Substance Use Disorders 425
and intends to start changing the substance using behavior within a month. The
user is very aware of the abuse, how it reached its current level, and available
solutions. Although users in this stage are prepared to change, some are more
ambivalent than others and may not implement the intended changes, essen-
tially reverting to the contemplation stage.- Action. The user actually changes his or her substance use behavior and en-
vironment. At this stage, others most clearly perceive the user’s intentions to
stop or decrease substance use; it is during this stage that family members and
friends generally offer the most help and support. - Maintenance. The user builds on gains already made in stopping or decreas-
ing substance use and tries to prevent relapses. Former substance users who do
not devote signifi cant amounts of energy and attention to relapse prevention
are likely to relapse all the way to the contemplation—or even the precontem-
plation—stage. Help and support from others, although important for mainte-
nance, are usually less forthcoming at this stage; friends and family members
usually mistakenly think that because the substance abuse has stopped or di-
minished, the former user is fi nished taking action. In fact, the former user must
actively prevent relapses, and help and support from friends and family mem-
bers is very important in this stage.
This description of the fi ve steps suggests a lock-step model: Each stage has dis-crete tasks that allow entry to the next in a linear progression. Research, however,
suggests that the stages are not mutually exclusive (Litrell & Girvin, 2002). For
example, most people in the stage of action have occasional relapses and engage in
the unwanted behavior, but they do not totally relapse into the old patterns. Also,
uninterrupted forward progress is not the most typical path. People often regress be-
fore moving forward again. For example, only 5% of smokers who think about quit-
ting go through all the stages of change within 2 years without a relapse (Prochaska,
Velicer, et al., 1994).
Motivational Enhancement Therapy
Motivational enhancement therapy(also referred to as motivational interviewing)
is specifi cally designed to boost patients’ motivation to decrease or stop substance
use (Hettema, Steeler, & Miller, 2005; Miller & Rollnick 1992). In this therapy, the
patient (referred to as client in the original transcript) sets his or her own goals re-
garding substance use, and the therapist points out discrepancies between the user’s
stated personal goals and his or her current behavior. The therapist then elicits the
user’s desire to meet the goals, overriding the rewarding effects of drug use. Thera-
pists using motivational enhancement therapy do not dispense advice or seek to
increase any specifi c skills; rather, they focus on increasing the motivation to change
drug use, discussing both positive and negative aspects of drug use, reasons to quit,
and how change might begin (Miller, 2001). Below is a transcript from a motiva-
tional interviewing session that illustrates how such treatment is used.
Client: So I see I need to cut down using cocaine, but it’s not as big a deal as
everyone seems to think. My husband nags me about it all the time, but
it’s not like he says.
Interviewer: Well, let me ask you this: What are the good things about using cocaine?
Client: What?
Interviewer: I’m curious what’s good about it.
Client: You mean like.. .?
Interviewer: What are the benefi ts in using it?
Client: (pause) There is nothing like the high I get from a snort.
Interviewer: (making a list) One good thing is the feeling that comes when you’re
high. Tell me more about that.
Client: Total euphoria. I feel like I can accomplish anything I put my mind to.
I’m Superwoman. Nothing bothers me, not even my whiny kids.Motivational enhancement therapy
A form of treatment specifi cally designed
to boost a patient’s motivation to decrease
or stop substance use by highlighting
discrepancies between stated personal
goals related to substance use and current
behavior; also referred to as motivational
interviewing.