example: Cons of drinking (drug use) = Sum of items (1+3+5+6+8+10+12+13+15+18) 

10 
Alcohol Effects Questionnaire 

This questionnaire consists of a series of statements that describe possible effects following alcohol use. 

We would like to find out about your present beliefs about alcohol. 

Please read each of the statements and respond according to your experiences with a heavy (5 drinks 

or more per occasion) amount of alcohol. If you believe alcohol sometimes or always has the stated effect 

on you, check AGREE. If you believe alcohol never has the stated effect on you, check DISAGREE.

Then, in the column to the far right, fill in the number that best corresponds to the strength of your 

belief , according to the following scale: 

1 2 3 4 5 6 7 8 9 10 

Mildly Strongly

Believe Believe

For example, if you strongly believe that alcohol makes you more intelligent, you would check 

AGREE and enter a “10” in the far column. 

Please answer every question without skipping any. 

For a HEAVY (5 or more drinks per occasion) amount of alcohol 

Agree Disagree Strength of

Belief

1. Drinking makes me feel flushed. ____ ____ ____

2. Alcohol decreases muscular tension in my body. ____ ____ ____ 

3. Drinking makes me feel less shy. ____ ____ ____ 

4. Alcohol enables me to fall asleep much more easily. ____ ____ ____ 

5. I feel powerful when I drink, as if I can really ____ ____ ____ 

influence others to do what I want. 

6. I’m more clumsy after I drink. ____ ____ ____

7. I’m more romantic when I drink. ____ ____ ____

8. Drinking makes the future seem brighter to me. ____ ____ ____ 

9. If I have had alcohol it is easier for me to tell someone ____ ____ ____ 

off.

10. I can’t act as quickly when I’ve been drinking. ____ ____ ____ 

11. Alcohol can act as an anesthetic for me; that is, it can ____ ____ ____ 

deaden the pain. 
Agree Disagree Strength of

Belief

12. I often feel sexier after I’ve been drinking. ____ ____ ____ 

13. Drinking makes me feel good. ____ ____ ____ 

14. Alcohol makes me careless about my actions. ____ ____ ____ 

15. Alcohol has a pleasant, cleansing, tingly taste to me. ____ ____ ____ 

16. Drinking increases my aggressiveness. ____ ____ ____

17. Alcohol seems like magic to me. ____ ____ ____ 

18. Alcohol makes it hard for me to concentrate. ____ ____ ____ 

19. After drinking, I’m a better lover. ____ ____ ____ 

20. When I’m drinking, it is easier to open up and express ____ ____ ____ 

my feelings. 

21. Drinking adds a certain warmth to social occasions for ____ ____ ____ 

me.

22. If I’m feeling restricted in any way, drinking makes ____ ____ ____ 

me feel better. 

23. I can’t think as quickly after I drink. ____ ____ ____ 

24. Having drinks is a nice way for me to celebrate special ____ ____ ____ 

occasions.

25. Alcohol makes me worry less. ____ ____ ____ 

26. Drinking makes me inefficient. ____ ____ ____ 

27. Drinking is pleasurable because it’s enjoyable for me ____ ____ ____ 

to join in with other people who are enjoying 

themselves.

28. After drinking, I am more sexually responsive. ____ ____ ____ 

29. I feel more coordinated after I drink. ____ ____ ____ 

30. I’m more likely to say embarrassing things after ____ ____ ____ 

drinking. 

31. I enjoy having sex more if I’ve had alcohol. ____ ____ ____ 

32. I’m more likely to get into an argument if I’ve had ____ ____ ____ 

alcohol. 
Agree Disagree Strength of

Belief

33. Alcohol makes me less concerned about ____ ____ ____ 

doing things well. 

34. Alcohol helps me sleep better. ____ ____ ____ 

35. Drinking gives me more confidence in myself. ____ ____ ____ 

36. Alcohol makes me more irresponsible. ____ ____ ____

37. After drinking it is easier for me to pick a fight. ____ ____ ____ 

38. Alcohol makes it easier for me to talk to people. ____ ____ ____ 

39. If I have alcohol it is easier for me to express my ____ ____ ____ 

feelings. 

40. Alcohol makes me more interesting. ____ ____ ____ 
______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

Alcohol Expectancy Questionnaire—III (Adult) 

The following pages contain statements about the effects of alcohol. Read each statement carefully and 

respond according to your own personal thoughts, feelings, and beliefs about alcohol now. We are 

interested in what you think about alcohol, regardless of what other people might think. 

If you think that the statement is true, or mostly true, or true some of the time, then mark (X) “Agree” 

on the answer sheet. If you think the statement is false, or mostly false, then mark (X) “Disagree” on the 

answer sheet. When the statements refer to drinking alcohol you may think in terms of drinking any 

alcoholic beverage, such as beer, wine, whiskey, liquor, rum, scotch, vodka, gin, or various alcoholic 

mixed drinks. Whether or not you have had actual drinking experiences yourself, you are to answer in 

terms of your beliefs about alcohol . It is important that you respond to every question .

PLEASE BE HONEST. REMEMBER, YOUR ANSWERS ARE CONFIDENTIAL. 

RESPOND TO THESE ITEMS ACCORDING TO WHAT YOU PERSONALLY BELIEVE TO 

BE TRUE ABOUT ALCOHOL 

(Mark “X” according to your beliefs)

 Agree Disagree 

1. Alcohol can transform my personality. 

2. Drinking helps me feel whatever way I want to feel. 

3. Some alcohol has a pleasant, cleansing, tingly taste. 

4. Alcohol makes me feel happy. 

5. Drinking adds a certain warmth to social occasions. 

6. Sweet mixed drinks taste good. 

7. When I am drinking, it is easier to open up and express my feelings. 

8. Time passes quickly when I am drinking. 

9. When they drink, women become more sexually relaxed. 

10. Drinking makes me feel flushed. 

11. I feel powerful when I drink, as if I can really influence others to do 

as I want. 

12. Drinking increases male aggressiveness. 
ANSWER ACCORDING TO WHAT YOU PERSONALLY BELIEVE NOW 

Agree Disagree

13. Alcohol lets my fantasies flow more easily. ______ ______ 

14. Drinking gives me more confidence in myself. ______ ______ 

15. Drinking makes me feel good. ______ ______ 

16. I feel more creative after I have been drinking. ______ ______ 

17. Having a few drinks is a nice way to celebrate special occasions. ______ ______ 

18. I can discuss or argue a point more forcefully after I have had ______ ______ a few drinks. 

19. When I am drinking, I feel free to be myself and to do whatever I want. ______ ______ 

20. Drinking makes it easier to concentrate on the good feelings I have ______ ______ at the time. 

21. Alcohol allows me to be more assertive. ______ ______ 

22. When I feel “high” from drinking, everything seems to feel better. ______ ______ 

23. A drink or two makes the humorous side of me come out. ______ ______ 

24. If I am nervous about having sex, alcohol makes me feel better. ______ ______ 

25. Drinking relieves boredom. ______ ______ 

26. I find that conversing with members of the opposite sex is easier for me ______ ______ after I have had a few drinks. 

27. After a few drinks, I feel less sexually inhibited. ______ ______ 

28. Drinking is pleasurable because it is enjoyable to join in with people who ______ ______ are enjoying themselves. 

29. I like the taste of some alcoholic beverages. ______ ______ 

30. If I am feeling restricted in any way, a few drinks make me feel better. ______ ______ 

31. Men are friendlier when they drink. ______ ______ 32. 
______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

ANSWER ACCORDING TO WHAT YOU PERSONALLY BELIEVE NOW 

Agree Disagree 

32. It is easier for me to meet new people if I’ve been drinking. 

33. After a few drinks it is easier to pick a fight. 

34. Alcohol can eliminate feelings of inferiority. 

35. Alcohol makes women more sensuous. 

36. If I have a couple of drinks, it is easier to express my feelings. 

37. I feel less bothered by physical ills after a few drinks. 

38. Alcohol makes me need less attention from others than I usually do. 

39. Alcohol makes me more outspoken or opinionated. 

40. After a few drinks, I feel more self-reliant than usual. 

41. After a few drinks, I don’t worry as much about what other people 

think of me. 

42. When drinking, I do not consider myself totally accountable or 

responsible for my behavior. 

43. Alcohol enables me to have a better time at parties. 

44. Anything that requires a relaxed style can be facilitated by alcohol. 

45. Drinking makes the future seem brighter. 

46. I am not as tense if I am drinking. 

47. I often feel sexier after I have had a couple of drinks. ______ ______ 

48. Having a few drinks helps me relax in a social situation. 

49. I drink when I am feeling mad. ______ ______ 

50. 50. Drinking alone or with one other person makes me feel calm and 

serene.
ANSWER ACCORDING TO WHAT YOU PERSONALLY BELIEVE NOW 

Agree Disagree

51. After a few drinks, I feel brave and more capable of fighting. ______ ______ 

52. Drinking can make me more satisfied with myself. ______ ______ 

53. There is more camaraderie in a group of people who have been drinking. ______ ______ 

54. My feelings of isolation and alienation decrease when I drink. ______ ______ 

55. A few drinks make me feel less in touch with what is going on around ______ ______ me.

56. Alcohol makes me more tolerant of people I do not enjoy. ______ ______ 

57. Alcohol helps me sleep better. ______ ______ 

58. Drinking increases female aggressiveness. ______ ______ 

59. I am a better lover after a few drinks. ______ ______ 

60. Women talk more after they have had a few drinks. ______ ______ 

61. Alcohol decreases muscular tension. ______ ______ 

62. Alcohol makes me worry less. ______ ______ 

63. A few drinks make it easier to talk to people. ______ ______ 

64. After a few drinks, I am usually in a better mood. ______ ______ 

65. Alcohol seems like magic. ______ ______ 

66. Women can have orgasms more easily if they have been drinking. ______ ______ 

67. At times, drinking is like permission to forget problems. ______ ______ 

68. Drinking helps me get out of a depressed mood. ______ ______ 
______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

______ ______ 

ANSWER ACCORDING TO WHAT YOU PERSONALLY BELIEVE NOW 

Agree Disagree 

69. After I have had a couple of drinks, I feel I am more of a caring, 

sharing person. 

