Demographic and clinical correlates of client motivation among substance abusers.

Demographic and clinical correlates of client motivation among substance abusers. Understanding the role of motivation is a central element ofengaging clients in treatment or "starting where the clientis' a valued concept in social work practice. Both the knowledgein the area of motivational constructs and sensitivity to specificclients inform several questions that social workers must askthemselves: Does initial motivation matter? Should I work anydifferently with coerced clients than I do with voluntary clients? Isthis client ready, or motivated, to make changes? Definitive answers tothese questions are made difficult given ambiguous evidence about theimpact that motivation has on retaining clients in the services thatsocial workers offer and on outcomes related to those services. Perhaps nowhere is an understanding of motivation more importantthan in work with substance abusers. Almost three-quarters of socialworkers are involved with substance-abusing clients in some capacity,either in a referral-to-treatment capacity (61 percent) or in providingsubstance abuse services (19 percent) (O'Neill, 2001). In bothroles social workers are called on to assess clients' readiness tomake changes and modify their interventions accordingly. Unfortunately,a pre-existing bias regarding motivation of substance abusers isreflected in a belief that resistance and denial are endemic in theseindividuals. This bias is formalized for��mal��ize?tr.v. for��mal��ized, for��mal��iz��ing, for��mal��iz��es1. To give a definite form or shape to.2. a. To make formal.b. in the definition of alcoholism alcoholism,disease characterized by impaired control over the consumption of alcoholic beverages. Alcoholism is a serious problem worldwide; in the United States the wide availability of alcoholic beverages makes alcohol the most accessible drug, and alcoholism is bythe American Society of Addiction Medicine addiction medicineSubstance abuse The health field that addresses the needs of individuals addicted to substances of abuse including alcohol and illicit drugs–eg, cocaine, marijuana, heroin, and others; AM focuses on prevention and treatment and mental health (Morse & Flavin flavin:see coenzyme. flavinAny of a class of organic compounds, pale yellow biological pigments that fluoresce green. They occur in compounds essential to life as coenzymes in metabolism. , 1992): a primary, chronic disease with genetic, psychosocial psychosocial/psy��cho��so��cial/ (si?ko-so��shul) pertaining to or involving both psychic and social aspects. psy��cho��so��cialadj.Involving aspects of both social and psychological behavior. andenvironmental factors ... characterized by ... use of alcohol despiteadverse consequences and distortions in thinking, most notably denial[emphasis added (p. 1013) Social workers often succumb suc��cumb?intr.v. suc��cumbed, suc��cumb��ing, suc��cumbs1. To submit to an overpowering force or yield to an overwhelming desire; give up or give in. See Synonyms at yield.2. To die. to the view that without motivationthere is little the worker can do until the client "hitsbottom?' This suggests that unless clients enter the socialworker's office already motivated to change, no intervention iseffective until they suffer almost complete devastation in their lives. To help social workers understand their role in facilitatingsubstance abusers' participation in treatment, the present researchassessed the relationship between motivation, selected clientcharacteristics, and outcomes in two state-funded, managed careaddictions treatment programs. Client characteristics included gender,ethnicity, employment, measures of problem severity; and two measures ofcoercion coercion,in law, the unlawful act of compelling a person to do, or to abstain from doing, something by depriving him of the exercise of his free will, particularly by use or threat of physical or moral force. (voluntary participation in treatment and involvement with thecriminal justice system). We also examined the relationship betweenmotivation and clients' drug and alcohol severity six months aftertreatment. These findings are discussed in the context of social workersin the roles of referral agent and treatment provider. The implicationsof these findings for social work practice in managed care contexts arediscussed. MOTIVATION AND SUBSTANCE ABUSE Although the relationship between substance abuse client factors(including motivation), treatment attrition AttritionThe reduction in staff and employees in a company through normal means, such as retirement and resignation. This is natural in any business and industry.Notes: rates, and outcomes havebeen explored for decades, the results have been ambiguous. Simpson andhis colleagues have consistently shown a positive relationship betweenhigher motivation and better treatment retention and outcomes (Simpson,Joe, Rowan-Szal, & Greener, 1997). Their model of