The Causes of Change and No-Change in Substance Users’ Talk During Motivational Interviewing in the Probation Service in Finland

Study Setting and Data Collection

The data for this study were collected during the counseling sessions of the Finnish Probation Service. The Probation Service is a part of the criminal sanctions system of Finland. It is in charge of the enforcement of community sanctions and other activities related to sanctions served outside imprisonment. Community sanctions consist of the supervision of conditionally sentenced young offenders, juvenile punishment, community service, and the supervision of parolees. In community sanction work, particular attention is paid to evaluating substance use problems and in increasing the use of programs for substance users.

In 2007, a Swedish MI-based program called Beteende–Samtal–Förändring (BSF [Behavior–Interviewing–Change]) developed specifically for the needs of the Probation Service was also introduced in the Finnish Probation Service. The BSF program is a structured adaptation of MI where the employees of the Probation Service are expected to use MI techniques to motivate clients to change their behaviors with regard to offending and substance use. The employee acts as a counselor who helps clients to enhance their intrinsic motivation to change by working in a client-centered but directive manner. The BSF program is a semistructured five-session MI-based intervention focusing on drug use and criminal behavior. During sessions, the client is encouraged to elicit change talk and to discover his or her personal strengths. The client is also encouraged to examine different stages of change, to see the positive side of change, to explore the discrepancies between his or her values and current behavior, and to map his or her social network (Farbring & Berge, 2006; Farbring & Johnson, 2008).

Even though the criminal justice context is perhaps not an ideal environment for MI due to its oppressive, directive, and autonomy-limiting features (Ashton, 2005), the BSF program is designed to be as open as possible for client autonomy. In the current study, the clients were under probation, but they were volunteers in this particular MI program. The counselors were not required to report to legal authorities of any possible drug use revealed by the client.

The analyses presented here are based on viewing 98 videotaped BSF sessions and studying the transcripts of these sessions. This database involves the first two counseling sessions of 49 client–counselor pairs. These initial sessions were chosen because previous research (Horvath & Greenberg, 1994) has shown that the key moments for bonding with treatment are often restricted to the very first sessions. What happens in that time frame is decisive for what follows. The sessions were approximately 1 hr long and were conducted in urban settings in Finland. They were videotaped in 12 probation services offices between 2007 and 2009.

The approval for the study was obtained from the Finnish Criminal Sanctions Agency, and informed written consent was obtained from all participating clients and MI counselors. The participants were volunteers, and they were not provided any incentives for their participation. All clients who participated in this study had either an alcohol or a drug use problem. Their problematic substance use was the main reason why they were in the BSF program. All counselors were trained to use BSF and MI techniques to motivate the clients of the Probation Service to change.

Sample

In this article, the focus is on the analysis of clients’ talk about the causes of change and no-change. It is concentrated on the 47 substance-using clients (out of 49) whose change talk utterances concern the factors of change and/or no-change. The data from the 47 clients were elicited in both of the videotaped sessions. Thus, the data source is 94 one-hour-long sessions. The average age of these clients was 35 years (SD = 11.3 years, range = 19-62 years), and they were predominantly male (44, 94%).

Analysis

The procedure used to analyze the data involved several steps. The first one consisted of identifying the client’s goal with regard to their use of alcohol and drugs (e.g., to quit or cut down the use of alcohol, cannabis, or other drugs). Identifying the goal was fairly easy because it was usually discussed at the beginning of the videotaped sessions. The second step was to search for sequences that are central from the point of view of this goal.