70. Alcohol decreases my feelings of guilt about not working. 

71. I feel more coordinated after I drink. 

72. Alcohol makes me more interesting. 

73. A few drinks make me feel less shy. 

74. If I am tense or anxious, having a few drinks makes me feel better. 

75. Alcohol enables me to fall asleep more easily. 

76. If I am feeling afraid, alcohol decreases my fears. 

77. A couple of drinks make me more aroused or physiologically excited. 

78. Alcohol can act as an anesthetic; that is, it can deaden pain. 

79. I enjoy having sex more if I have had some alcohol. 

80. I am more romantic when I drink. 

81. I feel more masculine/feminine after a few drinks. 

82. When I am feeling antisocial, drinking makes me more gregarious. 

83. Alcohol makes me feel better physically. 

84. Sometimes when I drink alone or with one other person it is easy to feel 

cozy and romantic. 

85. I feel like a more happy-go-lucky person when I drink. 

86. Drinking makes get-togethers more fun. 
ANSWER ACCORDING TO WHAT YOU PERSONALLY BELIEVE NOW 

Agree Disagree

87. Alcohol makes it easier to forget bad feelings. ______ ______ 

88. After a few drinks, I am more sexually responsive. ______ ______ 

89. If I am cold, having a few drinks will give me a sense of warmth. ______ ______ 

90. It is easier to act on my feelings after I have had a few drinks. ______ ______ 

91. I become lustful when I drink. ______ ______ 

92. A couple of drinks make me feel more outgoing. ______ ______ 

93. A drink or two can make me feel more wide awake. ______ ______ 

94. Alcohol decreases my hostilities. ______ ______ 

95. Alcohol makes me feel closer to people. ______ ______ 

96. I tend to be less self-critical when I have something alcoholic to drink. ______ ______ 

97. I find that conversing with members of the opposite sex is easier for me ______ ______ after I have had a few drinks. 

98. Drinking makes me feel flushed. ______ ______ 

99. It is easier to remember funny stories or jokes when I have been drinking. ______ ______ 

100. After a few drinks, I am less submissive to those in positions of ______ ______ authority.

101. Alcohol makes me more talkative. ______ ______ 

102. I am more romantic when I drink. ______ ______ 

103. Men can have orgasms more easily if they have had a drink. ______ ______ 

104. A drink or two is really refreshing after strenuous physical activity. ______ ______ 

105. Alcohol enables me to have a better time at parties. ______ ______ 

106. I can be more persuasive if I have had a few drinks. ______ ______ 
ANSWER ACCORDING TO WHAT YOU PERSONALLY BELIEVE NOW 

Agree Disagree

107. Drinking makes people feel more at ease in social situations. ______ ______ 

108. Alcohol helps me sleep better. ______ ______ 

109. After a drink, things like muscle aches and pains do not hurt as much. ______ ______ 

110. Women are friendlier after they have had a few drinks. ______ ______ 

111. Alcohol makes me worry less. ______ ______ 

112. Alcohol makes it easier to act impulsively or make decisions quickly. ______ ______ 

113. Alcohol makes me feel less shy. ______ ______ 

114. Alcohol makes me more tolerant of people I do not enjoy. ______ ______ 

115. Alcohol makes me need less attention from others than I usually do. ______ ______ 

116. A drink or two can slow me down, so I do not feel so rushed or ______ ______ pressured for time. 

117. I feel more sexual after a few drinks. ______ ______ 

118. Alcohol makes me feel better physically. ______ ______ 

119. Having a drink in my hand can make me feel secure in a difficult social ______ ______ situation.

120. Things seem funnier when I have been drinking, or at least I laugh more. ______ ______ 
Alcohol Use Disorders Identification Test (AUDIT) 

Please answer each question by checking one of the circles in the second column. 

Q1 Never 

 Monthly or less 

2-4 times per month 

2-3 times per week 

4+ times per week 

How often do you have a drink containing alcohol? 

Q2 1 or 2 

 3 or 4 

 5 or 6 

 7 to 9 

10 or more 

How many drinks containing alcohol do you have on a 

typical day when you are drinking? 

Q3 Never 

 Less than monthly 

 Monthly 

 Weekly 

 Daily or almost daily 

How often do you have six or more drinks on one occasion? 

Q4 Never 

 Less than monthly 

 Monthly 

 Weekly 

 Daily or almost daily 

How often during the last year have you found that you 

were not able to stop drinking once you had started? 

Q5 Never 

 Less than monthly 

 Monthly 

 Weekly 

 Daily or almost daily 

How often in the last year have you failed to do what was 

normally expected of you because you were drinking? 

Q6 Never 

 Less than monthly 

 Monthly 

 Weekly 

 Daily or almost daily 

How often during the last year have you needed a first drink 

in the morning to get yourself going after a heavy drinking 

session?

Q7 Never 

 Less than monthly 

 Monthly 

 Weekly 

 Daily or almost daily 

How often during the last year have you had a feeling of 

guilt or remorse about drinking? 
Q8 Never 

 Less than monthly 

 Monthly 

 Weekly 

 Daily or almost daily 

How often during the last year have you been unable to 

remember what happened the night before because you had 

been drinking? 

Q9 No 

 Yes, but not in the last year 

 Yes, during the last year 

Have you or someone else been injured as a result of your 

drinking?

Q10 No 

 Yes, but not in the last year 

 Yes, during the last year 

Has a relative, friend, doctor, or other health worker been 

concerned about your drinking or suggested 

that you cut down? 

Your score on the AUDIT is ____. 

A score of eight points or less is considered nonalcoholic, while nine points and above indicates 

alcoholism. 

Your score of ____ does not indicate a problem with alcoholism.
_____ 

_____ 

_____ 

Brief Situational Confidence Questionnaire (BSCQ) 

Name: Date:

Listed below are eight types of situations in which some people experience an alcohol or drug problem. 

Imagine yourself as you are right now in each of the following types of situations. Indicate on the scale 

provided how confident you are right now that you will be able to resist drinking heavily or resist the 

urge to use your primary drug in each situation by placing an “X” along the line, from 0% “Not at all 

confident” to 100% “Totally confident” as in the example below. 

I feel ...

X

0% 100% 

Not at all confident Totally confident 

Right now I would be able to resist the urge to drink heavily or use my primary drug in situations 

involving... 

1. UNPLEASANT EMOTIONS (e.g., If I were depressed about things in general; if everything were 

going badly for me). 

I feel... 

0% 100% 

Not at all confident Totally confident 

2. PHYSICAL DISCOMFORT (e.g., If I were to have trouble sleeping; if I felt jumpy and physically 

tense).

I feel... 

0% 100% 

Not at all confident Totally confident 

3. PLEASANT EMOTIONS (e.g., If something good happened and I felt like celebrating; if everything 

were going well). 

I feel... 

0% 100% 

Not at all confident Totally confident 
_____ 

_____

_____

_____

_____

Right now I would be able to resist the urge to drink heavily or use my primary drug in situations 

involving... 

4. TESTING CONTROL OVER MY USE OF ALCOHOL OR DRUGS (e.g., If I were to start to believe 

that alcohol or drugs were no longer a problem for me; if I felt confident that I could handle drugs or 

several drinks). 

I feel... 

0% 100% 

Not at all confident Totally confident 

5. URGES AND TEMPTATIONS (e.g., If I suddenly had an urge to drink or use drugs; if I were in a 

situation where I had often used drugs or drank heavily). 

I feel... 

0% 100% 

Not at all confident Totally confident 

6. CONFLICT WITH OTHERS (e.g., If I had an argument with a friend; if I were not getting along well 

with others at work). 

I feel... 

0% 100% 

Not at all confident Totally confident 

7. SOCIAL PRESSURE TO USE (e.g., If someone were to pressure me to “be a good sport” and drink 

or use drugs with him; if I were invited to someone’s home and he offered me a drink or drugs). 

I feel... 

0% 100% 

Not at all confident Totally confident 

8. PLEASANT TIMES WITH OTHERS (e.g., If I wanted to celebrate with a friend; if I were enjoying 

myself at a party and wanted to feel even better). 

I feel... 

