He who has a why to live can bear almost any how.
— Nietzsche

Editor’s note: This is the third in a series of five articles that concentrate on what
is working in the trenches for frontline counselors.

Any addiction counselor can relate to this scenario of rapid-fire questioning from clients lacking motivation. Regardless of where the client rests on the addictions continuum, interventions are strategies to assist in motivating, through non-judgmental and honest dialogue, a client to both accept treatment and stay in it. These strategies measure a willingness to change, while lowering the veil of resistance by building relationships and creating safe treatment environments built on trust.

The modern intervention concept is predicated on the belief that clients have the internal resources and capacities to help themselves, but will need guidance from counselors to identify and define the life they really want when compared to a life consumed by an addictive disorder. Non-confrontational, non-adversarial interventions help clients maintain their dignity in times when they may have lost a job, money, and/or their family. Much as the initial act of an addictive disorder is the result of a conscious act, so too is the first act of treatment for that addictive behavior.

This article will review six proven addiction recovery tools that have helped counselors successfully assess the utility of intervention and manage the process of change, as defined by Prochaska and DiClemente’s Transtheoretical Model (Prochaska & DiClemente, 1982). Drawing off of a common theoretical and practical body of clinical work that advocates a non-confrontational approach to addiction recovery, each of these recovery tools — matching interventions with motivation, motivational interviewing, structured family intervention, the Love First intervention, computer-assisted interventions, and Inspiring New Beginnings — embodies a unique treatment technique that mitigates defense mechanisms while harnessesing client motivation.

Matching interventions with motivation
When clients come to the counselor’s doorstep with varying degrees of motivation, it is the counselor’s responsibility to match this motivation with a treatment plan. This moment of interaction, be it the first client-counselor interview, a desperate first phone call made by the client in a moment of despair, or a dialogue in the midst of a family-sponsored intervention, is a critical juncture in the overall treatment plan. To recommend an intervention approach the client is not ready for can actually decrease the client’s overall motivation to change (Coombs, 2001).

The Transtheoretical Model (also called Stages of Change) pioneered by Prochaska and DiClemente (1982) is widely accepted as a critical benchmark for determining a client’s motivation for treatment (Howatt, 2000a). Prochaska and DiClemente understood that at each of the six stages of change, a client weighs the pros and cons of adopting a new behavior. Despite the harmful side effects of an addictive substance — be it food, alcohol or tobacco, giving up the euphoria of an addictive behavior can be a lot to ask of most clients. For most behavioral changes, the “sacrifices” are immediate, but the benefits are not. Prochaska and DiClemente call this weighing of pros and cons “decisional balance” (p. 1102). For counselors to help clients move along the treatment continuum, a focus point is to tip the scales: to have the pros of treatment outweigh the cons of addiction.

An innovative contribution of the Stages of Change model is its emphasis on maintaining change. The model recognizes that relapse is common in the recovery process. But instead of viewing relapse as a failure (i.e., the behavior change didn’t last), the Stages of Change model uses relapse as an opportunity to teach the client how to sustain change more effectively in the future. Divided into six stages of change, each with its own set of pros and cons, the model allows the addiction counselor to apply harm reduction and treatment strategies in the appropriate context (see Table 1). Once the addiction counselor is aware of the client’s present level of motivation, the appropriate intervention can be determined and implemented. As Bishop (2001) reports, this model is a powerful and effective strategy for assessing motivations and also stresses the importance of matching the client’s treatment with the client’s level of motivation.

Motivational interviewing
Old school, aggressive, confrontational treatment styles often can drive clients away from accepting treatment. In contrast, motivational interviewing (MI), developed in the early 1980s by William R. Miller, is a directive, client-centered counseling style. Congruent to, yet ultimately moving beyond the scope of, Roger’s core conditions of empathy, congruency, and unconditioned positive regards (Rogers, 1961), MI elicits behavioral change by helping clients explore and resolve ambivalence. Compared with this style of nondirective counseling, traditional treatment approaches tend to be too action-oriented, or at least too quick to press clients into focusing primarily on making changes in their lives.

MI is based on the philosophy that “motivation for change occurs when people perceive a discrepancy between where they are and where they want to be” (Miller, Zweben, DiClemente, & Rychtarik, 1992, p. 8). MI counselors work to develop this perception and the accompanying motivation by helping clients examine the discrepancies between their current behavior and future goals. The counselor facilitates this process through empathy, which involves seeing the world through the client’s eyes, thinking about things as the client thinks about them, feeling things as the client feels them, and sharing in the client’s experiences. Expression of empathy is critical to the MI approach. When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others (Coombs, 2001).

