Interventions to Enhance Motivation: The Client’s Perspective, Part III

This is the final column on motivation. The first two addressed levels of client motivation to change, factors impacting on motivation, and strategies for clients to address motivation issues. This column discusses evidenced-based motivational approaches and clinical strategies to address motivation issues with clients.

There are two motivational interventions that have significant research support and can be integrated into clinical practice and treatment programs: motivational interviewing (MI) and motivational incentives (MotInc), also called Contingency Management (Miller & Rollnick, 2012; NIDA, 2012; Stitzer, Petry, & Peirce, 2010; Wells, Saxon, Calsyn, Jackson, & Donovan, 2010). MI helps clients develop internal motivation to change as well as deal with ambivalence to change or factors that interfere with the change process. MI is effective with substance use, psychiatric, and medical disorders. MotInc is more of an external motivator that leads to improved substance use or mental health outcomes and session attendance. The reinforcement provided by external incentives helps the client make positive changes that can be sustained over time with other types of interventions that impact on internal motivators. In one of our quality improvement initiatives in a co-occurring disorders partial hospital treatment program, MotInc has a significant impact on increasing program attendance. External motivators can provide time for clients to internalize motivation to recover.  

Clients are often bombarded with internal cues (memories, thoughts, feelings, desires) as well as external cues (signs, smells, reminders, people, places, things, events) to use substances, which impact their motivation to continue recovery disciplines. I asked clients in several treatment groups to identify coping strategies that help them through periods of low motivation or increase their motivation to recover. I also asked several clinicians for their ideas on ways to help clients deal with motivational issues. All agree that education and awareness of motivational issues can have a positive impact on recovery. The following are some specific strategies to enhance motivation.

While helping clients deal with low motivation or increasing motivation to change can occur in any stage of the change process, clients in the precontemplation or contemplation stages often require the most effort related to their motivation to change. It makes little sense to focus on relapse issues with clients who are not sure if they even want to stop using alcohol or other drugs. Since level of motivation can change frequently in the early phases of treatment and recovery, regular assessment of the client’s current motivation enables the clinician to determine intervention strategies.

Clients benefit from having a direction to follow in managing their disorders. This may require them to listen to, and to let others influence, their behaviors regardless of their level of motivation to change. Or, as one clinician with decades of personal recovery stated, “In early recovery, you should be like a horse with blinders and let others guide you towards reaching the goal of sobriety.” This is a good example of the need to “surrender” and let others support and facilitate recovery.

Thinking Differently   

Attending treatment sessions and mutual support meetings, even when the client does not feel like it, often has a positive outcome. Or, as many people in recovery have stated about attending sessions or meetings when they did not feel like it, “drag your body and your mind will follow.” Sometimes clients have to take action even when they do not feel like it.  

When a client moves from thinking, “I cannot drink or use drugs because of the negative consequences” to “I can not drink or use drugs because I do not want to,” this indicates that motivation has moved from external to internal. The client is now showing recovery thinking. 

Keeping a Daily Log of Motivation  

This is similar to keeping a “mood thermometer” or “daily craving log” to monitor specific psychiatric symptoms or issues such as obsessions or cravings for alcohol or drugs. Clients attending structured programs can report their levels of motivation during check-in periods. This enables clinical staff and their peers to be aware of any significant changes in motivation. This also provides a context in which a client can get help and support with any current motivational issue. When I ask groups of clients if they thought about not coming to the program the day I meet with them, the majority acknowledge this thought crossed their mind. More importantly, they were able to share self-talk strategies they used to convince themselves to attend the program, regardless of how low their motivation was at that time.

This was developed by Dr. G. Alan Marlatt as an exercise aimed to help the client see both types of decisions related to using or not using a substance or engaging in an addictive behavior such as compulsive gambling or overeating. This can be adapted to behaviors such as taking, or not taking, medications for a psychiatric illness or substance addiction, attending treatment or mutual support programs, or engaging in any specific behavior (e.g., quitting a job or sticking with it; trying a new leisure activity; paying bills or going on a shopping spree; controlling anger or expressing it in inappropriate ways; asking a confidante for help or support or keeping personal struggles to oneself). A client can review the results of any decision matrix in a group session with peers, or an individual counseling session. Seeing both short- and long-term positive and negative aspects of any decision enables the client to think about options to change, potential barriers, and potential benefits.

