Motivational therapy

Motivational therapy (or MT) is a combination of humanistic treatment and enhanced cognitive-behavioral strategies, designed to treat substance abuse. It is similar to Motivational Interviewing and Motivational Enhancement Therapy

Method

The focus of motivational therapy is encouraging a patient to develop a negative view of their abuse, along with a desire to change their behavior. A motivational therapist does not explicitly advocate change and tends to avoid directly contradicting their patient, but instead expresses empathy, rolls with resistance, and supports self-efficacy.

Often, a methadone or similar program is used in conjunction with motivational therapy.

Some suggest that the success of motivational therapy is highly dependent on the quality of the therapist involved and, like all therapies, has no guaranteed result. Others explain the frequent successes of motivational therapy by noting that the patient is the ultimate source of change, choosing to reduce their dependency on drugs.

Motivational therapies are focused specifically on a persons needs, or on what their problems may be. Sessions are usually short the first time you see a patient, but time can vary the next few sessions. During these times there are different methods and techniques used by the therapist. Techniques consist of:

• brief solution focused therapy
• cognitive behavioural therapy
• schema focused therapy
• interpersonal therapy
• compassion focssed therapy
• compassionate mind training
• hypnosis.

History

First publicized by Miller and Rollnick in 1991, motivational therapy is now seen as a highly effective treatment strategy for substance abuse, especially in the case of opiate and euphoric-enhancement drugs, where users tend to resist traditional negative reinforcement strategies. Motivational Therapy was brought to public awareness by William Miller in a 1983 article published in Behavioural Psychotherapy. In 1991, Miller and Stephen Rollnick expanded on the fundamental approaches and concepts, while making more detailed descriptions of procedures in the clinical setting. He later defined it as a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, Motivational Therapy is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal. Since Miller and Rollnick, other psychologists have introduced models and various techniques to try to implement within the Motivational Therapy realm to help with substance abuse. Carlo DiClemente introduced models that linked motivation with change, proposing the Stages of Change Model, and using it to explain relapse, and the struggle of addiction being a matter of behavior change. The model states seven different stages of change, and a brief description of each stage:

Precontemplation

Not ready to change

Contemplation

Thinking about change

Preparation

Getting ready to make a change, planning and commitment

Action

Making the change, implementing the plan, taking the action

Maintenance

Sustaining behavior change until integrated into lifestyle, maintaining, integrating

Relapse/recycling

Slipping back to previous behavior and re-entering the cycle of change

Termination

Leaving the cycle of change

The models, along with the techniques formulated by Rollnick and Miller have helped create a client-driven form of therapy that has been known to help clients with substance abuse and different caliber athletes in achieving success. Motivational Therapy was designed to be less confrontational than other therapies that encourage clients to realize that they have a problem that they need to confront in order to change. MT is different than those therapies that:

• Argue that the person has a problem and needs to change
• Offer direct advice or prescribes solutions to the problem without the person's permission or without actively encouraging the person to make his or her own choices
• Use an authoritative/expert stance leaving the client in a passive role
• Do most of the talking, or functions as a unidirectional information delivery system
• Impose a diagnostic label
• Behave in a punitive or coercive manner

The aforementioned therapy techniques are known to violate the essential spirit of motivational therapy. MT is designed to be an interpersonal style of therapy that is not restricted to formal counseling settings. It focuses on the understanding of what initiates change while utilizing a guiding philosophy, and fosters a balance of components that are both directed and client-centered.

Intervention

Motivational intervention is described as a directive, patient-centered counseling style that enhances motivation for change by helping patients clarify and resolve ambivalence about behavior change.

This type of therapy helps patients refocus on their goals in life and restructure the important things in their life.

Motivational problems are increasing in addiction treatment settings, as more patients are identified by early interventions, and are court-ordered, ambivalent, and unmotivated. The earlier the intervention occurs, the less the motivation.

Early intervention allows people to set realistic goals for their recovery. Recovery can take a while, so it is ideal that the patients receives the therapy as soon as possible. the sooner the better because it allows the patients to have confidence in the recovery process and the help that they are receiving.

Motivational therapy and substance abuse

Motivational therapy is not only helpful to the substance abuser but also helpful towards the non-users in the family as well. There has been an equally growing understanding and concern for not only chronic substance abusers but also their family and friends. Current literature assessments have consistently identified three main findings: (1) involvement of family members during the pre-treatment phase significantly improves engagement of substance abusers in treatment; (2) involvement of the family also improves retention in treatment, and (3) long-term outcomes are more positive when families and/or social networks are components of the treatment approach. Within Motivational Therapy, specific models have been introduced relating to various reasons for treatment. The Systematic Motivational Therapy (SMT) Model is used for treatment of substance abuse. The emphasis of this model is the focus on family relationships. This model does not only show the happiness and appreciation of the family in these relationships but also the complications and ambivalent relationships that comes with substance abuse. There are two distinct versions of the SMT model. Version one of the model includes the family approach towards substance abuse; emphasizing four different principles: assessment, detoxification, relapse prevention, and rehabilitation. When being addressed, the entire family is present and attentive (not just the abuser). Version 2 of the SMT model uses motivational interviewing approaches and combines these with family systems by using five basic principles that are critical in shaping therapist behavior: expressing empathy about the patients condition(s), developing discrepancies regarding the patients beliefs about his or her behavior, avoiding arguments about continued substance use; rolling with resistance to change and supporting patient self-efficacy regarding decisions about behavior change.

