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Substance Abuse
Nov 21st, 2005
The Stages of Change Model, and Treatment Planning
Kevin Glavin – Kent State University
[email protected]
Agenda
1.
Background & Introduction to the Stages of Change Model
(Transtheoretical Model)
2.
The Stages of Change: Key points
3.
Practical Applications
• Teaching treatment planning and case conceptualization.
• Educating clients about the stages of change
4.
Moving through the stages: Techniques and Strategies
5.
Determining a Client’s Stage of Change using SOCRATES
Background Information
• During his college years, psychologist James Prochaska, Ph.D., lost his
father to alcoholism and depression. Prochaska reported his father’s
mistrust in psychotherapy and his refusal to participate in counseling.
This served to fuel Prochaskas’ research into substance abuse and the
stages of change.
• Prochaska and DiClemente started their research by observing
individuals who had over come an addiction to nicotine. They discovered
change occurred on a continuum and identified common stages and
processes individuals appear to progress through. The model is named
the Transtheoretical Model because it spans so many different theories.
• This model provides practitioners with a way in which to understand how
clients change, as well as what motivates them to change. It can be used
to teach case conceptualization, and build appropriate stage related
interventions into treatment plans.
The Stages of Change Model:
Transtheoretical Model
(Prochaska & DiClemente, 1982)
• The central organizing construct of the model is the
Stages of Change
• The Transtheoretical Model views change as a process
involving progress through a series of five stages
–
–
–
–
–
Precontemplation
Contemplation
Preparation
Action
Maintenance
• The goal is to determine which stage of change the client
is in and assist the client in progressing through
subsequent stages.
The Stages of Change
Has changed
behavior for more
than 6 months
No intention of
changing behavior
Has changed
behavior for
less than 6
months
Intends to change
in the next 6
months, but may
procrastinate
Intends to take action
soon, for example next
month
Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.62561
Change is Dynamic and Cyclical
•
It is important to note that the change process is cyclical, and individuals
typically move back and forth between the stages, and cycle through the
stages at different rates. In one individual, this movement through the stages
can vary in relation to different behaviors or objectives. Individuals can move
through stages quickly. Sometimes, they move so rapidly that it is difficult to
pinpoint where they are because change is a dynamic process. It is not
uncommon, however, for individuals to linger in the early stages.
•
For most substance-using individuals, progress through the stages of
change is circular or spiral in nature, not linear. In this model, relapse is a
normal event because many clients cycle through the different stages
several times before achieving stable change.
Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.61626
Key Points
1.
Prochaska and DiClemente argue that behavior change cannot be
thought of as a specific event occurring at a specific point in time.
Rather, change should be thought of as a process that may take
months or even years.
2.
Many ‘behavioral change’ programs are characterized as lasting for a
predetermined number of weeks and consisting of structured content.
Such programs do not take into account the uniqueness of each client,
and the subtle changes that often go unnoticed. Some clients will
respond very positively and make significant changes. However, for
those who do not, they are said to lack motivation and/or willpower.
3.
We tend to acknowledge change has occurred when we see a change
in behavior, e.g. a period of abstinence, leaving an unhealthy
relationship. These are then categorized as successes.
Key Points
5.
The stages of change model suggests that change occurs along a
continuum and therefore cannot be measured by one criteria alone, i.e.
a change in a specific problem behavior. If we view change as a
process then we can report positive changes each time an individual
progresses from one stage to the next. Small steps constitute changes
and should therefore be recognized and supported.
6.
Since clients differ in their readiness to make changes Prochaska
and DiClemente suggest matching interventions to the
appropriate stage (or readiness).
“Success, moreover, is defined not just by changing the behavior
but by any movement toward change, such as a shift from one
stage of readiness to another.”
7.
There is an emphasis on the maintenance of change. Relapse is
common and should not be seen as a sign of failure. Clients are
encouraged to learn from their relapse.
8.
A great deal of importance is placed on the decision making capability
of the individual
Practical Applications
• Teaching case conceptualization and treatment
planning in counselor education and supervision
– Common concerns of student counselors in supervision:
• “I don’t know what else to do with this client”
• “I feel like I do not know enough techniques”
• “I want to be prepared and have a diverse number of tools to draw
upon”
• “The client is stuck, I am stuck, I don’t know where to go”
• “I am exhausted, she or he, won’t budge.”
• Counselors need to become aware of when they
are working harder than their clients
Practical Applications
•
Counselors may get into difficulties if they rely too heavily on theoretical
techniques and attempt to draw from a “bag of tricks”. Eventually someone will
throw a spanner in the works.
•
Student counselors will benefit from learning about the stages of change
because it explains how clients change.
•
More emphasis is placed on the client, which will help alleviate some of the
pressure counselors feel.
•
Counselors can use the model to teach clients about the stages of change, and
thus set the tone for future counseling sessions.
•
All of the above can then be used to create a collaborative treatment plan based
on the clients current position
Motivational Interviewing
• Motivational interviewing is guided by several
principles:
•
•
•
•
•
•
•
Avoiding argumentation
Rolling with resistance
Expressing empathy
Developing discrepancies
Supporting self-efficacy
Counselors avoid harsh confrontations
MI counselors emphasize the need for change and
increase confidence and hope that change can occur.
