Enhancing Motivation for Change in Substance Abuse Treatment

Cara M. Smith, editorial assistant; Paul A.<br><br> Seaman, former editorial assistant; and Kurt Olsson, former editor/writer. The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS).<br><br> No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions. What Is a TIP?<br><br> Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems.<br><br> Enhancing Motivation for Change in Substance Abuse Treatment [Front Matter] 1 The TIPs Editorial Advisory Board, a distinguished group of substance use experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non 2Federal experts on the topic who have been nominated by their peers.<br><br> This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co 2Chairs) ensures that the guidelines mirror the results of the group's collaboration.<br><br> A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov.<br><br> The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state 2of 2the 2art information. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that 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.<br><br> For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided. This TIP, Enhancing Motivation for Change in Substance Abuse Treatment , embraces a fundamentally different way to conceptualize motivation.<br><br> In this approach, motivation is viewed as a dynamic and changeable state rather than a static trait. This TIP shows how clinicians can influence this change process by developing a therapeutic relationship, one that respects and builds on the client's autonomy and, at the same time, makes the treatment counselor a participant in the change process. The TIP also describes different motivational interventions that can be used at all stages of change, from precontemplation and preparation to action and maintenance.<br><br> The goal of this TIP is to make readers aware of the research, results, and promise of motivational interventions in the hope that they will be used more widely in clinical practice and treatment programs across the United States. Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729 26686 or (301) 468 22600; TDD (for hearing impaired), (800) 487 24889. Editorial Advisory Board Karen Allen, Ph.D., R.N., C.A.R.N.<br><br> Professor and Chair Department of Nursing Andrews University Berrien Springs, Michigan Richard L. Brown, M.D., M.P.H. Associate Professor Enhancing Motivation for Change in Substance Abuse Treatment Editorial Advisory Board 2 Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D.<br><br> 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.<br><br> Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants and Trainers Richmond, Virginia Pedro J.<br><br> Greer, M.D. Assistant Dean for Homeless Education University of Miami School of Medicine Miami, Florida Thomas W. Hester, M.D.<br><br> 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.<br><br> 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.<br><br> Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Enhancing Motivation for Change in Substance Abuse Treatment Editorial Advisory Board 3 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.<br><br> Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D.<br><br> 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.<br><br> 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.<br><br> Colby, Ph.D. Assistant Professor of Psychiatry and Human Behavior Center for Alcohol and Addiction Studies Brown University Providence, Rhode Island Enhancing Motivation for Change in Substance Abuse Treatment Consensus Panel 4 Carlo C. DiClemente, Ph.D.<br><br> 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.<br><br> 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.<br><br> 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.<br><br> Department of Psychology Loyola Marymount University Los Angeles, California Rosalyn Harris 2Offutt, B.S., C.R.N.A., L.P.C., A.D.S. UNA Psychological Associates Greensboro, North Carolina Don M. Hashimoto, Psy.D.<br><br> Clinical Director Ohana Counseling Services, Inc. Hilo, Hawaii Dwight McCall, Ph.D. Enhancing Motivation for Change in Substance Abuse Treatment Panelists 5 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.<br><br> 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.<br><br> Innovative Programs Research Group School of Social Work Seattle, Washington Linda C. Sobell, Ph.D. Professor NOVA Southeastern University Fort Lauderdale, Florida Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors.<br><br> 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 2Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.<br><br> The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Nelba Chavez, Ph.D.<br><br> Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Enhancing Motivation for Change in Substance Abuse Treatment Foreword 6 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.<br><br> It is redefined here as purposeful, intentional, and positive 2 2directed 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.<br><br> 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.<br><br> These approaches may be especially beneficial to particular populations (e.g., court 2mandated offenders) with a low motivation for change. Despite the preponderance of evidence supporting the efficacy of motivation 2focused 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.<br><br> The cognitive 2behavioral 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.<br><br> 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.<br><br> Motivation 2enhancing 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.<br><br> 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 2 2not the clinician's 2 2problem.<br><br> 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 2of 2change" model, developed by Prochaska and DiClemente and upon which this TIP is based.