treatmentparticipation 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 UseProblems, Desire for Help, and Treatment Readiness--each composed ofseven to nine items, were used to obtain measures of perceived problemseverity, motivation, and readiness to seek treatment, respectively(Simpson & Joe, 1993). Among more than 300 methadone maintenance Methadone maintenance is a way of stabilizing someone who is addicted to heroin or has severe pain problems that are resistant to other drugs.Methadone Maintenance Treatment clients admitted to threeoutpatient treatment agencies, higher motivation, specifically desirefor help, was identified as a significant predictor of treatmentretention for more than 60 days. Social stability (marriage, employment,and few prior arrests), previous treatment experience, expectations forreducing future drug use, and higher methadone methadone(mĕth`ədōn', –dŏn'), synthetic narcotic similar in effect to morphine. Synthesized in Germany, it came into clinical use after World War II. It is sometimes used as an analgesic and to suppress the cough reflex. dose level were alsorelated to better outcomes (Simpson & Joe, 1993). In anothermultisite sample of 527 daily opioid opioid/opi��oid/ (o��pe-oid)1. any synthetic narcotic that has opiate-like activities but is not derived from opium.2. any of a group of naturally occurring peptides, e.g. users, pretreatment pretreatment,n the protocols required before beginning therapy, usually of a diagnostic nature; before treatment.pretreatment estimate,n See predetermination. motivation wasrelated to better engagement in treatment during the first three months(Simpson et al., 1997). In yet another study using the same threemotivational components, higher motivation at intake predicted highertreatment involvement scores, regardless of the type of counselingreceived (Pitre, Dansereau, Newbern, & Simpson, 1998). In a retrospective study retrospective study,a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. Shen Shen,in the Bible, place, perhaps close to Bethel, near which Samuel set up the stone Ebenezer. and colleagues used a single questionto assess motivation: How important is it for you to receive treatmentfor these (substance abuse) problems? (Shen, McLellan, & Merrill,2000). Results suggested that a more serious problem and a higherperceived need for receiving assistance were good predictors of betteroutcomes for alcohol and drug use, medical problems, and psychiatricproblems. Furthermore, it appeared that motivation was determined moreby patient's recognition of recent, rather than lifetime, problems. Others have found higher motivation at treatment entry to beunrelated to either participation in or better outcomes from treatment.Using a sample of 444 primarily male crack cocaine users, motivation didnot predict time spent in postprimary (aftercare) treatment or criminaljustice involvement or drug use severity six months after treatment(Rapp, Siegal, Li, & Saha, 1998; Siegal, Li, & Rapp, 2002). Themeasure of motivation used in both studies was Simpson andcolleagues' (1997) Readiness for Treatment Scale. Using theCircumstances, Motivation, Readiness, and Suitability Scale developedwith patients in therapeutic communities (DeLeon, Gerald, & David,1997), researchers were not able to find a [ink between motivation andsuccess in completing a course of detoxification DetoxificationDefinitionDetoxification is one of the more widely used treatments and concepts in alternative medicine. It is based on the principle that illnesses can be caused by the accumulation of toxic substances (toxins) in the body. among people addicted ad��dict��edadj.1. Physiologically or psychologically dependent on a habit-forming substance.2. Compulsively or habitually involved in a practice or behavior, such as gambling. to opioid substances (Franken & Hendriks, 1999). Similarly; amongheroin addicts receiving methadone maintenance treatment, motivation wasrelated to better attendance in counseling sessions but worse outcomesas me asured by positive urinalysis urinalysis(yr'ənăl`ĭsĭs), clinical examination of urine for the purpose of medical diagnosis. (Kludt & Perlmuter, 1999). Theseauthors suggested that this might have been because of a relationshipbetween higher motivation and more serious problems. Whereas addicts whohad more serious problems were more motivated, they had more difficultyin achieving positive changes. The apparently inconsistent findings about the relevance ofmotivation in predicting retention or outcomes are likely the result ofseveral factors, including different models of motivation, variabilityin how motivation was measured, and examination of the phenomenon indifferentpopulations of substance abusers. As expressed in the Simpson model,numerous client and treatment process variables may influence motivationor its measurement. For example, treatment motivation has been found tobe lower among Mexican American and African American African AmericanMulticulture A person having origins in any of the black racial groups of Africa.See Race. drug users thantheir counterparts in other ethnic groups (Austin & Gilbert, 1989;Espada, 1979; Longshore long��shore?adj.Occurring, living, or working along a seacoast.