0% 100% 

Not at all confident Totally confident 
Personal Feedback Report 

Location: ____________________________________ 

Name: _________________________________________________________ ID: ________________________

1. YOUR DRINKING ______________________________________________________

Number of standard “drinks” per week: __________ drinks 

Your drinking relative to American adults (same sex): __________ percentile 

2. LEVEL OF INTOXICATION __________________________________________

Estimated Blood Alcohol Concentration (BAC) peaks: 

in a typical week: __________ mg % 

 on a heavier day of drinking: __________ mg % 

3. RISK FACTORS ___________________________________________________

Tolerance Level: 

_____ Low (0–60) _____ Medium (61–120) _____ High (121–180) _____ Very High (181 +)

 Other Drug Risk: 

_____ Low _____ Medium _____ High 

Family Risk: _____ 

Low: 0–1 Medium: 2–3 High: 4–6 Very High: 7 + 

MacAndrew Score: _______ 

Normal Range: 0–23 Medium Risk: 24–29 High Risk: 30 + 

Age at Onset: _____ years 

Under 25 Higher Risk 25–39 Medium Risk 40 + Lower Risk 
4. NEGATIVE CONSEQUENCES _______________________________________

Severity of Problems 

Low Medium High Very High 

AUDIT 0–7 8–15 16–25 26–40 

Your Score: _______ 

DRINC: Ever happened Low Medium High Very High 

55–60 61–75 76–90 91 + 

Your Score: _______ 

(Additional information on attached sheet.) 

5. BLOOD TESTS ____________________________________________________________ 

 SGOT (AST): __________ Normal range: 5–35 

GGTP (GGT): __________ Normal range: 0–30 Low Normal 31–50 High Normal 

51 + Elevated/Abnormal 

 SGPT (ALT): __________ Normal range: 7–56 

Uric Acid: __________ Normal range: 2.6–5.6 

Bilirubin: __________ Normal range: 0.2–1.2 

6. NEUROPSYCHOLOGICAL TESTS ____________________________________ 

Well Above Above Below Well Below 

Average Average Average Average Average 

SV 1 2 3 4 5

TMTA 1 2 3 4 5

TMTB 1 2 3 4 5

SYDM 1 2 3 4 5

SHVA 1 2 3 4 5

Therapist: __________________________________________________________________________ 
Understanding Your Personal Feedback Report 

The Personal Feedback Report summarizes results from your pretreatment evaluation. Your therapist 

has explained these to you. This information is to help you understand the written report you have 

received and to remember what your therapist told you. 

Your report consists of two sheets. The first sheet provides information from your pretreatment 

interviews. Attached to this is a second sheet summarizing your answers to a questionnaire, the Alcohol 

Use Inventory. The following information is presented section by section to help you understand what 

your results mean. 

1. Your drinking 

The first line in this section shows the number of drinks that you reported having in a typical drinking 

week. Because different alcohol beverages vary in their strength, we have converted your regular 

drinking pattern into standard “one drink” units. In this system, one drink is equal to 

10 ounces of beer (5 percent alcohol) or 

4 ounces of table wine (12 percent alcohol) or 

2.5 ounces of fortified wine 

(sherry, port, etc.) (20 percent alcohol) or 

1.25 ounces of 80 proof liquor (40 percent alcohol) or 

1 ounce of 100 proof liquor (50 percent alcohol) 

All of these drinks contain the same amount of the same kind of alcohol: one-half ounce of pure ethyl 

alcohol. 

ONE STANDARD DRINK IS:

Beer 10 oz 

Wine 4 oz 

80 proof liquor 11⁄4 oz 

100 proof liquor 1 oz 

This first piece of information, then, tells you how many of these standard drinks you have been 

consuming per week of drinking, according to what you reported in your interview. (If you have not 

been drinking for a period of time recently, this refers to your pattern of drinking before you stopped.) 

To give you an idea of how this compares with the drinking of American adults in general, the second 

number in section 1 is a figure. This tells you what percentage of U.S. men (if you are a man) or 

women (if you are a woman) drink than you reported drinking in a typical week of drinking. If this 

number were 60, for example, it would mean that your drinking is higher than 60 percent of Americans of 

your sex (or that 40 percent drink as much as you reported, or more). 

How much is too much? It depends on many factors. Current research indicates that people who 

average or more standard drinks per day have much higher risk of health and social problems. For 

some people, however, even 1–2 drinks per day would be too many. Pregnant women, for example, are 

best advised to abstain from alcohol altogether, because even small amounts of regular drinking have 

been found to increase risk for the unborn child. Certain health problems (such as liver disease) make 

even moderate drinking unsafe. Some people find that they are unable to drink moderately, and having 

even one or two drinks leads to intoxication. 
Your total number of drinks per week tells only part of the story. It is healthy, for example, to 

have 12 drinks per week by saving them all up for Saturdays. Neither is it safe to have even a few drinks 

and then drive. This raises the important question of level of intoxication. 

2. Level of intoxication 

A second way of looking at your past drinking is to ask what level of intoxication you have been 

reaching. It is possible to estimate the amount of alcohol that would be circulating in your bloodstream, 

based on the pattern of drinking you reported. Blood alcohol concentration (BAC) is an important 

indication of the extent to which alcohol would be affecting your body and behavior. It is used by police 

and the courts, for example, to determine whether a driver is too impaired to operate a motor vehicle. 

To understand better what BAC means, consider the list of common effects of different levels of 

intoxication.

Common Effects of Different Levels of Intoxication 

20–60 mg % This is the “normal” social drinking range. 

NOTE: Driving, even at these levels, is unsafe. 

80 mg % Memory, judgment, and perception are impaired. 

Legally intoxicated in some States. 

100 mg % Reaction time and coordination of movement are 

affected. Legally intoxicated in all States. 

150 mg % Vomiting may occur in normal drinkers; balance is often 

impaired.

200 mg % Memory “blackout” may occur, causing loss of recall for 

events occurring while intoxicated. 

300 mg % Unconsciousness in a normal person, although some 

remain conscious at levels in excess of 600 mg % if 

tolerance is very high. 

400–500 mg % Fatal dose for a normal person, although some survive 

higher levels if tolerance is very high. 

The two figures shown in section 2 are computer-calculated estimates of your highest (peak) BAC 

level during a typical week of drinking and during one of your heaviest days of drinking. 

It is important to realize that there is no known “safe” level of intoxication when driving or engaging 

in other potentially hazardous activities (such as swimming, boating, hunting, and operating tools or 

machinery). Blood alcohol levels as low as 40–60 mg % can decrease crucial abilities. Adding to the 

danger, drinkers typically do not that they are impaired. The only safe BAC when driving is .

If you must drive after drinking, plan to allow enough time for all of the alcohol to be eliminated from 

your body before driving. The tables below can be helpful in determining how long it takes to eliminate 

alcohol completely: 
Approximate hours from first drink to zero alcohol 

concentration levels for MEN 

Number

of Drinks Your weight in pounds 

120 140 160 180 200 220 240 260 

1 2 2 2 1.5 1 1 1 1

2 4 3.5 3 3 2.5 2 2 2

3 6 5 4.5 4 3.5 3.5 3 3

4 8 7 6 5.5 5 4.5 4 3.5 

5 10 8.5 7.5 6.5 6 5.5 5 4.5 

One drink = 10 oz of beer or 4 oz of wine or 1 oz of liquor (100 proof) 

Approximate hours from first drink to zero alcohol 

concentration levels for WOMEN 

Number

of Drinks Your weight in pounds 

120 140 160 180 200 220 240 260 

1 3 2.5 2 2 2 1.5 1.5 1

2 6 5 4 4 3.5 3 3 2.5 

3 9 7.5 6.5 5.5 5 4.5 4 4

4 12 9.5 8.5 7.5 6.5 6 5.5 5

5 15 12 10.5 9.5 8 7.5 7 6

One drink = 10 oz of beer or 4 oz of wine or 1 oz of liquor (100 proof) 

3. Risk factors 

It is clear that some people have a much higher risk of alcohol and other drug problems. This section 

provides you with some information about your own level of risk, based on your personal characteristics. 

“High risk” does not mean that one will definitely have serious problems with alcohol or other drugs. 

Neither does “low risk” mean that one will be free of such problems. High-risk people, however, have 

greater chances of developing serious problems. 

Your peak BAC levels, given in section 2, are one reasonably good reflection of your level of for 

alcohol. If you are reaching BAC levels beyond the normal social drinking range (especially if you are not 

feeling some of the normal effects of lower BACs), it means that you have a higher tolerance for alcohol. 

This is partly hereditary and partly the result of changes in the body that occur with heavier drinking. 

Some people are proud of this tolerance—the ability “to hold your liquor”—and think it means they are 

not being harmed by alcohol. Actually, the opposite is true. Tolerance for alcohol may be a serious 

 for alcohol problems. The person with a high tolerance for alcohol reaches high BAC levels, which 

can damage the brain and other organs of the body but has that it is happening. 

Tolerance is not a protection against being harmed by drinking; to the contrary, it makes damage more 

likely because of the false confidence that it encourages. It is a bit like a person who has no sense of pain. 
Pain is an important warning signal. People who feel no pain can seriously injure themselves without 

realizing it. It is the same with people who have a high tolerance for alcohol. 

Many people believe that tolerance (“holding your liquor”) means that a person gets rid of alcohol at a 

faster rate than others. Although people do differ in how quickly their bodies can clear alcohol, tolerance 

has more to do with actually at a high blood alcohol level and not feeling it. 

A person who uses other drugs besides alcohol runs several additional risks. Decreased use of one drug 

may simply result in the increased use of another. The effects of different drugs can multiply when they 

are taken together, with dangerous results. A tolerance to one drug can increase tolerance to another, and 

it is common for multiple drug users to become addicted to several drugs. The use of other drugs, then, 

increases your risk for serious problems. Based on the lifetime drug use that you reported during your 

interview, your risk in this regard was judged to be low, medium, or high. 

