MOTIVATION FOR CHANGE. Written by Margje de Rooij, Relapse Prevention Specialist

Have you ever tried to change your behaviour? Did you make a New Year’s resolution to go to the gym more often, stop smoking, or diminish your use of social media platforms? If you have said “yes” to one of the above, you probably know that it is not that easy to change overnight. In the beginning, it might have been relatively easy to stick to new routines, having the motivation of why you wanted to make a positive change in the first place still fresh in your mind. After a while, however, most people experience some difficulty in keeping up with it, slowly slipping back into old patterns of behaviour.

If it is already hard for healthy adults to change behaviours, just imagine how hard it must be for people suffering from substance use disorders. Their substance use is often seen as the only way of lessening their mental suffering. And to make things even more complicated, there might be a physical as well as a psychological dependency that needs to be fought first.

Substances - underlying causes

Substance use is serving a function. You can say that using alcohol and drugs are maladaptive coping skills to deal with unpleasant underlying feelings caused by, for example, depression, anxiety or trauma. Nobody chooses addiction. It is a behaviour process that develops over time, and it can come in many forms, shapes, and sizes. In some cases, the individual's ability to function is not really impaired or still good enough, while in other cases, a downward spiral can occur quite rapidly, having their lives impacted on so many levels that everything seems dark. In both cases, however, it is very hard to witness a loved one suffer from the sideline and feel helpless.

Most likely, the environment picks up on the problematic use much quicker than the individual. Appeals to seek help are met with resistance and denial, and frustration grows. It is hard to try to motivate someone to seek help if they have the belief that there is nothing wrong with what they are doing. Though it might be true that you cannot force someone to change, you do have the power to plant seeds. Let this blog help you look at behaviour differently as a first step in planting that seed by creating change talk.

Addictive behaviour: a (different) behavioural perspective

Functional behavioural analysis (FBA) might be a helpful way to look beyond the problem behaviour or substance use and understand human behaviour on a different level. FBA is a widely accepted method in child psychology in which difficult situations are analysed and categorised into antecedents (A), behaviour (B), and consequences (C). In other words, what happened beforehand, what did the person do, and what were the effects of that behaviour. This way, you can identify potentially triggering situations, reflect upon your own behaviour, and guide the child towards more helpful ways of regulating.

Now you might argue that ABC analyses already have a place in Relapse Prevention, and you would be absolutely right. Trigger recognition plays a large role in this type of therapy. What is interesting, however, is that this model goes one step further by linking it to a function. According to behavioural psychologists, human behaviour serves one (or more) of the following functions: Escape, Attention, Tangibles, and Sensory. Below you will find an overview of what these functions entail, linked to examples of how this might look like for someone with substance use disorder. The behaviours used in this example might not always be directly linked to alcohol or drug use but might be correlated.

Escape: Behaviours to try to avoid, delay or end something unpleasant (e.g. taking a drink before giving a presentation to calm the nerves, not picking up the phone when someone calls).

Attention: Behaviours that desire a response from someone. In substance use disorders, this can take the form of manipulation (e.g. lying about events to create an excuse for drinking that is being validated by others, drinking to fit in and being liked by others).

Tangibles: Behaviours to try to gain something physical (e.g. begging for money (to buy alcohol or drugs), engaging in casual encounters at the bar to get free drinks, engaging in (high-risk) sexual behaviours).

Sensory: Behaviours that make us feel good (about ourselves) or replace discomfort (e.g. drinking to numb or cope with the (mental or physical) pain, getting high).

Why is it important to understand the function of behaviour?

Developing an understanding of why someone is behaving the way he or she is might increase your comprehension of how the addiction monster is working. It helps you to see that the person and their behaviour are not one and the same. We might see the alcohol, the drugs, or the gambling, and all the associated risk factors, but there lies suffering underneath. Although FBA focuses on the here and now, it might give you a glimpse of unmet needs, pain, trauma or fear, or at least open a little window to explore this further. When the individual is ready to accept treatment and engage in therapy, he or she might open up and start to explore these experiences and challenges in a safe place, such as during relapse prevention sessions with a therapist.