[Short for alongshore.] , Hsieh, & Anglin, 1993). Taking the viewthat ethnicity is not a fixed personal characteristic but rather "acombination of contextual, social and personal factors ..."(Longshore, Grills, Annon, & Grady, 1998), recent studies attemptedto understand the unique characteristics and experiences of people ofcolor Noun 1. people of color - a race with skin pigmentation different from the white race (especially Blacks)people of colour, colour, colorrace - people who are believed to belong to the same genetic stock; "some biologists doubt that there are important that relate to motivation. Several indices of ethnicit y,including ethnic identity, ethnic behaviors, ethnic affirmation,other-group orientation, mistrust of whites, perceived racism (self andsociety) and Africentric values have been examined for theirrelationship to motivation, with mixed results (Longshore et al., 1998).In general, these indicators were not found to have a relationship withmotivation. In bivariate bi��var��i��ate?adj.Mathematics Having two variables: bivariate binomial distribution.Adj. 1. analyses only perceived racism was correlatedwith motivation but did not remain significant when examined in aregression analysis In statistics, a mathematical method of modeling the relationships among three or more variables. It is used to predict the value of one variable given the values of the others. For example, a model might estimate sales based on age and gender. ; Africentrism was found to interact with problemrecognition in predicting motivation (Longshore et al., 1998). In asimilar study conducted with Mexican American abusers of opioidsubstances, the same authors found that individuals who scored high onethnic identity also demonstrated the highest motivation for treatment(Longshore, 1997). The factors or interaction of factors that mayexplain findings of poor motivation among people of color are stilluncertain and need clarification. METHOD This study was conducted as part of the Hoosier Assurance PlanSubstance Abuse Continuum of Care (HAPSACC) project, which was funded bythe Indiana Division of Mental Health. HAPSACC was designed to determinethe feasibility of evaluating, on a statewide basis, the substance abusecontinuum of care mandated by the Hoosier Assurance Plan (HAP HAP. An old word which signifies to catch; as, "to hap the rent," to hap the deed poll." Techn. Dict. h.t. ). TheHoosier Assurance Plan is Indiana's system for purchasing publiclyfunded mental health and addictions services and is designed to beanalogous to commercial managed care programs. Providers are paid on amodified case-rate basis to serve eligible consumers and are responsiblefor a full continuum of services, which for addictions includesindividual treatment plans, detoxification, crisis services, residentialservices, day services including intensive outpatient treatment, casemanagement, family support services support servicesPsychology Non-health care-related ancillary services–eg, transportation, financial aid, support groups, homemaker services, respite services, and other services , and services to prevent unnecessarytreatment and hospitalization hospitalization/hos��pi��tal��iza��tion/ (hos?pi-t'l-i-za��shun)1. the placing of a patient in a hospital for treatment.2. the term of confinement in a hospital. (DeLiberty, Newman, & Ward, in press). A cohort of substance abuse treatment clients was recruited fromeach of the two programs participating in the HAPSACC project. Theseprograms were in the downtown area of a large city in Indiana and wereselected for participation because of their different approaches totreatment. One program featured a short-term detoxification center and aprimarily residential, faith-based treatment modality treatment modalityMedtalk The method used to treat a Pt for a particular condition ; the other was anexclusively outpatient substance abuse treatment program that is part ofa large health care system with a wide range of psychiatric, medical,and other support services. The study population consisted of aconvenience sample of consecutive admissions at both participatingagencies between March and December 1998. Trained research assistantscontacted clients immediately after their initial contact with agencystaff, whereupon where��up��on?conj.1. On which.2. In close consequence of which: The instructor entered the room, whereupon we got to our feet. informed consents were read to clients after which theysigned them. Eligibility for the HAPSACC study was the same as that forthe HAP: an income of 200 percent or less of t he federal poverty level($16,480 for an individual), a DSM-IV diagnosis of substance abuse orsubstance dependency, and acceptance into the treatment