<br><br> Chapter 2 presents interventions that can enhance clients' motivation, highlights their effective elements, and links them to the stages 2of 2change model. Developed by Miller and Rollnick, motivational interviewing is a therapeutic style used to interact with substance 2using clients that can help them resolve issues related to their ambivalence; this is discussed in Chapter 3. Enhancing Motivation for Change in Substance Abuse Treatment Executive Summary and Recommendations 7 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.<br><br> 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.<br><br> 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 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM 2IV] [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.<br><br> 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 2IV. Summary of Recommendations The Consensus Panel's recommendations, summarized below, are based on both research and clinical experience.<br><br> 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 substance 2using clients to initiate and continue substance abuse treatment.<br><br> A series of motivational approaches has been developed to elicit and enhance a substance 2using 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) f Motivation is multidimensional.<br><br> (2) f Motivation is a dynamic and fluctuating state. (2) f Motivation is interactive. (2) f Motivation can be modified.<br><br> (2) f The clinician's style influences client motivation. (2) f To incorporate these assumptions about motivation while encouraging a client to change substance 2using behavior, the clinician can use the following strategies: Focus on the client's strengths rather than his weaknesses. (2) f Respect the client's autonomy and decisions.<br><br> (2) f Make treatment individualized and client centered. (1) f Do not depersonalize the client by using labels like "addict" or "alcoholic." (2) f Develop a therapeutic partnership. (2) f Use empathy, not authority or power.<br><br> (1) f Focus on early interventions. Extend motivational approaches into nontraditional settings. (2) f Enhancing Motivation for Change in Substance Abuse Treatment Summary of Recommendations 8 Focus on less intensive treatments.<br><br> (1) f Recognize that substance abuse disorders exist along a continuum. (2) f Recognize that many clients have more than one substance use disorder. (1) f Recognize that some clients may have other coexisting disorders that affect all stages of the change process.<br><br> (1) f Accept new treatment goals, which involve interim, incremental, and even temporary steps toward ultimate goals. (2) f Integrate substance abuse treatment with other disciplines. (2) f Motivational approaches build on these ideas.<br><br> 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.<br><br> 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.<br><br> 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 2of 2change 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.<br><br> 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.<br><br> 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.<br><br> After a return to substance use, clients usually revert to an earlier change stage 2 2not 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.<br><br> 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 2minute brief intervention.<br><br> To understand what prompts a person to reduce or eliminate substance use, investigators have searched for the critical components 2 2the most important and common elements that inspire positive change 2 2of effective interventions. The Consensus Panel considers the following elements of current motivational approaches to be important: The FRAMES approach (1) f Enhancing Motivation for Change in Substance Abuse Treatment Transtheoretical Model of Change 9 Decisional balance exercises (1) f Developing discrepancy (1) f Flexible pacing (2) f Personal contact with clients who are not actively in treatment (1) f The FRAMES approach consists of the following components: F eedback 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.<br><br> f R esponsibility for change is placed squarely and explicitly with the individual. Clients have the choice to either continue their substance use behavior or change it. f A dvice about changing 2 2reducing or stopping 2 2substance use is clearly given to the individual by the clinician in a nonjudgmental manner.<br><br> It is better to suggest than to tell. Asking clients' permission to offer advice can make clients more receptive to that advice. f M enu of self 2directed change options and treatment alternatives is offered to the client.<br><br> f E mpathic counseling, showing warmth, respect, and understanding, is emphasized. Empathy entails reflective listening. f S elf 2efficacy or optimistic empowerment is engendered in the person to encourage change.<br><br> f Research has shown that simple motivation 2enhancing 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 2scale 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.<br><br> 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.<br><br> 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.<br><br> (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 2motivational 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.<br><br> (2) The Panel believes that motivational interviewing is supported by the following principles: Enhancing Motivation for Change in Substance Abuse Treatment Motivational Interviewing 10 Ambivalence about substance use and change is normal and constitutes an important motivational obstacle in recovery. (2) f Ambivalence can be resolved by working with the client's intrinsic motivations and values. (2) f The alliance between client and clinician is a collaborative partnership to which each brings important expertise.<br><br> (2) f 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) f The motivational interviewing style facilitates an exploration of stage 2specific 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.<br><br> The Consensus Panel recognizes that successful motivational interviewing will entail being able to Express empathy through reflective listening. (1) f Communicate respect for and acceptance of clients and their feelings. (2) f Establish a nonjudgmental, collaborative relationship.