1. Motivational Enhancement & Engagement Strategies
Joan E. Zweben, Ph.D.
Psychiatry Grand Rounds
Alta Bates/Herrick, Berkeley
January 10, 2011

2. Different Levels of Severity (ONDCP - 2010)
In Treatment ~ 2,300,000
LOTS
Addiction ~ 25,000,000
(Focus on Treatment)
Diabetes ~24,000,000
Before we talk about the specific priorities in the Strategy it is important to understand the full spectrum of the Substance USE problem in our country; different policies are needed for different parts of the overall problem This pyramid describes this very well
1 – As represented by the broad base of this pyramid –most people in the US either do not use substances or use them very very few times - Here the best policies are prevention – to keep use low
2 – As you go up the pyramid to the wavy dotted line – this shows when “use” becomes “harmful use” – either to an individual’s health or their productivity or their relationships. It is NOT a diagnosis and people can go back and forth across that line – but there are a lot of these folks about 65 – 70 million They are the people who drink and drive, or make their asthma problem worse by smoking marijuana, or are failing school because of too much weekend partying with drugs. Here we need convenient, attractive, potent but probably brief interventions to reduce use and prevent problems from becoming worse
3 –The bright solid line means that the frequency and intensity of use has reached a DIAGNOSTIC threshold – there are 23 – 25 million adults who meet diagnostic criteria for the most serious problems “SUSTANCE ABUSE AND DEPENDENCE” - Click – In comparison, most people think there is an “epidemic” of diabetes and there is - about 24 million people are diabetic.
4 - The orange pinnacle shows the number of people who are receiving any kind of treatment – about 2.3 – 2.5 million or only 1/10 of those who meet the diagnosis – even smaller proportion of those with “harmful use” – This is the “Treatment GAP” that we want to close – the worst in all of medicine
5 – The OVAL indicates that we need policies and interventions that will reach a FAR broader range of people with “substance use problems”
“Harmful Use:” – 68,000,000
(focus on Early Intervention)
Little or No Use
(focus on Prevention)
LITTLE 2

3. Screening, Brief Intervention & Referral to Treatment (SBIRT)
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with SUDS, as well as those who are at risk of developing these disorders.
Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur

4. SBIRT Activities
Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.
Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
Referral to treatment provides those identified as needing more extensive treatment with access to speciality care. (

5. Is SBIRT Effective?
SBIRT research has shown that large numbers of individuals at risk may be identified through primary care screening. Interventions such as SBIRT have been found to:
Decrease the frequency and severity of drug and alcohol use,
Reduce the risk of trauma, and
Increase the percentage of patients who enter specialized substance abuse treatment.
Screening and brief interventions have also been associated with fewer hospital days and fewer emergency department visits. Cost-benefit analyses and cost-effectiveness analyses have demonstrated net-cost savings from these interventions.

6. History & Current Context
1992 – In Search of How People Change (Prochaska, DiClemente & Norcross)
CSAT provided training and developed materials
Growing recognition that untreated substance abuse is expensive: physical and mental health, social services and criminal justice systems

7. History & Current Context
patients referred from other services with insufficient attention to motivation
no specific arena to address ambivalence
“Wait until they are ready”
AOD programs: discharge for non-compliance with high expectations
discovery that untreated substance abuse is expensive

8. Treatment Outcome Findings
retention improves outcome
enduring gains often require at least 6 months of treatment
addiction treatment works as well as treatment for other chronic relapsing disorders (asthma, diabetes, hypertension)
patient implementation of treatment recommendations is the key

9. Getting Motivated: Accumulating Consequences
increasing dysphoria, emotional distress
loss of important relationship(s)
loss of job; interference with performance
health problems
financial problems
legal problems

10. Enticements: Severely Mentally Ill
help in obtaining food, housing
access to entitlement programs
help in avoiding legal penalties
socialization, recreation, vocational opportunities
relief from distressing symptoms

11. Harm Reduction Valuable approach that produces public health benefits
Permits low threshold place to begin addressing AOD using behavior
Many pitfalls for the clinician
Clinician can make forthright recommendations and still work with patient’s goals

