Motivation for Change and Alcoholism Treatment

Alcohol Research & Health, Spring, 1999 by Carlo C. Diclemente, Lori E. Bellino, Tara M. Neavins

Motivation plays an important role in alcoholism treatment by influencing patients to seek, complete, and comply with treatment as well as make successful long-term changes in their drinking. Both alcohol-abusing and alcohol-dependent people can be classified into different "stages of change" in terms of their readiness to alter their drinking behavior. Consequently, researchers have had to consider more seriously the role of motivation in the treatment of and recovery from substance abuse and to incorporate motivational enhancement strategies into treatment programs. KEY WORDS: motivation; addiction care; stages of change; AODD (alcohol and other drug dependence) recovery; treatment; AOD (alcohol and other drug) use behavior; behavioral change; AODU (alcohol and other drug use) treatment method; motivational interviewing; intervention; patient treatment matching; literature review

Motivation is an important first step toward any action or change in behavior. Sayings such as "You can lead a horse to water, but you can't make it drink" reflect the fact that people generally will not perform desired behaviors unless or until they are motivated to do so. Until recently, many alcoholism treatment professionals used this approach when treating alcoholic patients, contending that interventions were useless until the alcohol-dependent patient was self-motivated to change his or her drinking behavior.

During the past several years, however, researchers and clinicians have shown increased interest in the concept of motivation and the role that motivation plays in recovery from alcohol problems. Researchers have outlined a series of stages of change to describe the process that a person goes through when making a behavioral change. Those stages--pre-contemplation (i.e., not yet considering change), contemplation (i.e., considering change but not taking action), preparation (i.e., planning to change), action (i.e., making changes in one's behavior), and maintenance (i.e., changing one's lifestyle to maintain new behavior)--offer a new perspective on motivation and the process of behavior change (DiClemente and Prochaska 1998; Prochaska et al. 1992). Recognizing that patients vary in their motivation or readiness to change, researchers have designed interventions and treatments to enhance motivation (DiClemente et al. 1992; Higgins and Budney 1993; Miller and Rollnick 1991; Miller et al. 1992; Stitzer et al. 1993). This article examines the concept of motivation and its influence on behavior change, the role of motivation m alcoholism treatment, and treatment methods designed specifically to influence motivation.

STAGES OF CHANGE AND THE TRANSTHEORETICAL MODEL OF CHANGE

A number of studies (e.g., Carney and Kivlahan 1995; DiClemente and Hughes 1990) have demonstrated that people with alcohol and other drug problems who seek or participate in treatment differ significantly in their levels of motivation to change. Using an alcohol version of the University of Rhode Island Change Assessment (URICA) scale, DiClemenre and Hughes (1990) reported on the various stages of change among alcohol-dependent patients seeking outpatient treatment. Patients in the precontemplation stage were more likely to deny that they had a drinking problem, stating, for example, "I am nor the person with the problem. It does not make much sense for me to be here" or "As far as I am concerned, I do not have any [alcohol] problems that need changing." Conversely, patients in the preparation and action stages were more likely to admit that they had a drinking problem, stating, for example, "I am actively working on my [alcohol] problem" and "I have a problem and I really think I should work on it."

Using the same scale, Carney and Kivlahan (1995) found similar profiles among a large group of substance-abusing veterans. The same variations in motivation have been found in other treatment-seeking populations, including inpatient substance abusers (Isenhart 1994) and polydrug users in methadone maintenance treatment (Belding et al. 1995). Recognizing these differences was the first step to evaluating how differences in motivation affect participation in treatment programs and drinking outcomes.

Assessment of motivation presents a significant challenge. External influences and pressures, as well as internal thoughts and feelings, contribute to a persons motivation both to consider and implment a change in behavior (Cunningham et al. 1994). Evaluating a person's motivation requires assessment of the persons attitudes and intentions, confidence and commitment, and decisionmaking ability (DiClemente and Prochaska 1998). Researchers have attempted to measure motivation in several different ways, including querying patients about their intentions and plans to change and asking multiple questions reflecting the different stages of change (DiClemente and Prochaska 1998; McConnaughy et al. 1989; Miller and Tonigan 1996; Rollnick et al. 1992). Other researchers have attempted to develop measures of motivation for treatment (DeLeon et al. 1997; Simpson and Joe 1993).