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There is, however, a constructive type of therapeutic confrontation. If helping clients confront and assess the reality of their behaviors 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 FieldAs 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 StrengthsWhereas 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 Client-Centered TreatmentIn 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 LabelingHistorically, 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 ChangeIn the past, especially in the medical model, clients passively received 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 PowerWhereas 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 InterventionsThe 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), Brief Interventions and Brief Therapies for Substance Abuse [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 TreatmentsA 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. Twenty-eight days was considered the proper length of time for successful inpatient (usually hospital-based) 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 what kinds 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 TreatmentChanges 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 ProblemsFormerly, substance misuse, particularly the disease 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 Diagnostic and Statistical Manual of Mental Disorders, 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 AbusePractitioners 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 GoalsIn 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 DisciplinesHistorically, 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, Brief Interventions and Brief Therapies for Substance Abuse [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 ChangeAs 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 ChangeThe 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 self-directed 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 self-directed 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 ChangeTheorists 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 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 self-change 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 stages-of-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 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. PrecontemplationDuring the precontemplation stage, substance-using 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. ContemplationAs 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. PreparationWhen 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. ActionIndividuals 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. MaintenanceDuring 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 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).
RecurrenceMost 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 ChangeThe multidimensional nature of motivation is captured, in part, in the popular phrase that a person is ready, willing, and able to change. This expression highlights three critical elements of motivation--but in reverse order from that in which motivation typically evolves. Ability refers to the extent to which the person has the necessary skills, resources, and confidence (self-efficacy) to carry out a change. One can be able to change, but not willing. The willing 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 ready 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 DoesThis 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 four-session 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 sufficient 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. SummaryLinking the new view of motivation, the strategies found to enhance it, and the stages-of-change 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. |
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