<br><br> (2) f Be a supportive and knowledgeable consultant. (2) f Compliment rather than denigrate. (2) f Listen rather than tell.<br><br> (2) f Gently persuade, with the understanding that change is up to the client. (2) f Provide support throughout the process of recovery. (2) f 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.<br><br> (2) f Avoid argument and direct confrontation, which can degenerate into a power struggle. (2) f Adjust to, rather than oppose, client resistance. (2) f Support self 2efficacy and optimism: that is, focus on clients' strengths to support the hope and optimism needed to make change.<br><br> (2) f 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: Ask open 2ended questions. Open 2ended 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) 1.<br><br> Listen reflectively. Demonstrate that you have heard and understood the client by reflecting what the client said. (2) 2.<br><br> Summarize. It is useful to summarize periodically what has transpired up to that point in a counseling session. (2) 3.<br><br> Affirm. Support and comment on the client's strengths, motivation, intentions, and progress. (2) 4.<br><br> Elicit self 2motivational statements. Have the client voice personal concerns and intentions, rather than try to persuade the client that change is necessary. (2) 5.<br><br> 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. Enhancing Motivation for Change in Substance Abuse Treatment Tailoring Motivational Interventions to the Stages of Change 11 To encourage change, individuals in the precontemplation stage must increase their awareness.<br><br> (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.<br><br> 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.<br><br> From precontemplation to contemplation According to the stages 2of 2change 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.<br><br> 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.<br><br> (2) f Establish rapport, ask permission to address the topic of change, and build trust. (2) f Elicit, listen to, and acknowledge the aspects of substance use the client enjoys. (2) f Evoke doubts or concerns in the client about substance use.<br><br> (2) f Explore the meaning of the events that brought the client to treatment or the results of previous treatments. (2) f Obtain the client's perceptions of the problem. (2) f Offer factual information about the risks of substance use.<br><br> (2) f Provide personalized feedback about assessment findings. (2) f Help a significant other intervene. (2) f Examine discrepancies between the client's and others' perceptions of the problem behavior.<br><br> (2) f Express concern and keep the door open. (2) f 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 broad 2based 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.<br><br> (1) Providing clients with personalized feedback on the risks associated with their own use of a particular substance 2 2especially for their own cultural and gender groups 2 2is a powerful way to develop a sense of discrepancy that can motivate change. Intervening through significant others Considerable research shows that involvement of family members or significant others (SOs) can help move substance 2using 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) f Enhancing Motivation for Change in Substance Abuse Treatment From precontemplation to contemplation 12 Encouraging the resolve of the client to change the negative behavior pattern (2) f Identifying the client's concrete and emotional obstacles to change (2) f Alerting the client to social and individual coping resources that lead to a substance 2free lifestyle (2) f Reinforcing the client for employing these social and coping resources to change the substance use behavior (2) f The clinician can engage an SO by asking the client to invite the SO to a treatment session.<br><br> 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) f Reinforce positive comments made by the SO about the client's current change efforts.<br><br> (2) f Discuss future ways in which the client might benefit from the SO's efforts to facilitate change. (2) f 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.<br><br> The SO must also support a client's substance 2free 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.<br><br> (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) Motivational interventions and coerced clients 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.<br><br> 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 2 2even though that opportunity was not voluntarily chosen.<br><br> (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.<br><br> (2) In addition to the standard practices for motivational interviewing (e.g., reflective listening, asking open 2ended 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.<br><br> (2) f Enhancing Motivation for Change in Substance Abuse Treatment Motivational interventions and coerced clients 13 Reframe a client's negative statement about perceived coercion by re 2expressing the statement with a positive spin. (2) f 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.<br><br> Techniques to use in decisional balancing exercises include the following: Summarize the client's concerns. (2) f Explore specific pros and cons of substance use behavior. (1) f Normalize the client's ambivalence.<br><br> (2) f Reintroduce feedback from previous assessments. (1) f Examine the client's understanding of change and expectations of treatment. (1) f Reexplore the client's values in relation to change.<br><br> (2) f 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.<br><br> Goal 2setting 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 2 2the goals of precontemplation and contemplation stages 2 2to using these strategies to strengthen a client's commitment and help her make a firm decision to change.<br><br> At this stage, helping the client develop self 2efficacy is important. (2) Self 2efficacy is not a global measure, like self 2esteem; rather, it is behavior specific. In this case, it is the client's optimism that she can take action to change substance 2use behaviors.