A client with a chronic or persistent psychiatric disorder has to accept that not all symptoms may totally disappear, and that some symptoms have to be endured; these are referred to “persistent symptoms.” Or, a client with a history of multiple relapses to addiction may have to fight through strong drug cravings or periods of low motivation. Even a modest decrease in psychotic, mood or addiction-related symptoms, or a modest increase in motivation to recovery, is a step in the right direction and evidence of improvement.

Maintaining Daily Recovery Disciplines    

Incorporating recovery into daily life can involve meeting or talking with a sponsor, a peer in recovery or other support person; attending mutual support meetings; reading recovery literature or listening to recovery stories on audiotapes or DVDs; or being of service to others (e.g., helping to set up or clean up after meetings or giving a peer a ride to a meeting). These are reminders of where one has been, that negative emotions or moods can be managed, and that recovery can continue regardless of what a client faces in daily life.

It helps if a client has a list of at least five people to rely on that can be contacted during periods of need as well as during periods when things go well. A regular connection with a recovery support system promotes accountability with others who know the client and his or her recovery plan. As one woman stated, “When I tell my husband I feel headed towards depression, he helps me get through it. If I don’t tell him, my depression is more likely to pull me down.”

Engaging in Pleasant and Healthy Activities  

These support the client’s recovery and promote well-being, which can enhance motivation to change. These can include regular physical workouts, praying, attending religious or spiritual activities, meditating, practicing mindfulness or participating in any organized group or activity that brings the client meaning or enjoyment. The “fly by the seat of my pants” and “engage in healthy activities only when I feel like it” approaches usually do not work in the long run. Keeping reminders of progress, such as calendars, journals, logs or coins given at Twelve Step meetings for specific periods of sobriety, and sharing events with peers (e.g., first thirty days sober with a stable mood or without any self-harm activities) can reinforce positive decisions.

• While MI has been adapted by many clinicians across behavioral health care systems, MotInc is used less frequently. There is still some resistance to the idea of “rewarding” clients for not using substances or attending sessions.
• Ambulatory treatment programs who use MotInc to increase attendance will find a significant return on their financial investment. For example, increasing daily attendance in a four- to six-week partial hospital program by five days per patient over the course of treatment can generate $500 for programs that receive $100 for a treatment day or $1250 for programs that receive $250 for a treatment day (less cost of incentives).

• What have you found helpful in working with clients to address motivational struggles related to their disorder(s) or any lifestyle issue?
• Rather than give up on a client who has had multiple relapses and chronic struggles with motivation, do you think of other ways you may reach this person and affect recovery?
• If your program has a problem with poor adherence to treatment by clients, have you considered implementing a Motivational Incentives program to improve adherence?

Evidenced-based motivational approaches (MI and MotInc) can easily be incorporated into clinical services and have a positive impact on outcomes for clients. It is important, however, to insure clinicians have access to ongoing training, supervision, and/or consultation as a mechanism to sustain the use of these approaches. There are many clinical strategies that can be used in individual or group sessions to educate clients and help them learn ways to deal with motivational struggles as these are so common in recovery, regardless of one’s disorders.  Catching and addressing motivational struggles early can enhance a client’s recovery.

National Institute on Drug Abuse (NIDA). (2012). Principles of drug addiction treatment (3rd ed.). Rockville, MD: National Institute on Drug Abuse, National Institutes of Health, US Department of Health and Human Services. 

Stitzer, M. L., Petry, N. M., & Peirce, J. (2010). Motivational incentives research in the National Drug Abuse Treament Clinical Trials Network. Journal of Substance Abuse Treatment, 38(Suppl. 1), S61–S69. 

Wells, E. A., Saxon, A. J., Calsyn, D. A., Jackson, T. R., & Donovan, D. M. (2010). Study results from the Clinical Trials Network first ten years. Journal of Substance Abuse Treatment, 38(Suppl. 1), S14–S30.