The third step was to code the client’s change-related talk in these central sequences. The author was trained on coding clients’ change talk in two workshops given by professor Paul Amrhein (Columbia University) who has developed the change talk coding system, in the spring of 2008 and 2009. It has also consulted with Dr. Theresa Moyers (University of New Mexico) on issues concerning MI sessions coding. Also, Dr. Carl Åke Farbring who has developed the BSF program has provided some advice. Two commonly used coding manuals (Amrhein, 2007; Miller, Moyers, Ernst, & Amrhein, 2008) were relied on for coding this change talk. After some experimentation with the data, the core ideas of these manuals were combined by focusing on the following categories of client’s change talk utterances:

There were both positive and negative change talks. In positive change talk utterances, the client moves toward his or her goal, whereas in negative change talk (sustain talk) utterances, he or she talks about his or her intention to maintain the status quo.

The fourth step was to identify all the causal attributions from the sequences of the client’s change talk. A main focus of the analysis was to explore the factors that substance-using clients believe have facilitated or hindered their change. Thus, as the fifth step, only the clients’ causal attributions with regard to substance use and change or no-change were chosen to analyze.

The data were subjected to an analysis inspired by semiotic theory. This study is part of the ongoing research project, which was launched with an aim to apply Charles S. Peirce’s theory of signs. The basic idea of the project is to map the semiotic features of MI sessions that appear to predict clients’ willingness to change their addictive behaviors. According to Peirce, the action of signs (semiosis) is a triadic process whose components include sign, object, and interpretant. Any sign is in a triadic relation with an object and an interpretant. The first division focuses on the sign as such. Peirce calls this division into qualisigns, sinsigns, and legisigns. The second division focuses the reference of signs to objects. Peirce calls this division into icons, indexes, and symbols. The third division focuses on the interpretation of signs and on the effects of signs on interpreters. Peirce calls this division into rhemes, dicents, and arguments (Liszka, 1996; Peirce, 1965; Short, 2007).

The second division of signs is relevant from the viewpoint of this study because it concerns the sign’s relation to its object. Icons refer to their object by means of similarity (e.g., an image, a diagram, or a metaphor); indexes refer by means of contiguity, causality, or by some other actual connection (e.g., smoke as the sign for fire); and symbols refer by means of a habit, convention, disposition, or law (e.g., words and numbers; Liszka, 1996; Peirce, 1965; Short, 2007). In this article, by applying Peirce’s theory, it is concentrated on the causal relations between signs and their object: The client’s utterance about causal attributions of change and no-change was explored as an indexical sign. So, as the sixth step, it was investigated change and no-change as an effect or object, and analyzed what kind of causes (indexical signs) the clients attribute to change and no-change.

The Causal Attributions of Change

The factors that the clients believe have facilitated their change can be divided into five categories of causes:

The clients frequently mentioned family members and friends as the indexical signs of change. These significant others were seen as an important social cause of positive substance use change. In these cases, spouses, parents, children, other relatives, and friends appear as significant and supporting factors in the resolution of substance use problems. The forms of family and friend support vary between clients. The support encourages the change but is also controlling, thereby preventing and restricting the substance use. Extract (1) shows a case where a client with a goal of reducing his cannabis use reflects on his addiction in response to a counselor’s request. The client brings up the role of his parents. In the client’s change talk, they appear as the cause of reducing drug use. In certain situations, the parents make him restrict the use of cannabis. The client gained support from the parents by their placing strict limits on cannabis use during visits to their home. In a Peircean sense, the parents are indexical signs that refer to reducing substance use as an effect.

(1) Yes, I think that I am dependent on cannabis, even though there are no withdrawal symptoms from it. However, I am dependent on cannabis in such a way that it is really difficult to refuse when it is offered. But there have also been situations in which I have been able to refuse it. My parents have banned me visiting them when I’ve been smoking. If you have been offered cannabis when you have been about to go to your parents’ house, you are able to say “no.” So, I am still able to refuse to smoke. Perhaps I’m not totally addicted [to cannabis]. (Client 1, age 25, male, change talk category: ability to change)

Several of the clients reported that intrinsic personal properties, such as the strength of mind, willpower, decision, intrinsic motivation, desire, and the ability for hard mental work, are factors that they believe have enabled their positive change. Extract (2) involves the client with a goal of maintaining abstinence. In the session, the counselor has raised the question about the supporting factors of this goal (“What are the personal factors that make you believe in yourself?”). The client’s response indicates that she thinks that her own decision, her own motivation and desire, and her willpower are the highly significant causes of her abstinence.