Asking clients to share their experiences with you in depth allows you to assess when and where they need support, and what potential pitfalls may need to be focused on in the change-planning process. Importantly, when clients perceive empathy on a counselor’s part, they become more open to gentle challenges by the counselor about lifestyle issues and beliefs about their addiction. Clients become more comfortable fully examining their ambivalence about change and less likely to defend ideas such as their denial of problems and reducing use versus abstaining. In short, the counselor’s accurate understanding of the client’s experience facilitates change.

Used in group or in one-on-one sessions, there are several different MI strategies for increasing client motivation, such as: Drinker’s Check-up (Cameron 1995), Motivational Enhancement Therapy (MET) (Miller, 1994), brief motivational interviewing (Miller 2002), and brief interventions (Webb 1999). Dunn (1996) developed the acronym GRACE to capture the application of MI concepts in a clinical environment. G stands for Gap between the client’s present situations and where the he or she would like to be; R is for Rolling with Resistance and refers to never taking the client’s resistance head on (a critical element is to not confront the client, which requires flexibility); A is for argue not, regardless of the client’s responses and not be to drawn into debates; C is for Can do, all clients have the potential and skill to begin to make change; and E is Expressing empathy.

One concern with MI is that clients often have mixed feelings about making changes. The counselor who presses a client to make changes immediately risks evoking client resistance, promoting premature termination from counseling, and/or encouraging clients to overlook the internal and external factors that may promote relapse even following initial success in change attempts. The MI framework fits best with a view that client change is efficiently enhanced through positive reinforcement. With positive reinforcement, clients find themselves in a treatment environment that rewards trying new behaviors that fit into defined long-term goals rather than continuing addictive behaviors that provide short-term gain at the cost of long-term loss. For more information on this strategy, see Rollnick and Miller (1995) and visit the MI Web site, www.motivationalinterview.org.

Structured intervention
Developed by Dr. Vernon E. Johnson more than 25 years ago, structured intervention (SI) is a motivational strategy where family members present the client with concerns and evidence of an addictive disorder. The principle objective of the intervention is to use family member(s) as the conduit for self-realization of an addicted state/condition. Johnson’s study (1973) noted that alcoholics did not seek help until a serious crisis, or collective crises, brought them to treatment. Only when their impenetrable defenses (denial system) collapsed under the weight of their alcohol-related problems did they seek treatment. Ironically, the very crises that the enabling family and friends often tried to help the alcoholic avoid were what ultimately motivated the client to seek treatment (Johnson, 1973, pp. 3-5). In this treatment approach, two things need to happen: First, family, friends, colleagues, and employers have to learn that keeping the problem a secret exacerbates the illness. Secondly, in order to get the client to treatment before he or she hits “bottom,” a crisis has to be precipitated. In other words, the client’s so-called “bottom” has to be raised so that he or she can see it. “Unlike hitting bottom, structured intervention provides a safe way for the denial to be broken” (Wheeler, 2001, p. 31). The idea is simple: no more secrets. What SI does, in effect, is present reality to the client in a receivable way. It forces a crisis, whereby treatment becomes the logical alternative.

SI’s are led by an addiction counselor who works with the family. The family members involved have a close relationship with the addicted family member and are willing to be a part of a loving, supportive intervention. Thoroughly planned and implemented in a safe and loving manner, SI’s include the following five components:

1. Decision to undertake the intervention
2. Education in which an understanding of the client’s defense mechanisms is reached
3. Preparation for the intervention by using learning tools, such as role play
4. Action/Intervention in which the actual intervention is completed
5. Post-intervention follow up.

SI’s generate strong emotions that are often difficult for the family member to ignore or dismiss. Provided family members adhere to the plan in a loving and patient manner, the results are often favorable, meaning that the client accepts treatment, which is the main goal of the SI. For more information, see Johnson Institute-QVS, Inc. (1996) and Global Interventions, www intervention.net.

Love First intervention
Similar to structured interventions, the Love First intervention is a strategy for implementing a family intervention. This intervention, created by Jeff and Debra Jay (2001), is explained in detail in their book Love First. The goal of this intervention is to motivate a family member to enter treatment. This approach dispels two myths: that interventions must be adversarial and that a client must hit rock bottom. Families worrying about the harshness of forcing loved ones into treatment often overlook the option of effectively asking them to enter treatment by implementing a loving, family intervention. When the role of love takes center stage during an intervention, most families never have to resort to using tough love, in which an adversarial position is taken to place the client in treatment.

A foundation of this intervention is that love breaks through denial first. Planning meetings are used to prepare answers to all the client’s objections, to line up the many details of treatment, and to unify the group. Most importantly, letters are prepared with a specific format and content, which will provide a script for the intervention. By writing everything down in advance, the intervention team can be confident that they will remain in control of the situation, delivering a powerful message to the individual with a substance abuse problem.