12. Negotiating an Abstinence Commitment
Connect AOD use with presenting complaints
facilitate progress through initial decision making phases of change
blend careful inquiry, giving information, gentle confrontation
experiment with abstinence; sobriety sampling
enhance motivation, vs punish ambivalence

13. Reasons to Resist an Abstinence Commitment
fear of failure
addiction pattern in family of origin
self medication
trauma history
survivor guilt

14. Motivational Enhancement Strategies
TIP 35
Enhancing Motivation for Change in Substance Abuse Treatment

15. Goals and Benefits 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

16. Stages of Change Precontemplation Contemplation Preparation Action
Maintenance

17. Motivational Interviewing Principles
expression of empathy
development of discrepancy
avoidance of argumentation
rolling with resistance
supporting self-efficacy

18. Basic Interventions
Develop discrepancy between client’s goals or values and their current behavior
Avoid argument and direct confrontation; roll with resistance
Express empathy through reflective listening
Adjust to client resistance rather than opposing it directly
Support self-sufficiency; self-efficacy and optimism

19. Eliciting Self-Motivating Statements
Ask evocative questions
In what way has drinking been a problem for you?
In what ways does it concern you?
Explore pros and cons
Ask for elaboration
Imagining extremes
If you don’t stop drinking/using, what is the worst thing that could happen

20. Eliciting Self-Motivating Statements, Continued
Looking forward
Think ahead 5 years, what would you like your life to be like?
How does what you are doing now fit into that?
What would it take for you to decide, “I have to do something?”
Looking back
When was the last time things were going well and what was your life like then?

21. Opening Strategies Ask open-ended questions Listen reflectively
Summarize periodically
Affirm: comment on client resources, strengths, positive behaviors
Elicit self-motivational statements; reinforce positive expressions

22. FRAMES Approach
Feedback about risk/impairment is given following assessment
Responsibility placed on client
Advice given clearly in nonjudgmental manner
Menu of options/alternatives is offered
Self-efficacy or optimistic empowerment is promoted to encourage change

23. Precontemplation Stage
Task is to raise awareness
Offer factual information
Explore events that brought the person in and the results of previous efforts
Explore pros and cons of drinking/using
(Jeanne L. Obert, MFT, Matrix Institute, Los Angeles)

24. Contemplation Stage
Taks is to resolve ambivalence about change and help client choose change
What does the client think the change will entail?
Level of self-efficacy and expectations
Continue exploration of pros and cons
Summarize self-motivational statements
(Jeanne L. Obert, MFT, Matrix Institute, Los Angeles)

25. Action Stage
Task: select and implement change strategies; address relapse hazards
Discuss and select change strategies
Enlist social and family support
Identify high-risk situations and develop coping strategies
Find new reinforcers of positive change
(Jeanne L. Obert, MFT, Matrix Institute, Los Angeles)

26. Maintenance Stage Task: develop new skills for maintaining recovery
Identify and try alternative behavior (stress management, enjoyment)
Develop an escape plan for high risk situations
Set new short and long term goals
(Jeanne L. Obert, MFT, Matrix Institute, Los Angeles)

27. References
Miller, W. R. (1999). Enhancing Motivation for Change in Substance Abuse Treatment (Vol. 35). Rockville, Maryland: U.S. Department of Health and Human Services.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In Search of How People Change: Applications to addictive behaviors. American Psychologist, 47,
Washton, A., & Zweben, J. E. (2009). Cocaine & Methamphetamine Addiction: Treatment, Recovery, and Relapse Prevention. New York: W.W. Norton.
Washton, A. M., & Zweben, J. E. (2006). Treating Alcohol and Drug Problems in Psychotherapy Practice: Doing What Works. New York: Guilford Press.

28. Resources Addiction Technology Transfer Centers: www.nattc.org
Center on Alcoholism, Substance Abuse & Addictions:
NIDA Blending Initiative – partnership with SAMHSA to disseminate research findings:
NIDA Dissemination Library:
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