(2) Well, at least my obstinacy is one. When I decide something, I will do it . . . motivation to stay sober comes from your own head. It does not help if other people want me to stay sober. It does not keep me sober. (Client 18, age 22, female, change talk categories: ability to change, desire to change)

The clients quite frequently mentioned the importance of bodily health as a factor in the positive change of substance use behavior. In these cases, the clients reported that anxiety for their health and worries about their body are a cause of change. In other words, worry about bodily health is a sign that refers to reducing or cutting down substance use as an effect in the clients’ talk. Extract (3) is taken from a session with a client with a reduced drinking goal. The client has told that he has used drugs in the past but does not now. In the extract, he talks about his experiences with substance use. Here, health seems to be a particular cause of change.

(3) It [using drugs] causes you bad health, and possible, leads to withdrawal symptoms. I have experienced them also . . . it does not do any good . . . I have seen how much damage the drugs are doing. I have experienced it myself. [The use of drugs] changes a person—you are not yourself. It affects your mental health and your health in general. There is a risk of developing many serious infectious diseases . . . well, my health should be better . . . I know how much alcohol can damage your liver. Therefore, I reduced the drinking, but still I think that I drink too much . . . It makes me sick. (Client 48, age 29, male, change talk categories: problem recognition, reason to change, taking steps)

Some clients talked about their working and studying life situation. These clients reported that unemployment and inactivity are a reason to drink or use drugs. If they got a job or study place, they could reduce the use of alcohol and other drugs. In these cases, a job and study place is an indexical sign that refers to reducing substance use as an effect. Examples of this kind of change talk appear in Extract (4). In the extract, a client with a goal of reducing his drinking brings up the significance of unemployment in the changing of his drinking habits. The finding of a job seems to be important factor that would help the client succeed in reaching his goal.

(4) This situation in life should be repaired. You should get a job or study. You drink a couple of times a week. It is precisely because there is nothing to do. That’s why you drink. You wouldn’t drink if you had something to do. You wouldn’t drink if you had a job. (Client 6, age 39, male, change talk category: reason not to change)

Religion was also suggested as a factor that facilitated change. It was discussed how religion and faith can play an important part in the resolution of substance use problems. In Extract (5), the client with a goal of maintaining abstinence brings up the significance of her faith as a facilitator of change.

(5) Faith gives me the strength. Faith fills the vacuum that left when drug use is terminated. It gives strength to live without drugs . . . to become a believer was the good decision. I decided to follow Jesus, I decided to change my life . . . when I was in prison, there were my enemies. When they began to threaten me, I was afraid to die. I was afraid that I might be killed in the prison. I knew that I couldn’t get to heaven without faith. It was the starting point. I wanted to get to heaven. (Client 18, age 22, female, change talk categories: ability to change, commitment to change, reason to change)

The Causal Attributions of No-Change

The factors of no-change/status quo in clients’ change talk utterances can be divided into five categories of causes:

The importance of alcohol and drug culture as a factor in the substance abuse was frequently mentioned by the clients. In these mentions, weekends, party culture, holidays, and summertime appeared as important factors. In particular, the weekend was seen as a significant cultural factor in the substance use. In these change talk utterances, weekend is strongly connected with the use of alcohol. It could be seen that this is reflection of Finnish and even wider substance use culture, in which particularly alcohol is mostly consumed on the weekends (Allamani, Hope, Burne, Room, & the ECAS Research Team, 2002; Heath, 2000; Mustonen, Metso, & Mäkelä, 2010; National Research and Development Centre for Welfare and Health, 2001). Extract (6) is taken from a MI session between a counselor (CO) and a client (CL) with a reduced drinking goal. During the session, the counselor and the client have discussed the client’s ability to reach his goal. The counselor brings up the topic of weekend and asks the client to tell about his experiences. We can see that the client doubts his ability to reach his goal of reducing drinking. This doubt is related to the experienced need to drink, and it appears when the client talks about weekend.