program. Using Simpson's model we examined several client-centeredvariables that have been related to motivation and treatment outcomes.In addition to age, gender, and ethnicity we examined individualmeasures of crack cocaine use, previous treatment, and unemployment andcomposite measures of alcohol and drug use severity. Two measures,representing both a direct and more oblique measure of willingness toparticipate in treatment, were examined for their relationship tomotivation. The first, self-referral to treatment, asked clients whetherthey came to treatment on their own. The second question asked whetherthey were involved" with the criminal justice system at the time ofreferral--that is, being on probation, being paroled, or awaitingcharges. Two composite measures from the Addiction Severity Index (ASI ASI,n See Anxiety Sensitivity Index. ),Version 5 (McLellan et al., 1992), were used to assess problem severityin drug and alcohol use. Composite scores measured respondents'functioning in the 30 days before entering treatment and the 30-dayperiod before the six-month follow-up interview. These scores have beenshown to be reliable and valid indicators of substance abusers'functioning (McLellan et al.). Questions common to each domain includedthe number of days when participants experienced a particular problem ina domain (for example, drug use) in the past 30 days andparticipants' ratings on how troubled they were by the problem andhow important treatment or counseling was to them for that problem(McGahan, Griffith, & McLellan, 1986). Other questions, specific toeach domain, were used to create the composite score. For example, thedrug use severity composite score was computed from 13 questions thatdetermined the frequency and consequences of drug use in the past 30days. We used the composite scores for alcohol and drugs from bothintake and six-month follow-up interviews. Client motivation for treatment was measured by combining the threesubscales of the Texas Christian University Texas Christian University,at Fort Worth; Christian Church (Disciples of Christ); coeducational; opened 1873 at Thorp Spring, chartered 1874 as Add Ran Male and Female College. It assumed its present name in 1902 and moved to Fort Worth in 1910. Self-Rating Form (Knight,Holcom, & Simpson, 1994; Simpson & Joe, 1993). The threesubscales were combined to yield a single, overall measure of clientmotivation. This combined scale represents the continuum of identifyinga problem, having a desire for help, and being ready to accept andbenefit from treatment. Each subscale was also used to examine therelationship between specific components of motivation and selecteddemographic and problem severity measures. The Problem Recognition (PR)subscale is based on nine questions regarding various problemsattributed to substance abuse; the Desire for Help (DH) subscalecontains seven items that address substance abusers' perceived needfor change and interest in getting help. The Treatment Readiness (TR)subscale includes eight items measuring commitment level andexpectations about treatment. Responses to all the questions were scoredfrom zero to four on a five-point Likert scale Likert scaleA subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc (from "stronglydisagree" to "strongly agree"), higher scores reflecthigher motivation levels. Cronbach's alpha Cronbach's (alpha) has an important use as a measure of the reliability of a psychometric instrument. It was first named as alpha by Cronbach (1951), as he had intended to continue with further instruments. for the internalconsistency In statistics and research, internal consistency is a measure based on the correlations between different items on the same test (or the same subscale on a larger test). It measures whether several items that propose to measure the same general construct produce similar scores. of the combined scale was .84 and for the subscales asfollows: PR, .84; DH, .80 and TR, .77. A total of 263 individuals were recruited from the two agencies.The study sample was predominantly African American (70.6 percent) andunemployed (81.9 percent), and 55.6 percent were men (Table 1). Thesample had a mean age of 37 years and almost a high school education(11.9 years). More than one-half of the sample (56.4 percent) reporteduse of crack or cocaine as their most serious problem. Approximately 60percent of the participants had received help for their alcohol or drugproblems before the current treatment. Nearly 40 percent of the sampleindicated that they we re self-referred to treatment; more thanone-third (37.6 percent) of the respondents were involved with thecriminal justice system at intake, including being on probation, onparole, or awaiting charge, trial, or sentencing. One hundred thirty-three clients (51 percent) completed the initialand six-month interviews and were included in this study. Follow-upefforts were conducted by trained outreach workers using trackinginformation that clients provided