Demographic and Clinical Correlates of Client Motivation among Substance Abusers
Rapp, Richard C., Li, Li, Siegal, Harvey A., DeLiberty, Richard N., Health and Social Work
Understanding the role of motivation is a central element of engaging clients in treatment or "starting where the client is' a valued concept in social work practice. Both the knowledge in the area of motivational constructs and sensitivity to specific clients inform several questions that social workers must ask themselves: Does initial motivation matter? Should I work any differently with coerced clients than I do with voluntary clients? Is this client ready, or motivated, to make changes? Definitive answers to these questions are made difficult given ambiguous evidence about the impact that motivation has on retaining clients in the services that social workers offer and on outcomes related to those services.
Perhaps nowhere is an understanding of motivation more important than in work with substance abusers. Almost three-quarters of social workers are involved with substance-abusing clients in some capacity, either in a referral-to-treatment capacity (61 percent) or in providing substance abuse services (19 percent) (O'Neill, 2001). In both roles social workers are called on to assess clients' readiness to make changes and modify their interventions accordingly. Unfortunately, a pre-existing bias regarding motivation of substance abusers is reflected in a belief that resistance and denial are endemic in these individuals. This bias is formalized in the definition of alcoholism by the American Society of Addiction Medicine (Morse & Flavin, 1992):
a primary, chronic disease with genetic, psychosocial and environmental factors ... characterized by ... use of alcohol despite adverse consequences and distortions in thinking, most notably denial [emphasis added (p. 1013)
Social workers often succumb to the view that without motivation there is little the worker can do until the client "hits bottom?' This suggests that unless clients enter the social worker's office already motivated to change, no intervention is effective until they suffer almost complete devastation in their lives.
To help social workers understand their role in facilitating substance abusers' participation in treatment, the present research assessed the relationship between motivation, selected client characteristics, and outcomes in two state-funded, managed care addictions treatment programs. Client characteristics included gender, ethnicity, employment, measures of problem severity; and two measures of coercion (voluntary participation in treatment and involvement with the criminal justice system). We also examined the relationship between motivation and clients' drug and alcohol severity six months after treatment. These findings are discussed in the context of social workers in the roles of referral agent and treatment provider. The implications of these findings for social work practice in managed care contexts are discussed.
MOTIVATION AND SUBSTANCE ABUSE
Although the relationship between substance abuse client factors (including motivation), treatment attrition rates, and outcomes have been explored for decades, the results have been ambiguous. Simpson and his colleagues have consistently shown a positive relationship between higher motivation and better treatment retention and outcomes (Simpson, Joe, Rowan-Szal, & Greener, 1997). Their model of treatment participation maps the complicated relationship between client factors, motivation, readiness to change, elements of the treatment process, retention in treatment, and desirable outcomes. Three scales--Drug Use Problems, Desire for Help, and Treatment Readiness--each composed of seven to nine items, were used to obtain measures of perceived problem severity, motivation, and readiness to seek treatment, respectively (Simpson & Joe, 1993).
Among more than 300 methadone maintenance clients admitted to three outpatient treatment agencies, higher motivation, specifically desire for help, was identified as a significant predictor of treatment retention for more than 60 days. …