Differences between motivational therapy (MT), motivational interviewing (MI), and motivational enhancement therapy (MET)

Although very often used in similar contexts, motivational therapy, motivational interviewing and motivational enhancement theory/therapy have their differences. Motivational interviewing (MI) is similar to motivational therapy in the sense that it attempts not to create change within an individual but give foundation and support to the change the individual finds within him or her self. As a treatment for individuals with all types of substance abuse disorders, motivational interview therapists focus on trying to erase any type of ambivalence the individual may have towards their abuse. Similar to MET, motivational interviewing finds ‘change talk’ very important and the clinician interacts with the patient through open-ended questions, affirmations, reflections and end-of-session summaries. There are three key elements that build the foundation of motivational interviewing; collaboration, evocation and autonomy. Evocation is expressed through the clinician’s responsibility to “draw out” the opinions and commitment to change of the client, rather than suggesting or imposing ideas. The client and the therapist, through collaboration, work together to build a trusting relationship, as opposed to the therapist taking the expert or higher role between the two. While Motivational Therapy is a method to treat substance abuse, Motivational Enhancement Therapy (MET) is also a very common way to treat alcoholism or alcohol abuse. MET is very focused on the individual or patient taking responsibility for their abuse and speaking about the actions needed to evoke change in their life. Through this therapy, patients learn alternative routes to deal with such a huge change in their lifestyle. Similar to MT, therapists attempt throughout MET to evoke a feeling of optimism within patients, but unlike motivational therapy, therapists are very clear on their advice and suggestions for change. Without taking the back seat and just listening to their patients’ thoughts, therapists of MET are more vocal in their feedback towards patient improvement. Like MT, there are five stages which set the stage for successful MET (in order, from beginning to end): Pre-contemplation, contemplation, determination, action, maintenance. If not permanently successful, there becomes a sixth stage to work through – relapse.

References

• American Psychological Associates 2003. Authors: Burke, Brian L.; Arkowitz Hal; and Menchola, Marisa. The Efficacy of Motivational Interviewing: A Meta-Analysis of Controlled Clinical Trials. Retrieved April 9, 2006.
• Advances in Psychiatric Treatment, Volume 9 (pp. 280–288). Author Luty, Jason. What works in drug addiction?. Retrieved April 9, 2006.
• American Psychological Associates 2004. Authors: Miller, William R.; Yahne, Carolina E.; Moyers, Theresa B.; Martinez James; and Pirritano, Matthew. A Randomised Trial of Methods to Help Clinicians Learn Motivational Interviewing. Retrieved April 9, 2006.
• DiClemente C. Motivational enhancement therapy. Program and abstracts of the American. Society of Addiction Medicine 2003 The State of the Art in Addiction. Medicine; October 30-November 1, 2003; Washington, DC. Session I.
• DiClemente CC. Motivation for change: implications for substance abuse treatment. Psychol Sci. 1999;10:209–213.
• Miller WR, Rollnick S. What Is Motivational Interviewing? Behavioural and Cognitive Psychotherapy. 1995; 23, 325–334.
• Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change, 2nd edition. New York: Guilford Press; 2002.
• http://www.stephenrollnick.com/index.php/all-commentary/64-what-is-motivational-interviewing
• American Psychological Associates 2003. Authors: Burke, Brian L.; Arkowitz Hal; and Menchola, Marisa.
• The Efficacy of Motivational Interviewing: A Meta-Analysis of Controlled Clinical Trials. Retrieved April 9, 2006.
• Advances in Psychiatric Treatment, Volume 9 (pp. 280–288). Author Luty, Jason. What works in drug addiction?. Retrieved April 9, 2006.
• American Psychological Associates 2004. Authors: Miller, William R.; Yahne, Carolina E.; Moyers, Theresa B.; Martinez James; and Pirritano, Matthew. A Randomised Trial of Methods to Help Clinicians Learn Motivational Interviewing. Retrieved April 9, 2006.
• Elizabeth Howell, MD. (2004). Motivation Therapy. Medscape Today.
• William R. Miller, PhD (2009). An Overview of Motivational Interviewing. MI.
• Steinglass, P. (2009). Systemic-motivational therapy for substance abuse disorders: An integrative model. Journal of Family Therapy, 31(2), 155–174. doi:10.1111/j. 1467-6427.2009.00460.x
• Edwards and Steinglass, 1995; Miller et al., 1999; O’Farrell and Fals-Stewart, 2003; Rowe and Liddle, 2003; Stanton and Heath, 2005; Thomas and Corcoran, 2001.