Lewis & Osborn, 2004
Stage 1: Precontemplation
Description
Techniques
Questions to ask
Individual’s in the precontemplation stage
are often viewed as unmotivated clients who
are not ready for change. They may not
believe they have a problem and state they
do not intend on making any changes in the
near future (not within the next 6 months).
• Validate client’s feelings
and thoughts regarding
lack of readiness
• "What would
have to happen
for you to know
that this is a
problem?“
It is also possible these individual’s may not
fully realize the negative consequences of
their behavior.
• Make client aware it is
her/his decision whether or
not to change.
• "What would
you consider as
warning signs
• Encourage re-evaluation of
that would let
current behavior
you know that
this is a
• Self exploration, not action,
problem?“
should be the goal
The goal of the precontemplation stage is to
raise the client’s awareness and hemp them
begin to think about the negative
consequences of their behavior and consider • Raise awareness and
change as a possibility.
doubt
Ultimately, we are trying to move the client to
the next stage of change, contemplation.
• Explain and personalize
the risk
• “What things
have you tried
in the past to
change?”
Adapted from: The National Center for Biotechnology Information: TIP 35: Enhancing Motivation for Change in
Substance Abuse Treatment: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302
Precontemplation: Strategies
•
Use self motivational statements with questions such as:
– “How does this concern you?”
– “What do you think will happen to you if you do not make any changes?”
– “What has your alcohol/drug use prevented you from doing?”
•
If client is reluctant, try asking
– "What would have to happen for you to know that this is a problem?“
– "What would you consider as warning signs that would let you know that this is a
problem?“
•
•
•
•
•
Try not to assume client has a substance abuse problem. Instead, start from the
viewpoint ‘there is a possibility substance abuse is a problem for you”
If subject seems willing, offer feedback from test results, such as the
SOCRATES. (but ask, ‘what do these results say to you?’)
Try not to come from the ‘counselor as expert’ point of view.
If client is willing, explain the concepts behind the stages of change model.
Involve them in the process.
Ask subject what they would like the next step to be.
Moving from Precontemplation
to Contemplation
•
There is a myth...in dealing with serious health-related addictive...problems, that more is
always better. More education, more intense treatment, more confrontation will necessarily
produce more change. Nowhere is this less true than with precontemplators. More intensity
will often produce fewer results with this group. So it is particularly important to use careful
motivational strategies, rather than to mount high-intensity programs...that will be ignored
by those uninterested in changing the...problem behavior... We cannot make
precontemplators change, but we can help motivate them to move to contemplation.
(DiClemente, 1991)
•
Individual’s in the precontemplation stage rarely show for treatment by choice. Most are
required to attend treatment for one reason or another. They may truly believe their
substance use is not a problem. One goal is therefore to create doubt within the client, such
that they may question their risky behaviors.
•
When you first meet with client:
–
–
–
•
Establish rapport and trust
Explore events that precipitated treatment entry
Commend clients for coming
"Why do you think your probation officer believes you have a problem?" This enables the
client to express the problem from the perspective of the referring party. It also provides you
with an opportunity to encourage the client to acknowledge any truth in the other party's
account (Rollnick et al., 1992a).
Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.61822
Moving from Precontemplation
to Contemplation
Readiness Ruler: (Source: Rollnick)
The simplest way to assess the client's willingness to change is to use a
Readiness Ruler or a 1 to 10 scale, on which the lower numbers represent no
thoughts about change and the higher numbers represent specific plans or
attempts to change. Ask the client to indicate a best answer on the ruler to the
question, "How important is it for you to change?" or, "How confident are you that
you could change if you decided to?" Precontemplators will be at the lower end of
the scale, generally between 0 and 3. You can then ask, "What would it take for
you to move from an x (lower number) to a y (higher number)?"
Moving from Precontemplation
to Contemplation
•
•
Description of a typical day
Another, less direct, way to assess readiness for change, as well as to build rapport and
encourage clients to talk about substance use patterns in a nonpathological framework, is
to ask them to describe a typical day. This approach also helps you understand the context
of the client's substance use. For example, it may reveal how much of each day is spent
trying to earn a living and how little is left to spend with loved ones. By eliciting information
about both behaviors and feelings, you can learn much about what substance use means to
the client and how difficult--or simple--it may be to give it up. Substance use is the most
cohesive element in some clients' lives, literally providing an identity. For others it is
powerful biological and chemical changes in the body that drive continued use. Alcohol and
drugs mask deep emotional wounds for some, lubricate friendships for others, and offer
excitement to still others.
Start by telling the client, "Let's spend the next few minutes going through a typical day or
session of...use, from beginning to end. Let's start at the beginning." Clinicians experienced
in using this strategy suggest avoiding any reference to "problems" or "concerns" as the
exercise is introduced. Follow the client through the sequence of events for an entire day,
focusing on both behaviors and feelings. Keep asking, "What happens?" Pace your
questions carefully, and do not interject your own hypotheses about problems or why
certain events transpired. Let clients use their own words and ask for clarification only when
you do not understand particular jargon or if something is missing
Source: (Rollnick et al., 1992a).