Each family member will write a letter to the client expressing their concerns as to how their addiction has negatively impacted them and their relationships with friends and family. Each letter will express the love and caring the family member has and “why” treatment is needed. A critical element to redirect blame and shame in the letter is how addiction is a disease. Once the letters are prepared, intervention timelines can be established. The most powerful part of the intervention happens when the letters are read aloud stating “why” the client needs to go into treatment that day. Emotions will run high and the sheer volume of unconditional love and concern often cuts through denial. The goal of this intervention is to arrive at a universal truth, that the client has an addictive disorder, and bring that construct out into the open. The authors of this treatment plan base the effectiveness of this intervention on research from Hazelden that reports that the success rate for persons going into treatment is the same regardless if they go on their own or are ordered (Jay & Jay, 2001). The bottom line is that it does not matter who is the driving force in getting a client into treatment.

This intervention has proven successful for families, older adults, and corporate executives. The authors report that families who understand the Love First process have been successful without the assistance of an addiction professional. However, in some cases, family members may request the assistance of an addiction specialist. The authors also recommend that if a family cannot find a local addiction specialist who is familiar with the Love First model, they can contact Hazelden (www.hazelden.org) and the Betty Ford Center (www.bettyfordcenter.org) for a list of interventionists who will travel the nation to do family interventions. For more information, see Jay and Jay (2001) and the Love First Web site, www.lovefirst.net.

Computer-assisted interventions
One consistent variable when exploring client motivation is that, in the end, the client is always in charge of his own motivation. For example, in the addiction field, there is a body of research that is exploring what is called spontaneous remission. In a study by Sobell, Sobell, and Toneatto (1990), the majority of excessive drinkers gave up alcohol without expert help. They were unaided and made the choice on their own to stop. Biernacki (1986) found the same results with the very challenging heroin-addicted population. Subsequently, clients, when provided with the appropriate tools, can self-monitor their recovery program.

With computers as commonplace as telephones and a level of computer literacy that now transcends generations, it is logical that the computer has been enlisted into the world of addiction treatment. Computer-assisted interventions can be used for: prevention, education, support, and self-monitoring. For clients who have access to a computer and possess basic Internet skills, this recovery tool provides clients with real-time information and interventions.

With interactive technology, even if clients lack basic technology skills, computer-assisted interventions are so effective that counselors can teach clients to learn them, at a local library or other location with computer resources. Rice (2001) explains that computer-assisted interventions have been highly effective and successful in educating clients about their addictive disorder and that they can provide the client with objective feedback. Regardless of the addictive disorder, there is the potential to design an application to assist a client, provided he or she is motivated to participate. Computers have an unlimited capacity for specialized treatment design, as well as a new kind of scheduling flexibility, because the Internet provides access from many locations at any time.

Computer-assisted interventions have many applications: they help monitor chemical use, offer learner-friendly environments, provide questions and information for self-reflection, promote the key concept that motivation is internally determined, provide clear advice on matters to do with addictions (e.g., educational facts), suggest behavioral options, provide a positive feedback support network, and offer written feedback to increase efficacy of interventions (Rice, 2001).
Similar to bibliotherapy, self-directed intervention based on reading materials, computer-assisted programs provide the client with a self-paced resource. Its success depends directly on the client’s motivation and effort. Current research suggests that clients will obtain better treatment outcomes using computer-assisted interventions than those who do not (Coombs, 2001). The key to using this recovery tool is to determine the needs of the client and then to either find or design an application. For example, Stop That and Be Healthy: Smoke Cessation Journal (Howatt, 2000b) is an electronic journal that the client can use for monitoring daily progress as well obtain educational information. It is a database program that has daily templates to fill in and readings to complete. Alleman (2002) and Anthony (2003) both provide counselors with frameworks that minimize the anxiety of working “online.” The power of computer programs, databases, and the Internet provides the addiction counselor, with minimal training, an unlimited, dynamic, adaptable resource for treating addictive disorders.

Four helpful Web sites for addiction counselors to refer their clients to for computer-assisted help are: www.nasarecovery.com/interventionkit.html; www.wellnessnet.com/tests.htm; www.egetgoing.com/lowB/index.asp; and www.habitsmart.com. See also: Coombs (2001).

Inspiring New Beginnings
The Inspiring New Beginnings model, which I have developed as an addiction counselor and used for the past five years as a teacher of addiction studies, provides a frame of reference for the beginning, middle, and end of the process of introducing a new client to treatment planning. Grounded in theoretical underpinnings of MI, person centered therapy (Corey, 1995), and microskills (Ivey, Pedersen, & Ivey, 2000), this dynamic approach allows for the insertion of multiple recovery and assessment tools that are appropriate for specific circumstances along the treatment continuum. This four-stage process is linear, in that each stage is to be completed before moving forward in the treatment process. This process is called Inspiration For Life Change because addiction counselors have the potential for inspiring change. The goal is to inspire change — not force it. In the end, clients are always in charge of motivation; the counselor must not be a deterrent but a resource for inspiration.

