The path to deaddiction

Motivation plays an important role in treatment for substance abuse
The path to deaddiction

Motivation is an important first step towards any action or change in behavior. We’ve all heard the saying -- “You can lead a horse to water, but you can’t make it drink” – implying that people generally will not perform desired behaviors unless they motivate themselves to do so. This is particularly true in cases of addiction or substance dependence.

A person, who is dependent on a substance, may take a long time to seek help for treatment, and comply with it. There may be fluctuations in their levels of motivation or readiness to change, even when they have begun with the intervention. The motivation enhancement approach to substance abuse treatment rests on the premise that individuals have the choice of continuing or changing their behavior. A motivational approach allows persons to be active rather than passive, by insisting that they choose their treatment and take responsibility for changing themselves. If the substance users are free to choose, they feel less need to resist or dismiss the idea of a therapist or family members. When the individuals realize they are responsible for the change process, they feel empowered and more invested in it, and this results in better treatment outcomes.

Researchers have outlined a series of stages to describe the process that a person goes through when making a behavioral change. These stages also apply to substance users when they take steps towards addiction treatment.

Pre-contemplation: This is a stage, where the person is not considering change, is aware of some of the negative consequences of their behavior, and is unlikely to take action soon. Therefore, in the opening sessions, the therapist should establish rapport and trust with the person to explore events that led them seek treatment, appreciate the person's decision to come in for treatment and then mark out a possible direction for treatment.

A brief intervention approach is usually followed during this stage, where the person is assessed for their readiness to change. They are also educated about the negative consequences of substance abuse. For example, if a man is depressed, he might be told how his alcohol abuse may cause or exacerbate the depression. The therapist may also seek help from the person and a family member in eliciting a substance use pattern, functioning problems in life and family history.

Contemplation: In this stage, the person is aware of the pros and cons of substance abuse, but feels ambivalent about change and has not decided to commit to change yet. Some clinicians find it helpful to ask the individual to write out a two-column list of pros and cons. This can be done as homework and discussed during the next session, or the list can be written during a session. Helping persons change their extrinsic motivation to an intrinsic one will help them move from contemplating change to deciding upon an action.

Here, the clinician can help motivate the person. For example, they can help the person explore feelings of ambivalence and the conflicts between their substance abuse and personal values. The intervention might make the person more aware of the consequences of continued abuse and the benefits of decreasing or stopping substance use.

Preparation: Once the person has decided to change, they begin to plan steps towards recovery. The therapist and person's family need to motivate them on strengthening their commitment; encourage the person to share their desire to change to at least one other person, besides the therapist. This important gesture will help the person become accountable and stay aware of any inner resistance. A brief intervention might give the person a list of options for treatment to choose. The person can plan on going about seeking the treatment that is best for them.

It is extremely important, at this stage, to acknowledge the significance of the decision to seek treatment, support self-efficacy, affirm the person's ability to successfully seek treatment, help the person decide on appropriate, achievable action and explain that relapse should not disrupt the the person's relationship with the clinician. So, in a crux, persons in the preparation stage need help identifying potential change strategies and choosing the most appropriate one for themselves.

Action: This is a stage at which most formal treatment occurs. Here, the person tries new behaviors, but these are not yet stable. This stage involves the first active steps toward change, where the person may need help to carry out and comply with the change strategies. They require help executing an action plan and may have to work on skills to maintain sobriety. The role of the therapist and family members at this stage, is to acknowledge the person's feelings and experiences as a normal part of recovery. Be a source of encouragement and support by reinforcing the importance of remaining in recovery.

Maintenance: When the person finally moves to this stage, it means that they are able to establish new behaviors on a long term basis and need help, particularly for preventing relapse. A brief intervention could reassure, evaluate present actions, and redefine long-term sobriety maintenance plans. Despite the person’s continued efforts for abstinence, their motivation level is bound to fluctuate and they may have a relapse.

Relapse: In this phase, the person experiences recurrence of symptoms. They must now cope with the consequences and decide what to do next. At this stage, the family members should support and assist the person in finding alternate coping strategies. The therapist, meanwhile, will usually help the client re-enter the change cycle, commend any willingness to reconsider positive change and explore the meaning and reality of the recurrence as a learning opportunity.

Research has proved that there is a better treatment outcome when a significant other, i.e spouse, partner or a family member close to the individual, is involved in the deaddiction treatment process. They help mobilize the person’s inner resources to generate, implement, and sustain actions that subsequently lead to a lifestyle that does not involve substance use. The significant other is expected to move the person toward generating their own solutions for change. Nevertheless, it is important to remember that the ultimate responsibility for change lies with the individual.

Although a strong relationship is necessary, it is not sufficient to involve the significant other in motivational counseling. A suitable candidate for significant other-involved treatment is an individual, who supports the person's substance-free life and whose support is highly valued by the person.

Dr Garima Srivastava is a Delhi-based clinical psychologist with a PhD from the All India Institute of Medical Sciences.

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