at the time of the baseline interview.Because of the high attrition rate Noun 1. attrition rate - the rate of shrinkage in size or numberrate of attritionrate - a magnitude or frequency relative to a time unit; "they traveled at a rate of 55 miles per hour"; "the rate of change was faster than expected" for the six-month follow-up group. weassessed a potential source of response biases on the basis of the maindependent variables in the study. No difference was found between thecombined scale or the three motivational subscales at baseline for thosewho participated in the six-month interviews and those who did not (meanvalues: Motivation = 133.7; PR = 45.9, DH = 41.4, TR= 46.4 andMotivation = 134.2, PR = 46.5, DH = 41.6, TR = 46.0, respectively). Thesame pattern was found with ASI alcohol and drug severity scores atintake; those who participated in the six-month interviews had ASIscores at intake (mean values .32 for alcohol and .18 for drugs,respectively) similar to those who did not participa te in the six-monthfollow-up (.31 for alcohol and .17 for drugs, respectively). There werestatistically significant, but practically irrelevant, differences inage between the two groups (follow-up mean age was 37 years; nofollow-up was 35 years) and educational attainment Educational attainment is a term commonly used by statisticans to refer to the highest degree of education an individual has completed.[1]The US Census Bureau Glossary defines educational attainment as "the highest level of education completed in terms of the (follow-up meaneducation was 11.9 years; no follow-up was 11.2 years). No differencewas found between the two groups on race, previous treatment, legalstatus, employment status, and treatment referral. Relationships between client motivation and other selectedvariables at treatment admission were examined by zero-order correlationand list-wise multiple regressions. These analyses provided us withinformation on the relationship between potentially importantpretreatment factors and client motivation at intake. Moreover, therelationship between three baseline characteristics (motivation andalcohol and drug severity) and alcohol and drug severity scores atsix-month follow-up was also examined. RESULTS Treatment Entry Relationships Higher client motivation was significantly associated with highercomposite alcohol and drug severity scores (r = .399, p < .001 and r= .580, p < .001, respectively) (Table 2). The single variables thatare also markers for degree of impairment Impairment1. A reduction in a company's stated capital.2. The total capital that is less than the par value of the company's capital stock.Notes:1. This is usually reduced because of poorly estimated losses or gains.2. (unemployment, previous helpfor alcohol or drug problems, and crack or cocaine as most seriousproblem) were also related to higher motivation. As might be expected,self-referral to treatment was positively related to client motivation(r = .260, p < .00 1), and involvement with the criminal justicesystem was negatively related to motivation (r = -.190, p < .05).Education was the only demographic characteristic related to the unitarymeasure of motivation. The bivariate examination of each individual subscale and theeleven other variables revealed a pattern similar to that present withthe combined motivation scale (Table 2). All three subscales werepositively related to composite measures of severity and theunemployment variable. Self-referral to treatment and criminal justiceinvolvement were related to the desire for help and treatment readinesssubscales but, as might be expected, not to problem recognition. Onlytwo demographic variables were related to any of the subscales:educational level to DH and being African American to DH and TR. Four of the five measures of more severe impairment remained strongand statistically significant to motivation in a multiple regressionanalysis where all other variables were held constant: drug severity(r=.424; p<.0001); alcohol severity (r= .242; p< .0001); without ajob (r= .l44, p<.05); had received previous help for alcohol or drugproblems (r= .153, p<.05) (Table 2). This finding suggests thatclients who came to treatment with a high level of motivation were oftenthose who had more serious substance abuse problems and that demographiccharacteristics such as gender, age, education, and ethnicity were notrelated to motivation. When considering each subscale in regressionanalyses, only the two composite measures of severity were consistentlyrelated to all three subscale scores. Ethnicity and being male wererelated to the TR and DH scales, respectively. Outcomes Because of the re-occurring relationship between motivation andproblem severity at entry into treatment, we examined their relationshipto drug and alcohol use outcomes six months later. With only oneexception there was no relationship among the eight possiblecombinations of client motivation at intake and alcohol and drugseverity