Stage 1 — Discovery of Personal Resources and Needs. First, the addiction counselor assesses: service match, client needs, scope of addictive disorder, risk-management issues, desired outcomes and goals, present medical and/or psychosocial stressors, and the point of entry to treatment (who is initiating the service). This stage is a critical part of treatment and can be done on the phone or in person. First impressions set the tone of the counseling environment. The addiction counselor must always be non-judgmental and display a professional, caring presence.

Stage 2 — Orientation. The goal in this stage is to assess the client’s present level of motivation. The motivation assessment model I recommend is the Transtheoretical/Stages of Change model (for more information, see page 33). It is important to begin treatment where the client is on the continuum. There are no magic wands in treating addictions. Treating clients with addictive disorders is complex and challenging because no two clients are exactly the same.

Stage 3 — Foundation for inspiration. In this stage, the counselor uses Roger’s person-centered therapy core conditions (empathy, unconditioned positive regards, and congruency) and microskills questioning techniques (e.g., clarification questioning) to assist the client to start to self-evaluate her present situation. Dunn (1996) has created the acronym OARS (open-ended questioning, affirmations, reflective listening, and summaries) that captures the means to establish the foundation for inspired reinforcement of the client’s treatment options in a safe and supportive environment. This foundation helps clients make internal cognitive shifts. The client can explore questions such as: will my present lifestyle lead me to where I want my life in 20 years (Bishop, 2000). Internal shifts assist the client to align present realities with internal wants. Until the client determines internally what he or she is “doing and not doing” is a problem, he or she will not be inspired to take action.

Stage 4 — Acting on Inspiration. Once the client begins expressing inspiration, this will open the door of opportunity for taking action (e.g., the client determines that he or she needs to go detox). Obviously, the exact choices will depend on the client’s present situation. The best action plans are ones that the client has fully bought into and is motivated to carry out. The client’s ownership of the action plan is paramount.

For further information, visit the following Web sites — for microskills training, www.emicrotraining.com/microskills4.html; for Person Centered International, www.personcentered.com/contents.htm; and for inspiration, quotes, and insights, www.insightquotes.com/gateway.htm.

Many paths to a common goal
Each of these motivational treatment tools strives to define the responsibilities of the client in the treatment process. Determining the level of motivation a client brings to any behavioral changes is the cornerstone in developing treatment strategies. These strategies allow the client and the counselor to manage expectations in a process that can be as difficult and arduous as it can be rewarding. While it is important for the counselor to be cognizant of the client’s state when committing to a treatment strategy, the counselor must also be aware of his or her own strengths and weaknesses. The counselor’s ability to draw upon a litany of treatment strategies allows both the client and the counselor to work effectively within a common treatment methodology toward a common goal, recovery.

William A. Howatt, PhD, EdD, ICADC, a Post Doc at the UCLA School of Medicine, serves on the faculty at Nova Scotia Community College and is Co-editor (with Robert H. Coombs) of the Wiley Book Series on Treating Addictions. He can be reached via e-mail at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it .

References
Alleman, J. R. (2002). Online counseling: The Internet and mental health treatment. Psychotherapy: Theory, Research, Practice, Training, 39, 199-209.
Anthony, K. (2003). The use and role of technology in counseling and psychotherapy. In S. Goss & K. Anthony (Eds.), Technology in counseling and psychotherapy: A practitioner’s guide (pp. 13-35). Houndmills: Palgrave Macmillan.
Biernacki, P. (1986). Pathways from heroin addiction: recovery without treatment. Philadelphia, PA: Temple University Press.
Bishop, F. M. (2001). Managing addictions: Cognitive, emotive, and behavioral techniques. Northvale, NJ: Jason Aronson.
Cameron, D. (1995) Liberating Solutions to Alcohol Problems: Treating Problem Drinkers without Saying No. Northvale, NJ: Jason Aronson.
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Howatt, W. A. (2000b). Stop that and be healthy: Smoke cessation journal. Kentville, NS: A Way With Words.
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Johnson, V. E. (1989). Intervention: How to help someone who doesn’t want help. Minneapolis, MN: Johnson Institute.
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Sobell, L. C., Sobell, M.B. & Toneatoo, T. (1991). Recovery from alcohol problems without treatment. In Heather, N., Miller, W.R. & Greeley, J. (Eds.) Self-control and addictive behaviors, pp. 198-242. New York, NY: Maxwell Macmillan.
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This article is published in Counselor,The Magazine for Addiction Professionals, December 2003, v.4, n.6, pp. 32-38.

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