The “Stages of Change” Model Prochaska, Norcross and DiClemente Precontemplation Contemplation Preparation Action Maintenance Relapse / Recycle
Evaluating Stages of Change Precontemplation (Denial) – “What problem? I’m not thinking about it.” Contemplation (Ambivalence) – “I wonder if I might have a problem? I’m thinking about it but not ready to decide anything yet.” Preparation / Determination (Admission) – “I have a problem.” Action (Taking steps / Making changes) – “I have a problem and I’m ready to do something about it.” Maintenance (Continuing what works) – “I’m stabilized and doing well. How can I support my ongoing recovery?” Relapse / Recycle (Trying again) – “I’m stabilized but have relapsed. How can I get back into active recovery?”
Precontemplation Stage: “Huh? What problem?” A Precontemplation-stage person is described as, “It’s not that they can’t see the solution. It’s that they can’t see the problem.” This stage of change has been given the label of “Denial” in times past. Treatment for someone in the Precontemplation stage would seek to engage them in the process of objectively evaluating whether they have a problem, and supporting movement along to the Contemplative stage of change.
Contemplation Stage: “Problem? Yeah... Action? Nah.” Contemplation-stage folks may know their destination, and even how to get there, but they are “not ready yet.” Someone in this stage of change may be ambivalent about doing anything about a problem that they can clearly identify having. Treatment for someone in the Contemplation stage would seek to engage them in the process of gaining motivation to address their problem, and supporting movement along to the Preparation stage of change.
Preparation Stage: “Almost ready to take action...” Preparation-stage individuals are planning to take future action, but are still making the final adjustments before committing. Someone in this stage of change may be working through the final obstacles that are getting in the way of taking action. Treatment for someone in the Preparation stage would seek to engage them in the process of taking action to address their problem, i.e., supporting movement along to the Action stage of change.
Action Stage: “Let’s get going” The Action Stage is described as the one in which individuals most overtly modify their behavior and surroundings to accomplish their goal. Someone in this stage of change is taking visible steps and making visible changes in order to work on their recovery. Treatment for someone in the Action stage would seek to assist them in taking all indicated steps to be successful in their recovery, and to support movement along to the Maintenance stage of change.
Maintenance Stage: “I’m in a good place, let’s keep it up!” In the Maintenance Stage, the focus is on consolidating gains and preventing relapse. Someone is this stage has an effective set of tools and “program of recovery” that they commit to continuing to practice. Treatment for someone in the Maintenance stage would seek to strengthen and increase their “tool kit” and to support ongoing recovery success.
Relapse / Recycle Stage: “How can I get back on track?” Relapse is often part of the chronic disease process, and recovering individuals need to be prepared to deal with it, including damage- control strategies. “Progress not perfection,” supports gentleness and freedom from shame, and “Progress not permission” emphasizes the importance of personal responsibility to stay active in one’s own recovery, even when slips or relapses occur. The Recycling aspect of relapse supports the view that recovery- strengthening lessons can be learned from relapse episodes – “The only bad relapse is a WASTED relapse”
ASAM Dimensions The American Society of Addiction Medicine’s Patient Placement Criteria for the Treatment of Substance- Related Disorders (2 nd Edition, Revised, 2001)
“Why bother learning about ASAM criteria?” To be better able to evaluate / assess the co- occurring substance abuse treatment needs of your clients To have a framework within which to inform PCPs, and to evaluate / assess progress in recovery To be able to “speak the language” of the substance abuse treatment system, so as to be better able to make effective and informed referrals, requests for treatment authorizations, and requests for treatment continuances
Leads to lack of control of behavior &/or emotion Symptoms can be controlled with treatment Physical, mental and spiritual disease Progressive illness w/o treatment Disease miscast as a moral issue Affects the entire family Depression & despair Shame and stigma Hereditary factors Biological Illness Guilt and failure Denial factor Incurable Chronic Dual Similarities / Common Ground
Determining “Level of Care” (Organized around 6 dimensions:) A.Intoxication / Withdrawal potential B.Biomedical conditions & complications C.Emotional / Behavioral conditions & complications D.Treatment acceptance / resistance E.Relapse / Continued use potential F.Recovery Environment
A.Intoxication / Withdrawal Potential 1.Risk of acute intoxication? 2.Risk of severe withdrawal symptoms? 3.Current withdrawal symptoms? 4.Available supports for ambulatory detoxification?