scores at follow-up (Table 3). No significant correlation wasfound between initial drug use severity and six-month follow-up; onlyalcohol use severity at follow-up was significantly related to the samemeasurement at intake (r= .33;p < .001). Previous help for alcohol ordrug problems (r = .20; p < .05) and crack cocaine use (r = -.18; p< .05) were significantly associated with alcohol severity atfollow-up. Discussion In this study of substance abusers entering managed care treatment,better motivation is consistently associated with the severity ofsubstance abuse problems at entry into treatment. Taken alone this wouldseem to support the belief that as substance abusers near their personallow point or "bottom" (that is, lose all that they have), theywill be more amenable to seeking help. Several other results point outthe risks of social workers ascribing undue significance to the maximthat substance abusers will not benefit from treatment until they havehit bottom. First, we found that when all factors are considered motivation, asmeasured by both a composite measure and separate subscales, was notrelated to two characteristics that are frequently seen as a visibleproxy for motivation. Neither the coercion that accompanies legal systeminvolvement (presumed lack of motivation) nor self-referral (presumedhigh motivation) were significantly related to measured levels ofmotivation. Hence, the tendency to create a picture of court-referred orself-referred clients as either not motivated or very motivated can setup detrimental expectations that do not seem to be supported by theevidence presented here. A second, and perhaps more noteworthy, finding was the lack of arelationship between measured motivation and outcomes six months later.Furthermore, the severity associated with motivation at treatment entrywas for the most part not related to clients' success six monthslater. Many clinicians and some researchers have offered therelationship among more severity, higher motivation, and better outcomesas support for the "bottoming out" concept, that is, only ifan individual has hit bottom will she or he be amenable to help (Shen etal., 2000). This study did not confirm that relationship, in that moreseverity and higher motivation did not predict better outcomes. Althoughextreme desperation in life circumstances may be related to somethingakin to motivation, clinicians must also remember that even if clientswith serious problems are motivated to seek help, they are still a groupwith more difficulties or barriers in recovery. Thus, the high levels ofmotivation they express at entry to treatment may not necessarily leadto positive outcomes after treatment, a relationship also foundelsewhere (Kludt & Perlmuter, 1999). No strictly demographiccharacteristics, including ethnicity, were related to motivation. Thislack of a relationship may have been a result of a simplistic sim��plism?n.The tendency to oversimplify an issue or a problem by ignoring complexities or complications.[French simplisme, from simple, simple, from Old French; see simple categorization of clients' ethnicity as "Caucasian" or"African American" the only measure of ethnicity available tous. A literal interpretation Noun 1. literal interpretation - an interpretation based on the exact wordinginterpretation - an explanation that results from interpreting something; "the report included his interpretation of the forensic evidence" of these findings suggests that bothreferring and treating social workers should be extremely cautious inassigning the label of "motivated" or "unmotivated."Under this premise social workers who refer individuals to treatmentwould not spend a great deal of time addressing motivational issues orperhaps debating the need for treatment. Instead, they would be free toconcentrate on the immediate concerns with which clients present. It isquite possible that in addressing client-identified needs for resourcessuch as housing and employment, staying involved in treatment and betteroutcomes will be enhanced, regardless of an emphasis on motivation. For social workers providing treatment to substance abusers, theimplications of these findings may be unsettling un��set��tle?v. un��set��tled, un��set��tling, un��set��tlesv.tr.1. To displace from a settled condition; disrupt.2. To make uneasy; disturb.v.intr. . If presentingmotivation is not related to outcomes, then it may not be necessary todirectly address denial or resistance, an activity that occupies a greatdeal of time in most treatment settings. When all things are considered,the issue of initial client motivation, especially withsubstance-abusing clients, runs the risk of diverting attention fromprogram factors that can affect client readiness to change. The findingsfurther suggest that something else is important in encouraging thesubstance abuser to stay involved in or drop out of treatment. Thechallenge for social workers and other treatment staff is to determinewhat it is about their