People who have a family history of alcohol or other drug problems among their blood relatives clearly 

are at higher risk themselves. The exact reason for this higher risk is unknown, but it appears that the 

risk is inherited to an important extent. People may inherit a higher tolerance for alcohol or a body that is 

particularly sensitive to alcohol in certain ways. In any event, a family history of alcohol problems 

increases personal risk. 

Although there is no single personality style associated with alcohol and drug problems, certain patterns 

are linked to higher risk. One questionnaire you completed—the MacAndrew Scale—measures this 

particular kind of risk. People who score higher on this scale as teenagers, for example, have been found 

to have higher risk for developing serious problems with alcohol in adulthood. 

Recent research indicates that the younger a person is when drinking problems start, the greater the 

person’s risk for developing serious consequences and dependence. Although serious problems can 

occur at any time of life, a younger beginning does represent a significant risk factor. 

4. Negative consequences 

From your pretreatment interview, two scores were calculated to reflect the current overall severity of 

your negative consequences from drinking. 

The AUDIT is a scale devised by the World Health Organization to evaluate a person’s problematic 

involvement with alcohol. Higher scores reflect recent problems related to drinking. 

Another way to look at risks and effects of drinking is to add up alcohol’s negative effects throughout 

one’s lifetime. Your score on this scale reflects the extent to which your drinking has had negative effects 

over the course of your life thus far. The higher your score, the more harm has resulted from your 

drinking. 
5. Blood tests 

Your pretreatment evaluation also included a blood sample. These particular blood tests were chosen 

because they have been shown in previous research to be negatively affected by heavy drinking. You 

should realize that normal results on these tests do not guarantee that you are in good health (for 

example, that your liver is functioning completely normally). An abnormal score on one or more of these 

tests, however, probably reflects unhealthy changes in your body resulting from excessive use of alcohol 

and/or other drugs. 

Research indicates that modestly abnormal scores on the blood tests reported here will often show 

improvement and a return to normal range when harmful drinking and other drug use patterns are 

changed. The longer one continues drinking, however, the more difficult it is to reverse the physical 

damage.

These tests are directly related to how the liver is working. Your liver is extremely important to your 

health. It is involved in producing energy, and it filters and neutralizes impurities and poisons in your 

bloodstream. Alcohol damages the liver, and after a long period of heavy drinking, parts of the liver 

begin to die. This is the process of cirrhosis, but physical changes in the liver can be caused by drinking 

long before cirrhosis appears. As the liver becomes damaged, it begins to leak enzymes into the blood 

and is less efficient in doing its work. This can be reflected in abnormally elevated values on the tests 

reported in this section. 

Elevated values on any of these tests should be taken seriously. They do not happen by chance and 

are very likely related to physical changes in the body caused by excessive drinking. Consult a physician 

who is knowledgeable about the effects of alcohol on the body. 

6. Neuropsychological tests 

Some of the earliest damaging effects of drinking may be seen in certain types of abilities that are affected 

by alcohol. Certain patterns of brain impairment have been shown to be especially related to heavy 

drinking. The brain is very vulnerable to alcohol, and over a long span of time, a substantial amount of 

damage can occur in a heavy drinker. (Brain impairment from the use of certain other drugs has also 

been shown.) 

Such damage occurs gradually. In later stages, it can be seen in x-rays of the brain, which show actual 

shrinkage and other changes in shape and density. Long before this occurs, however, harmful changes in 

brain functioning can be measured by psychological tests, several of which you completed. Research 

indicates that such negative effects can often be reversed, sometimes completely, if the individual stops or 

reduces drinking. 

The four tests included in section 6 have been found to be related to heavy drinking. For comparison 

purposes, we include one test (SV) that is not usually affected by drinking to give you an idea of where 

your scores might normally be expected to fall. People who are heavy drinkers tend to score more poorly 

(higher) on the four alcohol-sensitive tests (TMTA, TMTB, SYDM, and SHVA) than on SV. 

A high score on any one scale is not necessarily reason for concern. There are many reasons why a 

single score might be elevated. A of elevated scores, however, resembles the kinds of problems 

that emerge among excessive drinkers. Studies of individuals currently in treatment for alcohol problems 

consistently show impairment on these measures. 

Alcohol’s effects on the brain have sometimes been described as “premature aging.” The abnormal 

changes in the brain of a heavy drinker do resemble normal changes that occur with advanced age. For 

this reason, your scores reflected above take into account your present age. Scores of 4 or 5 represent 

below-average performance relative to others in your age group. 
Summary

Your Personal Feedback Report summarizes a large amount of information that you provided during 

your pretreatment interviews. Sometimes this information can seem surprising or even discouraging. 

The best use of feedback like this is to consider it as you decide what, if anything, you will do about your 

drinking. Many of the kinds of problems covered in your Personal Feedback Report do improve when 

heavy drinking is stopped. What you do with this information is up to you. Your report is designed to 

give you a clear picture of where you are at present so that you can make good decisions about where 

you want to go from here. 




Appendix B 

Readiness To Change Questionnaire 

(Treatment Version) (RCQ-TV) 

Note: The original 30-item Readiness To Change Questionnaire (Treatment Version) that appeared in this 

TIP was replaced with the 15-item version below. This newer version is described in the following article: 

Heather, N.; Luce, A.; Peck, D.; Dunbar, B.; and James, I. Development of a treatment version of the 

Readiness to Change Questionnaire. Addiction Research 7:63–68, 1999.

The Questionnaire below is reprinted with permission from the Centre for Alcohol and Drug Studies, 

Newcastle City Health National Health Service Trust.

The following questions are designed to identify how you personally feel about your drinking right now.

Please think about your current situation and drinking habits, even if you have given up drinking 

completely. Read each question below carefully, and then decide whether you agree or disagree with the 

statements. Please tick the answer of your choice to each question. If you have any problems please ask 

the questionnaire administrator.

Your answers are completely private and confidential 

Key: SD = Strongly disagree D = Disagree U = Unsure 

A = Agree SA = Strongly agree 

SD D U A SA For office 

use only 

1. It’s a waste of time thinking about my PC drinking because I do not have a problem. 

2. I enjoy my drinking but sometimes I drink 

C too much.

3. I am trying to stop drinking or drink less 

A than I used to.

4. There is nothing seriously wrong with my PC drinking. 

5. Sometimes I think I should quit or cut down 

C on my drinking. 

214 
Screening and Assessment Instruments 

SD D U A SA For office 

use only 

6. Anyone can talk about wanting to do 

something about their drinking, but I’m 

actually doing something about it.

 A

7. I am a fairly normal drinker.

 PC

8. My drinking is a problem sometimes.

 C

9. I am actually changing my drinking habits 

right now (either cutting down or quitting).  A

10. Giving up or drinking less alcohol would be 

pointless for me.  PC

11. I am weighing up the advantages and 

disadvantages of my present drinking habits.  C

12. I have started to carry out a plan to cut down 

or quit drinking.  A

13. There is nothing I really need to change 

about my drinking.  PC

14. Sometimes I wonder if my drinking is out of 

control.  C

15. I am actively working on my drinking 

problem.  A

For Office Use Only 

Please enter the subject’s scores below: 

Scale Scores 

PC Score ________ 

C Score ________ 

A Score ________ 

215 
Appendix B 

Scoring the Readiness To Change Questionnaire (Treatment Version) 

The scale score codes represent each of the stages of change: PC = Precontemplation; C = Contemplation; 

A = Action.

Items numbered 1, 4, 7, 10, and 13 = Precontemplation 

Items numbered 2, 5, 8, 11, and 14 = Contemplation 

Items numbered 3, 6, 9, 12, and 15 = Action 

All items are to be scored on a 5-point ranging scale ranging from: 

-2 = Strongly Disagree 

-1 = Disagree

 0 = Unsure 

 +1 = Agree 

+2 = Strongly Agree 

To calculate the score for each scale, simply add the item scores for the scale in question. The range of 

each scale is -10 through 0 to +10. A negative scale score reflects an overall disagreement with items 

measuring the stage of change, whereas a positive score represents overall agreement. The highest scale 

score represents the Stage of Change Designation.

Note: If two or more scale scores are equal, then the scale farther along the continuum of change 

(Precontemplation-Contemplation-Action) represents the subject’s Stage of Change Designation. For 

example, if a subject scores 6 on the Precontemplation scale, 6 on the Contemplation scale and -2 on the 

Action scale, then the subject is assigned to the Contemplation stage.

If one of the five items on a scale is missing, the subject’s score for that scale should be pro-rated (i.e.

multiplied by 5/4 or 1.25). If two or more items are missing, the scale score cannot be calculated. In this 

case the Stage of Change Designation will be invalid.

216 
Situational Confidence Questionnaire (SCQ-39) 

Listed below are a number of situations or events in which some people experience a drinking problem. 

Imagine yourself as you are right now in each of these situations. Indicate on the scale provided how 

confident you are that you would be able to resist the urge to drink heavily in that situation. 

Circle 100 if you are 100 percent confident right now that you could resist the urge to drink heavily; 80

if you are 80 percent confident; 60 if you are 60 percent confident. If you are more unconfident than 

confident, circle 40 to indicate that you are only 40 percent confident that you could resist the urge to 

drink heavily; 20 for 20 percent confident; 0 if you have no confidence at all about that situation.