I think we are all aware that substance abuse is not only affecting the life of the individual. Living with someone who is struggling with alcohol, cocaine, or other drugs is hard and difficult to cope with. Most of us do our best to help and support loved ones, creating a patient and stable environment and/or offering assistance with daily life. We can, however, also unintentionally enable alcohol or drug abuse. The identification of high-risk situations and other risk factors can not only help us to identify or determine what lifestyle factors play a role but also when it is time to set healthy boundaries. It might teach us to consider taking a step back or put our own mental health first. Looking after yourself is always highly encouraged, but maybe even more so when the relationship is under severe stress.

How to create change talk?

So let's cut to the chase and focus on what you probably wanted to know all along. How can you motivate someone and encourage introspection with the ultimate goal of creating change, seeking support, and embracing recovery? My answer would be: through active listening skills, gentle questioning, and sharing your experiences from a place of love, care, and empathy.

This might sound easy, but active listening, remaining calm and being reflective at the same time is an art. It is not only about hearing what is being said but also about what has not been said. It is about comprehending the content and the context, making sure you understand what it must be like for the other person. In other words, how it would be to walk in their shoes. Quite likely, this triggers some unpleasant feelings in yourself. Becoming defensive, however, might be counterproductive, so try to keep an open mind.

Making a start

You could start the conversation by asking the following:

I am worried about your alcohol/drug use. I have the feeling that you find it difficult to keep away from it, and I am worried that it is negatively impacting your life and (mental) health. How do you see this?

It could be that this is very difficult for your loved one to hear, and your concerns might be met with denial or resistance. One way of reacting could be by saying that you hear what he or she is saying but that you have observed X, Y, and Z that is making you concerned. Guiding your loved one towards ambivalence might then be the first step towards abstinence. Don't forget that ambivalence is a necessary first step in making change possible in the first place, allowing the possibility of abstinence and recovery to exist. Creating feelings of hope or faith can already be a huge step forward. Having a glimpse of positive expectancies might increase feelings of self-efficacy as well.

Having an overview of examples or situations ready can guide you when you are ready to instigate change talk. When sharing your observations of high-risk situations and your feelings, use "I" messages and try to refrain from blaming or shaming your loved one. Make sure that the other person knows that your worries are motivated by love and care.

If it turns out to be very difficult to follow or understand the other person's way of thinking, it can be helpful to ask clarification questions. Leading questions should ideally be avoided, so try to keep them open. Just remember the 5 W's + H framework when formulating a question. Start your sentence with Who, What, Where, When, Why or How.

Motivational Interviewing

Rollnick & Miller (2013) wrote a fantastic book called Motivational Interviewing: Helping People Change. Motivational Interviewing training is well known for its effectiveness in substance use disorder recovery settings. Research has shown how valuable Motivational Interviewing is in overcoming challenges and resistance. Families can easily use the range of skills to improve communication and improve the likelihood of helping the person to overcome blocks to support that often occur.

One of the tools highlighted in the book by Rollnick & Miller (2013, pp. 171-173) is the use of the DARN technique. DARN stands for Desire, Ability, Reasons, and Needs. Formulating open questions using this technique might help you to counsel your loved one in a neutral, judgement-free way, addressing substance use or other high-risk situations from different angles. Maybe one of the examples below can help you when you are in the process of preparing an intervention:

Desire: How would you like things to change?

Ability: What changes do you think you would be able to make?

Reasons: What would be a reason to stop drinking?

Needs: How important is it for you to change your drug use?

Keep the faith, and don't give up

Remember that change doesn't come easily, and try to be patient. Recovery is a long process. If your intervention did not result in the desired outcome, it does not mean that the attempt was a failure. Progress comes slowly, and accepting social support takes courage. In the meantime, it is important to self-care. Monitor your own emotional states and look after yourself. Remember what is being said in the aeroplane: put on your oxygen mask first before helping others.

Literature:

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Preparing People for Change (3rd ed.). New York: Guilford Press.