(6) CO: Does it depend on the day . . . whether it is weekend or not . . . Are there some days when you feel like it [reducing drinking] can succeed? On the other hand, are there . . .

CL: Yeah, that’s the way it really is. There’s an internal clock for the weekend. It can truly be noticed.

CO: Quite so. So, the risk that you suddenly find yourself standing next to the beer shelves in a supermarket, that risk always increases before weekend.

CL: Well, yeah, yes.

(Client 20, age 42, male, change talk category: incapability to change)

Significant others were often seen as a significant social cause of substance use by the clients. In particular, friends and family members are connected with substance use. In these cases, significant others appear as an obstacle or a threat to change. An example of an obstacle to change–type change talk appears in Extract (7). It involves a client with a goal of reducing his drinking. He says that he has taken steps toward change, but the external setting is not ideal from the point of view of reaching the goal. It is difficult for the client to reduce his drinking because his circle of acquaintances drinks plenty of alcohol. The family’s drinking habits, particularly those of the father and uncle, expose the client to the risk of a relapse. In this case, the family seems to be a cause of drinking even if the client also gets support from his father.

(7) Although progress has been achieved, the drinking problem is not completely gone . . . sometimes [I] also drink too much because there is drinking in my social circle. It seems that my uncle also has quite a serious drinking problem. My father has some kind of drinking problem but we have helped each other. But sometimes we have relapsed together too. (Client 48, age 29, male, change talk categories: taking steps toward change, incapability to change)

Several of the clients reported that personal properties such as suggestibility, obstinacy, asociality, self-indulgence, and lack of self-control, social tools, and problem-solving skills are a cause of their substance use. Extract (8) shows a case where a client with a goal of reducing her drinking brings up the significance of her obstinacy. This obstinacy seems to be an important cause that threatens the goal. Because of this personal aspect, it is difficult for the client to change her drinking habits.

(8) If I decide that I want to drink, nobody can prevent me. I will go even through the wall. No one can stop me. I am so stubborn that no one can change my mind. (Client 22, age 52, female, change talk category: problem recognition)

A number of clients talked about their working life situation. In these cases, unemployment and pressures in working life appear as a cause of substance use. Examples of a change talk where unemployment as an indexical sign stands for substance use as an effect appear in Extract (9) and also in Extract (4). In Extract (9), the goal of the client is to quit using drugs. He mentions idleness and unemployment as the main causes of his drug use.

(9) There are those days when you feel really bored. Today, for example, was such a risk of relapse. . . . Now there is a feeling that you need to get to work or something. . . . [I] have awakened a desire to get to work. In the past when I have been bored, I used drugs. But, now I have started to think about alternatives [to drug use]. I want to go to work, get money and do something else [than to use drugs to manage boredom]. (Client 12, age 42, male, change talk categories: problem recognition, desire to change)

Lifestyle was also mentioned by quite several of the clients as a cause of no-change. It was discussed how habits and routines can play an important part in life and substance use. In these cases, lifestyle, habits, and routines appear as the cause of substance use. In Extracts (10) and (11), the clients doubt their ability to reach the goal of reducing their use of alcohol or amphetamine. In a Peircean sense, these change talk utterances about lifestyle are indexical signs that refer to substance use as an effect.

(10) Drinking is a familiar way of life to you. It is surely not easy to give it up. (Client 2, age 27, male, change talk category: incapability to change)

(11) So [I] have a desire for change, but on the other hand, it [the use of amphetamine] has been a way of life for so long. (Client 28, age 34, male, change talk category: incapability to change)