intervention, rather than about the client, thatencourages participation and better outcomes. After all, the goal oftreatment, especially treatment provided by social workers, is to findtechniques that engage clients, especially clients who do not manifestwhat we call motivation. although not available in this study, numerousmeasures of the treatment process have been identified as having a rolein encouraging retention in treatment and better outcomes, includingquality of treatment, ease of accessibility, individualized in��di��vid��u��al��ize?tr.v. in��di��vid��u��al��ized, in��di��vid��u��al��iz��ing, in��di��vid��u��al��iz��es1. To give individuality to.2. To consider or treat individually; particularize.3. treatment(Condelli, 1993) and client-centered-strengths-based case managers(Rapp, 1997; Rapp et al., 1998). Our findings suggest a minimal role for motivation in predictingwho does well or poorly after treatment, but the limitations of thisstudy and the body of literature that presents a positive relationshipbetween motivation and outcomes must still be considered. First, ofcourse, it is possible that what we call "motivation" exists,or that it can be measured through more tangible characteristics, suchas problem severity. Even if motivation is a distinct characteristicthat can be measured, the methods used to do so may be different fordifferent populations of substance abusers. For instance, the measure ofmotivation used in this study was originally validated with a samplethat was more ethnically diverse and more involved with opioidsubstances than the present sample (Simpson & Joe, 1993). Also,comparisons of motivation as represented here by problem recognition,desire for help, and treatment readiness may not be comparable tomeasures in studies that use different conceptualizations. (for example,p erceptions of intrinsic or external pressure) (DeLeon & Jainchlll,1986). All of the possible explanations for these findings must beviewed in the context of the self-report nature of the responses in thisstudy. This is a particularly pertinent concern when consideringmotivation and reported use of illegal substances. Because of the uncertainty associated with motivation's role,social workers must be cognizant of the issue without being undulybiased by either its apparent presence or absence. The admonition Any formal verbal statement made during a trial by a judge to advise and caution the jury on their duty as jurors, on the admissibility or nonadmissibility of evidence, or on the purpose for which any evidence admitted may be considered by them. to"start where the client is" is useful in this regard. Thesocial worker must make every effort to help the client identify his orher own concerns and the areas that are important to them. In so doing,the worker, whether a referral agent or treatment provider, does nothingto create or strengthen resistance to the helping relationship. Whetheror not the client has the initial motivation to address substance abuseproblems directly, the social worker can help in solving problems thatare often typical of substance abusers. At the same time the willingness to accept a client'spresenting attitude need not lead the social worker to engage in atotally nondirective approach. A technique such as motivationalinterviewing Motivational interviewing refers to a counseling approach initially developed by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D. offers social workers a strategy that acknowledgesclients' motivation level (whatever it maybe), engages clients onthe basis of their presenting motivation, and mobilizes clients'interest in identifying problems that need to be resolved (Miller, 1985;Miller & Rollnick, 1991). The precepts of motivational interviewingare highly compatible with social work's basic values and can beused by social workers who are in a position to enhance clientwillingness to enter treatment by focusing on the needs that brings theclient to their services. Similarly, a more elaborate clinical strategy such as motivationalenhancement therapy (MET) can be used by social workers who areresponsible for substance abuse treatment. Based on motivationalinterviewing, MET is a four- or five-session brief intervention A Brief intervention is a technique, similar to an intervention, to help reduce alcohol misuse. It work in two ways: by getting people to think differently about their alcohol use so that they begin to think about or make changes in their alcohol consumption. thatprovides a highly structured framework for engaging clients indiscussions about their substance use and providing information toclients that may help them move toward constructive decisions (Miller,Zweb en, DiClemente, & Rychtarik, 1995). Social workers have a substantial obligation to engage the clientwith these types of techniques. This is especially true in a clinicalsetting affected by managed care or that operates with limitedresources, which is to say most treatment settings. The impetus