B. Medical Conditions & Complications 5.Current physical illness other than withdrawal? 6.Chronic illness present that would be exacerbated by withdrawal? (ex. hypertension) 7.Chronic medical conditions that affect treatment? (ex. chronic pain condition)
C. Emotional/Behavioral Conditions & Complications 8.Current psychiatric illness / behavioral or emotional problems that may complicate / distract from treatment? 9.Chronic psychiatric disorder that may affect treatment? (Axis I &/or II) 10.At risk for harming self?
C. Emotional/Behavioral Conditions & Complications 11.At risk for harming others? 12.Exhibiting delusions, disorientation, memory impairment? 13.Exhibiting repeated inability to control impulses?
D. Treatment Acceptance / Resistance 14.Client feels coerced into treatment, or actively objects to receiving treatment? 15.Client shows readiness to change? 16.Client willing to accept treatment recommendations?
D. Treatment Acceptance / Resistance 17.Client agrees with others that he / she has an addiction problem? 18.Client willing to comply with treatment to avoid negative external consequences? 19.Client is in internal distress, and self- motivated to change substance use?
E. Relapse / Continued Use Potential 20.Client is at immediate risk of ongoing drinking / drugging behavior? 21.Client able to recognize / understand skills to cope with addiction problems? 22.Client able to prevent relapse or continued use?
E. Relapse / Continued Use Potential 23.Client able to identify relapse triggers? 24.Client able to cope with cravings? 25.Client is able to control impulses to use?
F. Recovery Environment 26.Are client’s significant other or family members a threat to treatment engagement or success? 27.Is client’s school or work environment a threat to treatment engagement or success? 28.Does client have friendships that support an abstinent lifestyle?
F. Recovery Environment 29.Are there available financial / education / vocational resources that support an abstinent lifestyle? 30.Are there barriers to accessing treatment? (ex. transportation, childcare) 31.Are there mandates (legal, vocational, FIA, housing, etc) that may enhance motivation for the client to engage in tx?
Motivational Interviewing: A Brief Overview of some key tools / skills of Motivational Interviewing “When given a choice between changing and proving that it is not necessary, most people get busy with the proof” - John Galbraith
What is Motivational Interviewing? An Overall Person-Centered Approach that is: Collaborative Evocative Respectful Honoring of the Person’s autonomy, resourcefulness, and ability to choose
Relationship is the Key Change Component we can influence 40% - Client Attributes, Change & Change events + 30% - Relationship Factors + 15% - Hope and Expectation for the Future + 15% - The treatment approach / model that best matches the client’s style of change = 100% of how individuals change
Ambivalence and Change Talk “Lack of Motivation” is often ambivalence If you argue for change, the client is likely to defend the status quo Resist the “bait” to go for the good side of ambivalence Counsel in a way that invites the person to make the arguments for change Commitment language is the best predictor of actual / eventual change. It declares a future
D-A-R-N Common dimensions to ask about change: Desire - want, prefer, wish Ability - able, can, could, possible Reasons - specific arguments for change - Why do it? What would be good/better if...? Need - important, have to, need to, matter, got to...
Basic Skills to get things moving OARS Ask OPEN questions- not short answer, yes/no AFFIRM the person – comment positively about strengths,efforts, intention REFLECT what the person says – ”active listening” SUMMARIZE - draw together the person’s own perspective on change
Reflective Listening: Speak back what you think the person means You make a statement – not a question Levels of Reflection – Repeat - direct restatement of what is said – Rephrase - saying the same thing in slightly different words – Paraphrase - making a guess about meaning, usually adding something no said directly – Double sided - on the one hand…on the other
Eliciting Change Talk Ask for it – In what way would ________ be good for you? Balance – What would be good / not so good about __________? On a scale of 0-10 how important is ________? If things don’t change, what will be happening in _________ years?