 I would be able to resist the urge to drink heavily 

not at all 

confident 

1. If I felt that I had let myself down 0

2. If there were fights at home 0

3. If I had trouble sleeping 0

4. If I had an argument with a friend 0

5. If other people didn’t seem to 0

like me 

6. If I felt confident and relaxed 0

7. If I were out with friends and they 0

stopped by the bar for a drink 

8. If I were enjoying myself at a party 0

and wanted to feel even better 

9. If I remembered how good it tasted 0

10. If I convinced myself that I was a 0

new person and could take a few 

drinks

very

confident 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

20 40 60 80 100 

11. If I were afraid that things weren’t 0 20 40 60 80 100 

going to work out 
I would be able to re sist the urge to drink heavily 

not at all 

confident 

very

confident 

12. If other people interfered with my 

plans

0 20 40 60 80 100 

13. If I felt drowsy and wanted to stay 

alert 

0 20 40 60 80 100 

14. If there were problems with people 

at work 

0 20 40 60 80 100 

15. If I felt uneasy in the presence of 

someone

0 20 40 60 80 100 

16. If everything were going well 0 20 40 60 80 100 

17. If I were at a party and other people 

were drinking 

0 20 40 60 80 100 

18. If I wanted to celebrate with a 

friend 

0 20 40 60 80 100 

19. If I passed by a liquor store 0 20 40 60 80 100 

20. If I wondered about my self-control 

over alcohol and felt like having a 

drink to try it out 

0 20 40 60 80 100 

21. If I were angry at the way things 

had turned out 

0 20 40 60 80 100 

22. If other people treated me unfairly 0 20 40 60 80 100 

23. If I felt nauseous 0 20 40 60 80 100 

24. If pressure built up at work because 

of the demands of my supervisor 

0 20 40 60 80 100 

25. If someone criticized me 0 20 40 60 80 100 

26. If I felt satisfied with something I 

had done 

0 20 40 60 80 100 
I would be able to re sist the urge to drink heavily 

not at all 

confident 

very

confident 

27. If I were relaxed with a good friend 

and wanted to have a good time 

0 20 40 60 80 100 

28. If I were in a restaurant, and the 

people with me ordered drinks 

0 20 40 60 80 100 

29. If I unexpectedly found a bottle of 

my favorite booze 

0 20 40 60 80 100 

30. If I started to think that just one 

drink could cause no harm 

0 20 40 60 80 100 

31. If I felt confused about what I 

should do 

0 20 40 60 80 100 

32. If I felt under a lot of pressure from 

family members at home 

0 20 40 60 80 100 

33. If my stomach felt like it was tied in 

knots

0 20 40 60 80 100 

34. If I were not getting along well with 

others at work 

0 20 40 60 80 100 

35. If other people around me made me 

tense

0 20 40 60 80 100 

36. If I were out with friends “on the 

town” and wanted to increase my 

enjoyment

0 20 40 60 80 100 

37. If I met a friend and he/she 

suggested that we have a drink 

together

0 20 40 60 80 100 

38. If I suddenly had an urge to drink 0 20 40 60 80 100 

39. If I wanted to prove to myself that I 

could take a few drinks without 

becoming drunk 

0 20 40 60 80 100 
Stages of Change Readiness and Treatment Eagerness 

Scale (SOCRATES 8A) 

INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that you 

might (or might not) feel . For each statement, circle one number from 1 to 5, to 

indicate how much you agree or disagree with it . Please circle one and only one number for 

every statement. 

NO!

Strongly 

Disagree

No

Disagree

?

Undecided 

or Unsure 

Yes

Agree 

YES!

Strongly 

Agree 

1. I really want to make changes in my 

drinking. 1 2 3 4 5

2. Sometimes I wonder if I am an alcoholic. 1 2 3 4 5

3. If I don’t change my drinking soon, my 

problems are going to get worse. 1 2 3 4 5

4. I have already started making some 

changes in my drinking. 1 2 3 4 5

5. I was drinking too much at one time, but 

I’ve managed to change my drinking. 1 2 3 4 5

6. Sometimes I wonder if my drinking is 

hurting other people. 1 2 3 4 5

7. I am a problem drinker. 1 2 3 4 5

8. I’m not just thinking about changing my 

drinking, I’m already doing something 

about it. 

1 2 3 4 5

9. I have already changed my drinking, and 

I am looking for ways to keep from 

slipping back to my old pattern. 

1 2 3 4 5

10. I have serious problems with drinking. 1 2 3 4 5

11. Sometimes I wonder if I am in control of 

my drinking. 1 2 3 4 5

12. My drinking is causing a lot of harm. 1 2 3 4 5

13. I am actively doing things now to cut 

down or stop drinking. 1 2 3 4 5
NO!

Strongly 

Disagree

No

Disagree

?

Undecided 

or Unsure 

Yes

Agree 

YES!

Strongly 

Agree 

14. I want help to keep from going back to 

the drinking problems that I had before. 1 2 3 4 5

15. I know that I have a drinking problem. 1 2 3 4 5

16. There are times when I wonder if I drink 

too much. 1 2 3 4 5

17. I am an alcoholic. 

1 2 3 4 5

18. I am working hard to change my 

drinking. 1 2 3 4 5

19. I have made some changes in my 

drinking, and I want some help to keep 

from going back to the way I used to 

drink. 

1 2 3 4 5

For scoring and interpretation information of SOCRATES, see pp. 221–223. 
Stages of Change Readiness and Treatment Eagerness 

Scale (SOCRATES 8D) 

INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that you 

might (or might not) feel . For each statement, circle one number from 1 to 5, to 

indicate how much you agree or disagree with it . Please circle one and only one number for 

every statement. 

NO!

Strongly 

Disagree

No

Disagree

?

Undecided 

or Unsure 

Yes

Agree 

YES!

Strongly 

Agree 

1. I really want to make changes in my use 

of drugs. 1 2 3 4 5

2. Sometimes I wonder if I am an addict. 1 2 3 4 5

3. If I don’t change my drug use soon, my 

problems are going to get worse. 1 2 3 4 5

4. I have already started making some 

changes in my use of drugs. 1 2 3 4 5

5. I was using drugs too much at one time, 

but I’ve managed to change that. 1 2 3 4 5

6. Sometimes I wonder if my drug use is 

hurting other people. 1 2 3 4 5

7. I have a drug problem. 1 2 3 4 5

8. I’m not just thinking about changing my 

drug use, I’m already doing something 

about it. 

1 2 3 4 5

9. I have already changed my drug use, and 

I am looking for ways to keep from 

slipping back to my old pattern. 

1 2 3 4 5

10. I have serious problems with drugs. 1 2 3 4 5

11. Sometimes I wonder if I am in control of 

my drug use. 1 2 3 4 5

12. My drug use is causing a lot of harm. 1 2 3 4 5
NO!

Strongly 

Disagree

No

Disagree

?

Undecided 

or Unsure 

Yes

Agree 

YES!

Strongly 

Agree

13. I am actively doing things now to cut 

down or stop my use of drugs. 1 2 3 4 5

14. I want help to keep from going back to 

the drug problems that I had before. 1 2 3 4 5

15. I know that I have a drug problem. 1 2 3 4 5

16. There are times when I wonder if I use 

drugs too much. 1 2 3 4 5

17. I am a drug addict. 1 2 3 4 5

18. I am working hard to change my drug 

use. 1 2 3 4 5

19. I have made some changes in my drug 

use, and I want some help to keep from 

going back to the way I used before. 

1 2 3 4 5

SOCRATES Scoring Form (19-Item Version 8) 

Transfer the client’s answers from questionnaire (see note below): 

Recognition Ambivalence Taking Steps 

1 ________ 

3 ________ 

7 ________ 

10 ________ 

12 ________ 

15 ________ 

17 ________ 

2 ________ 

5 ________ 

6 ________ 

9 ________ 

11 ________ 

14 ________ 

16 ________ 

4 ________ 

8 ________ 

13 ________ 

18 ________ 

19 ________ 

Totals: Re: ________ 

Possible 

Range: 7–35 

Am: ________ 

4–20

Ts: ________ 

8–40
SOCRATES Profile Sheet (19-Item Version 8A) 

INSTRUCTIONS: From the SOCRATES Scoring Form (19-Item Version) transfer the total scale scores 

into the empty boxes at the bottom of the Profile Sheet. Then for each scale, CIRCLE the same value 

above it to determine the decile range. 

DECILE 

SCORES 

Recognition Ambivalence Taking Steps 

90 (Very High) 19–20 39–40 

80 18 37–38 

70 (High) 35 17 36

60 34 16 34–35 

50 (Medium) 32–33 15 33

40 31 14 31–32 

30 (Low) 29–30 12–13 30

20 27–28 9–11 26–29 

10 (Very Low) 7–26 4–8 8–25

RAW SCORES 

(from Scoring Sheet) 

Re= Am= Ts=

These interpretive ranges are based on a sample of 1,726 adult men and women presenting for treatment 

of alcohol problems through Project MATCH. Note that individual scores are therefore being ranked as 

low, medium, or high .

Guidelines for Interpretation of SOCRATES-8 Scores 

Using the SOCRATES Profile Sheet, circle the client’s raw score within each of the three scale columns. 

This provides information as to whether the client’s scores are low, average, or high 

 The following are provided as general guidelines for 

interpretation of scores, but it is wise in an individual case also to examine individual item responses for 

additional information. 