<br><br> 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.<br><br> (2) The following can signal a client's readiness to act: The client's resistance (i.e., arguing, denying) decreases. (2) f The client asks fewer questions about the problem. (2) f The client shows a certain amount of resolve and may be more peaceful, calm, relaxed, unburdened, or settled.<br><br> (2) f The client makes direct self 2motivational statements reflecting openness to change and optimism. (2) f The client asks more questions about the change process. (2) f The client begins to talk about how life might be after a change.<br><br> (2) f 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) f 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.<br><br> When working with clients in the preparation stage, clinicians should try to Enhancing Motivation for Change in Substance Abuse Treatment From preparation to action 14 Clarify the client's own goals and strategies for change. (2) f Discuss the range of different treatment options and community resources available to meet the client's multiple needs. (2) f With permission, offer expertise and advice.<br><br> (2) f Negotiate a change 2 2or treatment 2 2plan and a behavior contract (2); take into consideration Intensity and amount of help needed f Timeframe f Available social support, identifying who, where, and when f The sequence of smaller goals or steps needed for a successful plan f Multiple problems, such as legal, financial, or health concerns f f Consider and lower barriers to change by anticipating possible family, health, system, and other problems. (2) f Help the client enlist social support (e.g., mentoring groups, churches, recreational centers). (2) f Explore treatment expectancies and client role.<br><br> (2) f Have clients publicly announce their change plans to significant others in their lives. (2) f 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 2oriented substance abuse treatment is a different domain and that motivational strategies are no longer required.<br><br> 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.<br><br> (2) Second, many clients remain ambivalent in the action stage of change or vacillate between some level of contemplation 2 2with associated ambivalence 2 2and 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.<br><br> 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) f Induct clients into their role in the treatment process.<br><br> (2) f Explore what clients expect from treatment and determine discrepancies. (2) f 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) f Investigate and resolve barriers to treatment.<br><br> (2) f Increase congruence between intrinsic and extrinsic motivation. (2) f Examine and interpret noncompliant behavior in the context of ambivalence. (2) f Reach out to demonstrate continuing personal concern and interest to encourage clients to remain in the program.<br><br> (2) f 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) f Support a realistic view of change through small steps. (2) f Acknowledge difficulties for clients in early stages of change.<br><br> (2) f Help the client identify high 2risk situations through a functional analysis and develop appropriate coping strategies to overcome these. (2) f Assist the client in finding new reinforcers of positive change. (2) f Enhancing Motivation for Change in Substance Abuse Treatment From action to maintenance 15 Assess whether the client has strong family and social support.<br><br> (2) f 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 2free sources of pleasure 2 2i.e., new reinforcers. (1) f Support lifestyle changes.<br><br> (2) f Affirm the client's resolve and self 2efficacy. (2) f Help the client practice and use new coping strategies to avoid a return to substance use. (2) f Maintain supportive contact.<br><br> (2) f 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.<br><br> (1) A competing reinforcer is anything that clients enjoy that is or can become 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.<br><br> 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 win out over substances over time.<br><br> 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 2efficacy (2) f Becoming involved in 12 2Step 2based activities and other self 2help groups (2) f Setting goals to improve their work, education, exercise, and nutrition (2) f Spending more time with their families and significant others (2) f Participating in spiritual or cultural activities (2) f Socializing with nonsubstance 2using friends (2) f Learning new skills or improving in such areas as sports, art, music, and other hobbies (2) f 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.<br><br> 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.<br><br> Instead, the Consensus Panel recommends that substance abuse treatment staff use a variety of tools to measure several dimensions of motivation, including (2): Self 2efficacy f Importance of change f Readiness to change f Enhancing Motivation for Change in Substance Abuse Treatment Measuring Client Motivation 16 Decisional balancing f Motivations for using substances f 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) f 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) f As an empowering brief consultation when a client is placed on a waiting list, rather than telling a client to wait for treatment (1) f As a preparation for treatment to increase retention and participation (1) f To help clients coerced into treatment to move beyond initial feelings of anger and resentment (2) f To overcome client defensiveness and resistance (2) f As a stand 2alone intervention in settings where there is only brief contact (1) f As a counseling style used throughout the process of change (1) f 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.<br><br> Researchers should consider some of the following questions when planning and developing future research studies (2): What are the active ingredients of motivational interventions? f Can motivational interventions be standardized and taught? f What types of clients are most amenable to motivational interventions?