Responding to Change Talk When you hear change talk, how can you support it? – Reflect it – state it back – Ask for examples – what things could help.. – Ask for more – what else – Affirm, reinforce, encourage
Giving Advice – with Permission ( More likely to listen when permission asked) 3 types of permission – Person asks for advice – You ask permission to give it – You preface your advise with permission to disagree or disregard (I don’t know if this makes sense to you…) It is often better to offer several options, rather than suggesting only one. Choice empowers
Responding to Resistance Don’t take the bait – – Don’t argue against resistance; it makes it grow! – Roll with it – Effective responses refocus on change: Simply reflect it back Overstate it a bit On the one hand I hear you…on the other hand.. Emphasize choice,autonomy
Strengthening Commitment Remember: Change talk – desire, – ability, – reasons, – needs increases commitment. Language signals behavioral change: I might, I could, I’ll try I will, I’m going to Is the obstacle confidence? I wish I could, I would if I could
Closing Summary “ Now let me see if I can go over the things you’ve shared.” Draw together the person’s desire, ability, reasons, values,and needs Briefly acknowledge reluctance – if there Summarize the person’s commitment strength – things that have been done in other areas of their life. If commitment is strong, elicit / negotiate change
Traps to Avoid Premature Focus – Don’t assume readiness to change Confronting Denial or “Taking Sides” Labeling – avoid stigmatizing/diagnostic driven responses Blaming – who’s at fault Question / Answer – pressure to move too fast to formal assessment tool Expert trap – moving to “fix” things so that the client can be passive
Six Steps For Substance Abuse Treatment Planning 1.Evaluate pressing needs (assessment & pre-plan), 2.Determine the individual’s level of motivation to address substance use problems (where is the person at in their recovery / documentation), 3.Select target behaviors for change (determine target treatment priorities, outcomes), 4.Determine intervention for achieving desired outcomes (steps for outcomes), 5.Choose measures to evaluate the effects of the interventions (steps for outcomes), and 6.Select follow-up times to review the plan and consumer success (steps for outcomes).
Guidelines for Defining & Writing Outcomes S pecific – clearly state the outcome statement & steps that are going to be taken to achieve this outcome. Personal statements are best. M easurable – How will you know you attained the outcome? A ction-oriented – Positive action towards outcome R ealistic – Is the goal where the person is at in their recovery? Is it obtainable? T ime-oriented – Time frames for completion
Guidelines for Defining & Writing Outcomes (Continued) 1.Write outcomes as they apply to the individual (i.e., too general to say: “individual is in denial”; be more specific: “individual blames his drinking on pressures at work”). It is important to get personal statements from the individual for the outcome statement; ask for clarification if needed. 2. Outcomes & steps need to be specific enough so that you, as well as other support people, can assess if the individual is achieving the outcome.
Guidelines for Defining & Writing Outcomes (Continued) 3.Ask yourself what behavior / action / attitude would help the individual to achieve the outcome. This suggests a strategy (“Individual to ask significant others if they have noticed any out of control drinking times not related to work. Individual will report back to group”) 4.Ask yourself if the outcomes & steps are: Clearly Stated Time limited Action-oriented (what are you going to do?) Realistic Able to be accomplished by the person responsible for this outcome – (AT THE STAGE OF RECOVERY WHERE THE PERSON CURRENTLY IS)
Change Plan Outline The changes I want to make are... The most important reasons why I want to make these changes are... The steps I plan to take in changing are... The ways other people can help me are... I will know that my plan is working if... Some things that could interfere with my plan are... What will I do if the plan is not working?
Let’s Develop a Person-Centered Plan: Ferdinand’s Vignette Discovery Phase Pre-contemplative Preparation stages of change Meet the person where they are at What are they a customer for? Recovery Phase Preparation Action Maintenance stages of change
Making the Person-Centered Plan a “Living” Document Involve the consumer and/or significant others in the developing and tracking of the person-centered plan. Inserting documentation in the therapeutic process The Person-Centered Plan should address consumer needs, not the consumer’s diagnosis