RECOGNITION
HIGH scorers directly acknowledge that they are having problems related to their drinking, 

tending to express a desire for change and to perceive that harm will continue if they do not 

change. 

LOW scorers deny that alcohol is causing them serious problems, reject diagnostic labels such as 

“problem drinker” and “alcoholic,” and do not express a desire for change. 

AMBIVALENCE 

HIGH scorers say that they sometimes if they are in control of their drinking, are drinking 

too much, are hurting other people, and/or are alcoholic. Thus a high score reflects ambivalence 

or uncertainty. A high score here reflects some openness to reflection, as might be particularly 

expected in the contemplation stage of change. 

LOW scorers say that they whether they drink too much, are in control, are hurting 

others, or are alcoholic. Note that a person may score low on ambivalence because he 

“knows” his drinking is causing problems (high Recognition), because he “knows” that he 

does not have drinking problems (low Recognition). Thus a low Ambivalence score should be 

interpreted in relation to the Recognition score. 

TAKING STEPS 

HIGH scorers report that they are already doing things to make a positive change in their 

drinking and may have experienced some success in this regard. Change is under way, and they 

may want help to persist or to prevent backsliding. A high score on this scale has been found to 

be predictive of successful change. 

LOW scorers report that they are not currently doing things to change their drinking and have 

not made such changes recently. 
University of Rhode Island Change Assessment Scale 

(URICA)

Each statement below describes how a person might feel when starting therapy or approaching problems 

in his life. Please indicate the extent to which you tend to agree or disagree with each statement. In each 

case, make your choice in terms of how you feel right now, not what you have felt in the past or would 

like to feel. For all the statements that refer to your “problem,” answer in terms of problems related to 

your drinking (illegal drug use). The words “here” and “this place” refer to your treatment center. 

There are five possible responses to each of the items in the questionnaire: 

1 = Strongly Disagree 

2 = Disagree 

3 = Undecided 

4 = Agree 

5 = Strongly Agree 

Circle the number that best describes how much you agree or disagree with each statement. 

STRONGLY DISAGREE UNDECIDED AGREE STRONGLY

DISAGREE AGREE 

1. As far as I’m concerned, I don’t 

have any problems that need 

changing.

1 2 3 4 5

2. I think I might be ready for some 

self-improvement.

1 2 3 4 5

3. I am doing something about the 

problems that had been 

bothering me. 

1 2 3 4 5

4. It might be worthwhile to work on 

my problem. 

1 2 3 4 5

5. I’m not the problem one. It doesn’t 

make much sense for me to consider 

1 2 3 4 5

changing.

6. It worries me that I might slip back 

on a problem I have already 

changed, so I am looking for help. 

1 2 3 4 5

7. I am finally doing some work on my 

problem.

1 2 3 4 5
STRONGLY DISAGREE UNDECIDED AGREE STRONGLY

 DISAGRE AGREE 

8. I’ve been thinking that I might want 

to change something about myself. 

1 2 3 4 5

9. I have been successful in working on 

my problem, but I’m not sure I can 

keep up the effort on my own. 

1 2 3 4 5

10. At times my problem is difficult, but 

I’m working on it. 

1 2 3 4 5

11. Trying to change is pretty much a 

waste of time for me because the 

1 2 3 4 5

problem doesn’t have to do with me. 

12. I’m hoping that I will be able to 

understand myself better. 

1 2 3 4 5

13. I guess I have faults, but there’s 

nothing that I really need to change. 

1 2 3 4 5

14. I am really working hard to change. 1 2 3 4 5

15. I have a problem, and I really think I 

should work on it. 

1 2 3 4 5

16. I’m not following through with what 

I had already changed as well as I 

had hoped, and I want to prevent a 

relapse of the problem. 

1 2 3 4 5

17. Even though I’m not always 

successful in changing, I am at least 

working on my problem. 

1 2 3 4 5
STRONGLY DISAGREE UNDECIDED AGREE STRONGLY

DISAGREE AGREE 

18. I thought once I had resolved the 1 2 3 4 5

problem I would be free of it, but 

sometimes I still find myself 

struggling with it. 

19. I wish I had more ideas on how to 1 2 3 4 5

solve my problem. 

20. I have started working on my 

problem, but I would like help. 

1 2 3 4 5

21. Maybe someone or something will 

be able to help me. 

1 2 3 4 5

22. I may need a boost right now to help 

me maintain the changes I’ve 

already made. 

1 2 3 4 5

23. I may be part of the problem, but I 

don’t really think I am. 

1 2 3 4 5

24. I hope that someone will have some 

good advice for me. 

1 2 3 4 5

25. Anyone can talk about changing; I’m 1 2 3 4 5

actually doing something about it. 

26. All this talk about psychology is 

boring. Why can’t people just forget 

about their problems? 

1 2 3 4 5

27. I’m struggling to prevent myself 1 2 3 4 5

from having a relapse of my 

problem.

28. It is frustrating, but I feel I might be 1 2 3 4 5

having a recurrence of a problem I 

thought I had resolved. 
STRONGLY

DISAGREE

DISAGREE UNDECIDED AGREE STRONGLY 

AGREE

29. I have worries, but so does the next 

guy. Why spend time thinking 

about them? 

1 2 3 4 5

30. I am actively working on my 

problem.

1 2 3 4 5

31. I would rather cope with my faults 

than try to change them. 

1 2 3 4 5
What I Want From Treatment 

William R. Miller and Janice M. Brown 

Instructions

People have different ideas about what they want, need, and expect from treatment. 

This questionnaire is designed to help you explain what you would like to have happen in your 

treatment. Many possibilities are listed. For each one, please indicate how much you would like for this 

to be part of your treatment.

You can do this by circling one number (0, 1, 2, or 3) for each item. This is what the numbers mean: 

0 NO means that you definitely do NOT want or need this from treatment. 

1 ? means that you are UNSURE . MAYBE you want this from treatment. 

2 YES means that you DO want or need this from treatment. 

3 YES! means that you DEFINITELY want or need this from treatment. 

FOR EXAMPLE:

Consider item #1, which says, “I want to receive detoxification.” If you definitely do NOT want or need 

to receive detoxification, you would circle 0. If you are UNSURE whether you want or need 

detoxification, you would circle 1. If you DO want detoxification, you would circle 2. If you 

DEFINITELY know that detoxification is an important goal for your treatment, you would circle 3.

If you have any questions about how to use this questionnaire, ask for assistance before you begin. 

DO YOU WANT THIS FROM TREATMENT ? NO

0

Maybe

1

Yes

2

YES!

3

1. I want to receive detoxification, to ease my withdrawal 

from alcohol or other drugs. 0 1 2 3

2. I want to find out for sure whether I have a problem 

with alcohol or other drugs. 0 1 2 3

3. I want help to stop drinking alcohol completely. 0 1 2 3

4. I want help to decrease my drinking. 0 1 2 3

5. I want help to stop using drugs (other than alcohol). 0 1 2 3
DO YOU WANT THIS FROM TREATMENT ? NO

0

Maybe

1

Yes

2

YES!

3

6. I want to stop using tobacco. 0 1 2 3

7. I want to decrease my use of tobacco. 0 1 2 3

8. I want help with an eating problem. 0 1 2 3

9. I want help with a gambling problem. 0 1 2 3

10. I want to take Antabuse (a medication to help me stop 

drinking). 0 1 2 3

11. I want to take Trexan (a medication to help me stop 

using alcohol or heroin). 0 1 2 3

12. I want to take methadone. 0 1 2 3

13. I want to learn more about alcohol/drug problems. 0 1 2 3

14. I want to learn some skills to keep from returning to 

alcohol or other drugs. 0 1 2 3

15. I would like to learn more about 12-Step programs like 

Alcoholics Anonymous (AA) or Narcotics Anonymous 

(NA). 0 1 2 3

16. I would like to talk about some personal problems. 0 1 2 3

17. I need to fulfill a requirement of the courts. 0 1 2 3

18. I would like help with problems in my marriage or 

close relationship. 0 1 2 3

19. I want help with some health problems. 0 1 2 3

20. I want help to decrease my stress and tension. 0 1 2 3

21. I would like to improve my health by learning more 

about nutrition and exercise. 0 1 2 3

22. I want help with depression or moodiness. 0 1 2 3
DO YOU WANT THIS FROM TREATMENT? NO

0

Maybe

1

Yes

2

YES!

3

23. I want to work on my spiritual growth. 0 1 2 3

24. I want to learn how to solve problems in my life. 0 1 2 3

25. I want help with angry feelings and how I express 

them. 0 1 2 3

26. I want to have healthier relationships. 0 1 2 3

27. I would like to discuss sexual problems. 0 1 2 3

28. I want to learn how to express my feelings in a more 

healthy way. 0 1 2 3

29. I want to learn how to relax better. 0 1 2 3

30. I want help in overcoming boredom. 0 1 2 3

31. I want help with feelings of loneliness. 0 1 2 3

32. I want to discuss having been physically abused. 0 1 2 3

33. I want help to prevent violence at home. 0 1 2 3

34. I want to discuss having been sexually abused. 0 1 2 3

35. I want to work on having better self-esteem. 0 1 2 3

36. I want help with sleep problems. 0 1 2 3

37. I want help with legal problems. 0 1 2 3

38. I want advice about financial problems. 0 1 2 3

39. I would like help in finding a place to live. 0 1 2 3

40. I could use help in finding a job. 0 1 2 3
DO YOU WANT THIS FROM TREATMENT? NO

0

Maybe

1

Yes

2

YES!