<br><br> f What types of outcomes can be defined and measured? f What clinician characteristics affect the outcomes of motivational interventions? f Are stage 2matched interventions appropriate?<br><br> f How do motivational interventions compare with other substance abuse treatments in terms of cost 2effectiveness? f How do culture and context influence the effectiveness of motivational interventions? f What kinds of training and support are needed to teach motivational interventions?<br><br> f How can motivational interventions be applied successfully to an even broader variety of problems, populations, and settings? f 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.<br><br> However, it soon became apparent that this approach constitutes an intervention in itself. Benefits have been reported with severely substance 2dependent populations, polydrug 2abusing adolescents, and users of heroin and marijuana. In Project MATCH, the largest clinical trial ever conducted to compare different Enhancing Motivation for Change in Substance Abuse Treatment Integrating Motivational Approaches Into Treatment Programs 17 alcohol treatment methods, a four 2session motivational enhancement therapy yielded long 2term overall outcomes virtually identical to those of longer outpatient methods.<br><br> 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 African 2American 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 2identified ethnicity and socioeconomic status as predictors of outcome.<br><br> 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.<br><br> Chapter 1 2 2 Conceptualizing Motivation And Change Motivation can be understood not as something that one has but rather as something one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy. There are, it turns out, many ways to help people move toward such recognition and action.<br><br> Miller, 1995 Why do people change? What is motivation? Can individuals' motivation to change their substance 2using behavior be modified?<br><br> Do clinicians have a role in enhancing substance 2using 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.<br><br> 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 2 2motivational interviewing 2 2with a transtheoretical stages 2of 2change model offers a fresh perspective on what clinical strategies may be effective at various points in the recovery process.<br><br> 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).<br><br> 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.<br><br> 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 seemed amenable to clinical advice or accepted the label 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).<br><br> Although there are reasons why this view developed that will Enhancing Motivation for Change in Substance Abuse Treatment Chapter 1 2 2 Conceptualizing Motivation And Change 18 be discussed later, this guideline views motivation from a substantially different perspective. 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. f Motivation is multidimensional.<br><br> f Motivation is dynamic and fluctuating. f Motivation is influenced by social interactions. f Motivation can be modified.<br><br> f Motivation is influenced by the clinician's style. f The clinician's task is to elicit and enhance motivation. f Motivation is a key to change The study of motivation is inexorably linked to an understanding of personal change 2 2a concept that has also been scrutinized by modern psychologists and theorists and is the focus of substance abuse treatment.<br><br> 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 2 2the 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.<br><br> Certainly, we believe that reasoning and problem 2solving 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 phenomenological theory of psychology, most familiarly expressed in the writings of Carl Rogers. In this humanistic view, an individual's experience of the core inner self is the most important element for personal change and growth 2 2a process of self 2actualization that prompts goal 2directed behavior for enhancing this self (Davidson, 1994).<br><br> In this context, motivation is redefined as purposeful, intentional, and positive 2 2directed 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.<br><br> 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.<br><br> 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 2 2or not to act. Enhancing Motivation for Change in Substance Abuse Treatment A New Definition 19 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).<br><br> 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.<br><br> 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.<br><br> 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 2image (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).<br><br> For example, many individuals are prompted to change and seek help during or following episodes of severe anxiety or depression. f 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).<br><br> f 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). f 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).<br><br> Helping clients see the connection between substance use and adverse consequences to themselves or others is an important motivational strategy. f Positive and negative external incentives also can influence motivation. Supportive and empathic friends, rewards, or coercion of various types may stimulate motivation for change.<br><br> f 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).<br><br> 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. Enhancing Motivation for Change in Substance Abuse Treatment Motivation is influenced by social interactions 20 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 2centered, supportive, and empathic style that uses reflective listening and gentle persuasion (Miller et al., 1993).<br><br> 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 2using 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.<br><br> 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

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