to"get it right" relative to engaging the client effectively,whatever his or her referral status, previous history, or motivationlevel, is compounded when services are limited or rationed, becausethere may be no readily available second chance for obtaining treatment.Table 1Characteristics of Substance-Abusing Clients in Treatment (N = 133)Variable % nMale 55.6 74African American 70.6 94Unemployed at treatment entry 81.9 109Involved with the legal system at treatment entry 37.6 50Crack or cocaine as most serious problem 56.4 75Self-referred to treatment 39.8 53Received past help for alcohol/drug problems 59.4 79 M SDAge 37.4 8.3Years of education 11.9 2.2Motivation 133.7 24.4Drug use severity at intake .18 .15Alcohol use severity at intake .33 .27Drug use severity at six-month follow-up .04 .08Alcohol use severity at six-month follow-up .11 .15Table 2Correlation and Multiple Regression Coefficients of Motivation (Combinedand Subscales) and Other Predicting Variables Zero-order Correlation Coefficients (r)Variables at Intake Motivation PR DH TRMale -.14 -.11 -.13 -.11Age -.06 -.04 -.03 -.07African American .16 .04 .21 * .20 *Education (years) .17 * .14 .20 * .11Unemployed .29 *** .20 * .24 ** .34 ***Involved with the legal -.19 * -.06 -.22 * -.26 ** systemCrack/cocaine as most serious problem .18 * .13 .23 ** .23 **Self-referred to treatment .26 *** .14 .23 ** .35 ***Received help in the past .21 ** .29 *** .18 * .04Drug use severity .58 *** .54 *** .59 *** .38 ***Alcohol use severity .40 *** .35 *** .40 *** .29 ***[R.sup.2] Standardized Multiple Regression Coefficients ([beta])Variables at Intake Motivation PR DHMale -.13 -.09 -.14 *Age .03 .07 .08African American .10 -.01 .13Education (years) .12 .07 .13Unemployed .14 * .10 .07Involved with the legal .06 -.00 -.10 systemCrack/cocaine as most serious problem -.00 -.00 .03Self-referred to treatment .06 -.05 .01Received help in the past .15 * .23 .13 *Drug use severity .42 *** .45 *** .44 ***Alcohol use severity .24 *** .20 * .26 ***[R.sup.2] .49 .41 .51 Standardiz ed Multiple Regression Coefficien ts ([beta])Variables at Intake TRMale -.10Age -.08African American .17 *Education (years) .12Unemployed .21 **Involved with the legal -.09 systemCrack/cocaine as most serious problem -.05Self-referred to treatment .23 ***Received help in the past -.01Drug use severity .19 *Alcohol use severity .17 *[R.sup.2] .36NOTE: PR = problem recognition; DH = desire for help; TR = treatmentreadiness.* p< .05.** p< .01.*** p< .001.Table 3Correlation Coefficients of Motivation and Alcohol and Drug SeverityScores at Six-Month Follow-Up Severity Scores at Six-Month Follow-UpVariables at Intake Drug Use Alcohol UseMotivation .13 .10Problem recognition .22 ** .16Desire for help .08 .08Treatment readiness -.03 -.02Drug use severity at intake .09 -.04Alcohol use severity at intake .00 .33 ***Male -.08 .01Age -.11 -.03African American -.07 -.16Education (years) .04 .06Unemployed -.05 .03Involved with the legal system .01 .02Crack/cocaine as most serious problem .03 -.18 *Self-referred to treatment -.00 .02Received help in the past .09 .20 *** p<.01.*** p<.001. 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Motivation as a predictor ofearly dropout (1) On magnetic media, a bit that has lost its strength due to a surface defect or recording malfunction. If the bit is in an audio or video file, it might be detected by the error correction circuitry and either corrected or not, but if not, it is often not noticed by the human from drug abuse treatment. Psychotherapy psychotherapy,treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. , 30, 357-368. Simpson, D. D., Joe, G. W., Rowan-Szal, G. A., & Greener, J. M.(1997). Drug abuse treatment process components that improve retention.Journal of Substance Abuse Treatment, 14, 565-572. ABOUT THE AUTHORS Richard C. Rapp, MSW (MicroSoft Word) See Microsoft Word. , is project director and assistant professor,Center for Interventions, Treatment and Addictions Research, School OfMedicine, Wright State University 215 Medical Sciences, 3640 ColonelGlenn Highway See also: Alaska Route 1The Glenn Highway (part of Alaska Route 1) is a highway in the U.S. state of Alaska, extending 187 miles (301 km) from Anchorage near Merrill Field to Glennallen on the Richardson Highway. The Tok Cut-Off (q.v. , Dayton, Ohio Dayton is a city in southwestern Ohio, United States. It is the county seat and largest city of Montgomery County. As of the 2005 census estimate, the population of Dayton was 158,873. 45435; e-mail: richard.rapp@wright.edu. LiLi, PhD, is research scientist and associate professor, and Harvey A.Siegal, PhD, is director and professor, Center for Interventions,Treatment and Addictions Research, School Of Medicine, Wright StateUniversity Dayton, Ohio. Richard N. DeLiberty, MSW, is executive vicepresident for administration, Cummins Mental Health Center, Inc., Avon,IN. The research was supported by funding from the Indiana Division ofMental Health.