3

41. Someone close to me has died or left, and I would like 

to talk about it. 0 1 2 3

42. I have thoughts about suicide, and I would like to 

discuss this. 0 1 2 3

43. I want help with personal fears and anxieties. 0 1 2 3

44. I want help to be a better parent. 0 1 2 3

45. I feel very confused and would like help with this. 0 1 2 3

46. I would like information about or testing for 

HIV/AIDS. 

0 1 2 3

47. I want someone to listen to me. 0 1 2 3

48. I want to learn to have fun without drugs or alcohol. 0 1 2 3

49. I want someone to tell me what to do. 0 1 2 3

50. I want help in setting goals and priorities in my life. 0 1 2 3

51. I would like to learn how to manage my time better. 0 1 2 3

52. I want help to receive SSI/disability payments. 0 1 2 3

53. I want to find enjoyable ways to spend my free time. 0 1 2 3

54. I want help in getting my child(ren) back. 0 1 2 3

55. I would like to talk about my past. 0 1 2 3

56. I need help in getting motivated to change. 0 1 2 3

57. I would like to see a female counselor. 0 1 2 3

58. I would like to see a male counselor. 0 1 2 3

59. I would like to see the counselor I had before. 0 1 2 3
DO YOU WANT THIS FROM TREATMENT? NO

0

Maybe

1

Yes

2

YES!

3

60. I would like to see a doctor or nurse about medical 

problems.

0 1 2 3

61. I want to receive medication. 0 1 2 3

62. I would like my spouse or partner to be in treatment 

with me. 

0 1 2 3

63. I would like to have private, individual counseling. 0 1 2 3

64. I would like to be in a group with people who are 

dealing with problems similar to my own. 0 1 2 3

65. I need someone to care for my children while I am in 

treatment.

0 1 2 3

66. I want my treatment to be short. 0 1 2 3

67. I believe I will need to be in treatment for a long time. 0 1 2 3

Is there anything else you would like from treatment? If so, please write on the back of this sheet. 
Appendix C

Ordering Information for

Assessment Instruments

Alcohol and Drug Consequences Questionnaire (ADCQ)

This instrument is not copyrighted and may be obtained by writing its developer:

John A. Cunningham, Ph.D.

Clinical Research Dissemination Unit

Addiction Research Foundation

33 Russell Street

Toronto, ON

Canada M5S 2S1

Phone: (416) 595‐6701

Fax: (416) 595‐6617

E‐mail: jcunning@arf.org

Alcohol Effects Questionnaire (AEQ)

This instrument is in the public domain and may be downloaded from the Web site at

http://www.ncbi.nlm.nih.gov/books/NBK64976/#A62222

Alcohol Expectancy Questionnaire

This instrument is in the public domain and may be downloaded from the Web site at

http://www.ncbi.nlm.nih.gov/books/NBK64976/#A62222

Alcohol Use Disorders Identification Test (AUDIT)

This instrument is in the public domain and may be downloaded from the Web site at

http://silk.nih.gov/silk/niaaa1/publication/instable.htm

235
Brief Situational Confidence Questionnaire (BSCQ) 

This instrument is copyrighted and may be obtained by writing its author: 

 Linda Sobell, Ph.D. 

NOVA Southeastern University 

Center for Psychological Studies 

3301 College Avenue 

Fort Lauderdale, FL 33314 

Phone: (954) 262-5811 

Fax: (954) 262-3895 

E-mail: sobelll@cps.nova.edu 

Personal Feedback Report

This instrument is not copyrighted and may be obtained by writing its developer: 

Project MATCH Series 

National Institute on Alcohol Abuse and Alcoholism 

P.O. Box 10686

Rockville, MD 10849-0686 

Readiness To Change Questionnaire (Treatment Version) (RCQ-TV) 

This instrument is copyrighted and may be obtained by contacting: 

Professor Nick Heather 

Consultant Clinical Psychologist 

Newcastle City Health NHS Trust 

Northern Regional Drug and Alcohol Service 

Newcastle upon Tyne 

United Kingdom 

Fax: 44 191 219-5601 

Situational Confidence Questionnaire (SCQ-39) 

This instrument is copyrighted and may be obtained by writing the copyright holder: 

Marketing Services 

Addiction Research Foundation 

33 Russell Street 

Toronto, ON 

Canada M5S 2S1 

Phone: (416) 595-6557 

Fax: (416) 593-4694 
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) 

This instrument is in the public domain and may be obtained by contacting its author: 

William R. Miller, Ph.D. 

Director

Center on Alcoholism, Substance Abuse, and Addictions 

2350 Alamo SE

University of New Mexico 

Albuquerque, NM 87106 

Phone: (505) 768-0100

Fax: (505) 768-0113

E-mail: wrmiller@unm.edu

University of Rhode Island Change Assessment Scale (URICA)

This instrument is in the public domain and may be obtained by contacting its author: 

Carlo C. DiClemente, Ph.D. 

Professor and Chair 

University of Maryland Baltimore County

Department of Psychology 

1000 Hilltop Circle

Baltimore, MD 21250

Phone: (410) 455-2415

Fax: (410) 455-1055

E-mail: diclemen@umbc.edu

Other Resources 

Allen, J.P., and Columbus, M. . Rockville, 

MD: National Institute on Alcohol Abuse and Alcoholism, 1995. 

This volume contains psychometrically sound assessment instruments. A brief discussion is provided 

for each instrument, along with a copy of the instrument and scoring instructions. Examples of 

assessment instruments that may be used to enhance motivation include the Situational Confidence 

Questionnaire; AUDIT; self-monitoring form; the alcohol timeline; and daily drinking feedback. Free 

copies may be obtained by calling the National Clearinghouse for Alcohol and Drug Information at (800) 

729-6686.

Sobell, L.C., and Sobell, M.B. Toronto: Addiction Research 

Foundation, 1996. 

Software is available to provide visual, easily understood feedback on individual consumption of 

alcohol, marijuana, cigarettes, or other substance use compared with norms. This interactive version 

allows the treatment provider or client to complete calendars onscreen and to generate printouts. A
user’s guide contains a paper and pencil version of the calendar method. In addition, a video 

demonstrates techniques for conducting interviews using timeline follow-back data. To order, please 

contact the following: 

Addiction Research Foundation 

Marketing Services 

33 Russell Street 

Toronto, ON 

Canada M5S 2S1 

(800) 661-1111 
Appendix D 

Resource Panel 

Peter J. Cohen, M.D., J.D. 

Adjunct Professor of Law 

Georgetown University Law Center 

Washington, D.C. 

Frances Cotter, M.A., M.P.H. 

Senior Public Health Advisor 

Office of Managed Care 

Center for Substance Abuse and Treatment 

Rockville, Maryland 

Dorynne Czechowicz, M.D. 

Associate Director 

Division of Clinical and Services Research 

Treatment Research Branch 

National Institute on Drug Abuse 

Bethesda, Maryland 

Gil Hill 

Director

Office of Substance Abuse 

American Psychological Association 

Washington, D.C. 

Linda Kaplan 

Executive Director 

National Association of Alcoholism and 

Drug Abuse Counselors 

Arlington, Virginia

Pedro Morales, J.D. 

Director

Equal Employment Civil Rights 

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Harold I. Perl, Ph.D. 

Public Health Analyst 

Division of Clinical and Prevention Research 

National Institute on Alcohol Abuse and 

Alcoholism

Bethesda, Maryland

Barbara J. Silver, Ph.D. 

Center for Mental Health Services 

Substance Abuse and Mental Health Services 

Administration

Department of Health and Human Services 

Rockville, Maryland 

Lucretia Vigil 

Policy Advisor 

National Coalition of Hispanic Health and 

Human Services Organization (COSSMO) 

Washington, D.C. 

Appendix E 

Field Reviewers 

Noel Brankenhoff, L.M.F.T., L.C.D.P. 

Child and Family Services 

Middletown, Rhode Island 

Rodolfo Briseno, L.C.D.C. 

Coordinator for Cultural/Special 

Populations and Youth Treatment 

Program Services, Program Initiatives 

Texas Commission on Alcohol and Drug 

Abuse

Austin, Texas

Richard L. Brown, M.D., M.P.H. 

Associate Professor 

Department of Family Medicine 

University of Wisconsin School of Medicine 

Madison, Wisconsin 

Michael Burke 

Senior Substance Abuse Specialist 

Student Health 

Rutgers University 

New Brunswick, New Jersey 

Kate Carey, Ph.D. 

Associate Professor 

Department of Psychology 

Syracuse University 

Syracuse, New York 

Anthony J. Cellucci, Ph.D. 

Director of Idaho State University Clinic 

Associate Professor of Psychology 

Idaho State University 

Pocatello, Idaho 

Gerard Connors, Ph.D. 

Research Institute on Alcoholism 

1021 Main Street 

Buffalo, New York 

John Cunningham, Ph.D. 

Scientist

Addiction Research Foundation Division 

Centre for Addiction and Mental Health 

Toronto, Ontario 

Janie Dargan, M.S.W. 

Senior Policy Analyst 

Office of National Drug Control Policy/EOP 

Washington, D.C. 

George De Leon, Ph.D. 

Center for Theraputic Community Research 

New York, New York 

Nereida Diaz-Rodriguez, L.L.M., J.D. 

Project Director 

Director to the Master in Health Science in 

Substance Abuse 

Centro de Entudion on Adiccion (Altos Salud 

Mental)

Edif. Hosp. Regional de Bayamon 

Santa Juanita, Bayamon, Puerto Rico 
Thomas Diklich, B.A.

Portsmouth CSR 

Portsmouth, Virginia 

Chris Dunn, Ph.D., M.A.C., C.D.C. 

Psychologist 

University of Washington 

Psychiatry and Behavioral Science 

Seattle, Washington 

Madeline Dupree, L.P.C. 

Harrisonburg-Rockingham CSB 

Harrisonburg, Virginia 

Gary L. Fisher, Ph.D. 

Nevada Addiction Technology Transfer 

Center

College of Education 

University of Nevada at Reno 

Reno, Nevada

Cynthia Flackus, M.S.W., L.I.C.S.W. 

Therapist

Camp Share Renewal Center 

Walker, Minnesota 

Stephen T. Higgins, Ph.D. 

Professor 

Departments of Psychiatry and Psychology 

University of Vermont 

Burlington, Vermont 

Col. Kenneth J. Hoffman, M.D., M.P.H., M.C.F.S. 

Preventive Medicine Consultant 

HHC 18th Medical Command 

Seoul, Korea 

James Robert Holden, M.A. 

Program Director 

Partners in Drug Abuse Rehabilitation 

Counseling

Washington, D.C. 

Ron Jackson, M.S.W. 

Executive Director 

Evergreen Treatment Services 

Seattle, Washington 

Linda Kaplan 

Executive Director 

National Association of Alcoholism and 

Drug Abuse Counselors 

Arlington, Virginia 

Matthew Kelly, Ph.D. 

Clinical Director 

Robert Wood Johnson Foundation 

Northwest Mexico Fighting Back, Inc. 

Gallup, New Mexico 

Karen Kelly-Woodall, M.S., M.A.C., N.C.A.C.II 

Criminal Justice Coordinator 

Cork Institute 

Morehouse School of Medicine 

Atlanta, Georgia 

Richard Laban, Ph.D. 

Laban’s Training 

Harrisburg, Pennsylvania 

Lauren Lawendowski, Ph.D. 

Acting Project Director 

Center on Alcoholism, Substance Abuse, and 

Addiction

University of New Mexico

Albuquerque, New Mexico

Bruce R. Lorenz, N.C.A.C. II 

Director

Thresholds, Inc. 

Dover, Delaware 

Russell P. MacPherson, Ph.D., C.A.P., C.A.P.P., 

C.C.P., D.A.C., D.V.C. 

President

RPM Addiction Prevention Training 

Deland, Florida 

George Medzerian, Ph.D. 

Pensacola, Florida 

Lisa A. Melchior, Ph.D. 

Vice President 

The Measurement Group 

Culver City, California 
Paul Nagy, M.S., C.S.A.C. 

Director

Duke Alcoholism and Addictions Program 

Duke University Medical Center 

Durham, North Carolina 

Tracy A. O’Leary, Ph.D. 

Clinical Supervisor 

Assistant Project Coordinator 

Center for Alcohol and Addiction Studies 

Brown University 

Providence, Rhode Island 

Gwen M. Olitsky, M.S. 

CEO

The Self-Help Institute for Training and 

Therapy

Lansdale, Pennsylvania 

Michele A. Packard, Ph.D. 

Executive Director 

SAGE Institute 

Training and Consulting 

Boulder, California 

Michael Pantalon, Ph.D. 

Yale School of Medicine 

New Haven, Connecticut 

Joe Pereira, L.I.C.S.W., C.A.S. 

Recovery Strategies 

Medford, Massachusetts 

Harold Perl, Ph.D. 

Public Health Analyst 

Division of Clinical and Prevention Research 

National Institute on Alcoholism and 

Alcohol Abuse 

Bethesda, Maryland 

Raul G. Rodriguez, M.D. 

Medical Director 

La Hacienda Treatment Center 

Hunt, Texas 

Richard T. Suchinsky, M.D. 

Associate Director for Addictive Disorders 

and Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences 

Services

Department of Veterans Affairs 

Washington, D.C. 

Suzan Swanton, M.S.W. 

Clinical Director 

R.E.A.C.H. Mobile Home Services 

Baltimore, Maryland

Michael J. Taleff, Ph.D., C.A.C., M.A.C., 

N.C.A.C.II

Assistant Professor and Coordinator 

Graduate Programs in Chemical Dependency 

Counselor Education 

Department of Counselor Education 

Counseling Psychology and Rehabilitation 

Services

Pennsylvania State University 

University Park, Pennsylvania 

Nola C. Veazie, Ph.D., L.P.C., C.A.D.A.C. 

Superintendent

Medical Services Department 

United States Air Force 

Family Therapist/Drug and Alcohol 

Counselor

Veazie Family Therapy 

Santa Maria, California

Mary Velasquez, Ph.D. 

Psychology Department 

University of Houston 

Houston, Texas 

Christopher Wagner, Ph.D. 

Division of Substance Abuse Medicine 

Virginia Commonwealth University 

Richmond, Virginia 
244

Appendix F: Acknowledgments

Numerous people contributed to the

development of this TIP, including the Editorial

Advisory Board (see page ix), TIP Consensus

Panel (see page xi), Resource Panel (see

Appendix D), and TIP Field Reviewers (see

Appendix E).  

This publication was produced under KAP, a

Joint Venture of The CDM Group, Inc. (CDM),

and JBS International, Inc. (JBS), under contract

number 270‐95‐0013 for the Substance Abuse

and Mental Health Services Administration’s

Center for Substance Abuse Treatment.

CDM KAP personnel included Rose M. Urban,

M.S.W., J.D., LCSW, LCAS, CDM TIPs project

director; Raquel Witkin, M.S., project manager;

Jonathan Max Gilbert, M.A., managing editor; Y‐

Lang Nguyen, production editor; Janet G.

Humphrey, M.A., editor/writer; Paddy Cook,

freelance writer; Joanna Taylor, editor; Cara

Smith, editorial assistant; Paul Seaman, editorial

assistant; and Kurt Olsson, editor/writer.
The TIPs Series

TIP 2 Pregnant, Substance‐Using Women BKD107

TIP 5 Improving Treatment for Drug‐Exposed Infants BKD110

TIP 6 Screening for Infectious Diseases Among Substance Abusers BKD131

TIP 11 Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases BKD143

TIP 13 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders BKD161

TIP 14 Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment BKD162

TIP 16 Alcohol and Other Drug Screening of Hospitalized Trauma Patients BKD164

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers BKD173

TIP 21 Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System SMA 08‐4073

TIP 23 Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing SMA 12‐3917

TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians SMA 08‐4075

TIP 25 Substance Abuse Treatment and Domestic Violence SMA 12‐4076

TIP 26 Substance Abuse Among Older Adults SMA 12‐3918

TIP 27 Comprehensive Case Management for Substance Abuse Treatment SMA 12‐4215

TIP 29 Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities SMA 12‐4078

TIP 30 Continuity of Offender Treatment for Substance Use Disorders From Institution to Community SMA 08‐3920

TIP 31 Screening and Assessing Adolescents for Substance Use Disorders SMA 12‐4079

TIP 32 Treatment of Adolescents With Substance Use Disorders SMA 12‐4080

TIP 33 Treatment for Stimulant Use Disorders SMA 09‐4209

TIP 34 Brief Interventions and Brief Therapies for Substance Abuse SMA 12‐3952

TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment SMA 12‐4212

TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues SMA 08‐3923

TIP 37 Substance Abuse Treatment for Persons With HIV/AIDS SMA 12‐4137

TIP 38 Integrating Substance Abuse Treatment and Vocational Services SMA 12‐4216

TIP 39 Substance Abuse Treatment and Family Therapy SMA 12-4219

TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction SMA 07‐3939

TIP 41 Substance Abuse Treatment: Group Therapy SMA 09‐3991

TIP 42 Substance Abuse Treatment for Persons With Co‐Occurring Disorders SMA 08‐3992

TIP 43 Medication‐Assisted Treatment for Opioid Addiction in Opioid Treatment Programs SMA 08‐4214

TIP 44 Substance Abuse Treatment for Adults in the Criminal Justice System SMA 05‐4056

TIP 45 Detoxification and Substance Abuse Treatment SMA 08‐4131

TIP 46 Substance Abuse: Administrative Issues in Outpatient Treatment SMA 06‐4151

TIP 47 Substance Abuse: Clinical Issues in Outpatient Treatment SMA 06‐4182

TIP 48 Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery SMA 12‐4353

TIP 49 Incorporating Alcohol Pharmacotherapies Into Medical Practice SMA 09‐4380

TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment SMA 09‐4381

TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women SMA 09‐4426

TIP 52 Supervision and the Professional Development of the Substance Abuse Counselor SMA 09‐4435

TIP 53 Addressing Viral Hepatitis in People With Substance Use Disorders SMA 11‐4656

TIP 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders SMA 11‐4661

Other TIPs may be ordered by calling 1‐877‐SAMHSA‐7 (1‐877‐726‐4727) (English and Español)

or visiting http://store.samhsa.gov.

HHS Publication No. (SMA) 12-4212

Substance Abuse and Mental Health Services Administration

First Printed 1999

Revised 2000, 2001, 2002, 2003, 2004, 2006, 2007, 2008, 2011, and 2012