Moving from Precontemplation to
Contemplation
•
Provide Information About the Effects and Risks of Substance Use
Provide basic information about substance use early in the treatment process if
clients have not been exposed to drug and alcohol education before and seem
interested. Tell clients directly, "Let me tell you a little bit about the effects of..." or
ask them to explain what they know about the effects or risks of the substance of
choice. To stay on neutral ground, illustrate what happens to any user of the
substance, rather than referring just to the client. Also, state what experts have
found, not what you think happens. As you provide information, ask, "What do
you make of all this?"
•
It is sometimes helpful to describe the addiction process in biological terms to
persons who are substance dependent and worried that they are crazy.
Understanding facts about addiction can increase hope as well as readiness to
change. For example, "When you first start using substances, it provides a
pleasurable sensation. As you keep using substances, your mind begins to
believe that you need these substances in the same way you need life-sustaining
things like food--that you need them to survive. You're not stronger than this
process, but you can be smarter, and you can regain your independence from
substances.“
Source: (Rollnick et al., 1992a).
Stage 2: Contemplation
Description
Techniques
Questions to ask
During the contemplation
stage, individuals are
ambivalent about changing.
They are aware their
behavior is resulting in
negative consequences
and may be considering
making a change.
However, no commitment
has been made to take
action. One could say
these individuals are ‘sitting
on the fence’.
Contemplation is
characterized by
ambivalence and feelings
of being ‘stuck’.
• Make client aware
it is her/his
decision whether or
not to change.
• Encourage
evaluation of pros
and cons of
behavior change
with the goal of
helping tip the
balance toward
change.
• Identify and
promote new,
positive outcome
expectations
• Have client state
their next step
• What are the pros and cons for
not changing?
• What are the pros and cons
(costs/benefits) for changing?
• Why do you want to change at
this time?
• What would keep you from
changing at this time?
• What are the barriers today that
prevent you from changing?
• What things (people, programs
and behaviors) have helped in
the past?
• What would help you at this
time?
Contemplation Strategies: Cost Benefit Analysis Scale
Source: Davis & Osborn (2000)
Costs of Use
Benefits of Use
Benefits
Costs
Costs of Sobriety
Benefits of Sobriety
Costs
Benefits
Contemplation: Strategies
Figure 8-3
Deciding To Change: Use ‘decisional balance’ techniques.
Changing
Not Changing
Benefits
•Increased control over my life
•Support from family and friends
•Decreased job problems
•Financial gain
•Improved health
Benefits
•More relaxed
•More fun at parties
•Don't have to think about my
problems
Costs
•Increased stress/anxiety
•Feel more depressed
•Increased boredom
•Sleeping problems
Costs
•Disapproval from friends and family
•Money problems
•Could lose my job
•Damage to close relationships
•Increased health risks
Source: Sobell et al., 1996b.
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.table.62797
Stage 3: Preparation
Description
Techniques
Individuals in the
• Identify and assist in
preparation stage intend
problem solving, e.g.
to take action (within the
identify barriers and
next month) and may
brainstorm solutions
already have had
previous failed attempts • Help identify client
at trying to change.
resources such as
Some may have already
social supports
‘tested the waters’ by
engaging in small
• Encourage and
changes, e.g. going
support small initial
without a drink for a
steps
night.
Client may have an
initial plan.
Questions to ask
• What barriers do see
ahead, and how can
you minimize or
eliminate them?
• Who can you turn to
for support?
• What kind of support
do you feel you need
the most, and where
can you get this
support?
Preparation: Activities
•
•
•
Identify client’s needs/wants/desires
Emphasis is on outlining and developing plans in order to break the pattern of
substance abuse, and find other ways of meeting clients needs.
Goal Setting
– Use the miracle question.
– Where do you want to be 6 months, 1 year, 5 years from now? What will life look like
for you?
•
Encourage client to come up with their own plans, and have them state
specifically how they will achieve them.
•
Identify alternative ways in which to meet needs. Identify areas of support that
can be utilized.
•
Commend client for deciding to change because they always have the option
not to.
•
Create an action plan
•
Have client state their next step.
Stage 4: Action
Description
Techniques
Individuals are actively • Focus on restructuring
changing their behavior
cues and social
and/or environment in a
support
positive manner in order
to address their
• Bolster self-efficacy for
problem(s). Client has
dealing with obstacles
changed behavior for
less than 6 months.
• Combat feelings of
loss and reiterate
long-term benefits
Questions to ask
•Use strategies listed for
Preparation Stage if
necessary.
•Continue consolidating
client’s motivation for
change
•What actions have you
taken?
•What has helped/not
helped?
•What might you do to
replace things that have
not helped?
Action: Strategies
• Elicit client’s sources of support
• Understand client is trying to fill a void having
given up their substance of choice.
• How can this void be filled with healthier behaviors
so that they client can meet their needs
Stage 5: Maintenance
Description
Techniques
Maintenance involves the individual • Conducting a Functional Analysis
proactively working to prevent
• Developing a Coping Plan
relapse. Change is continuous, it
• Plan for follow-up support
does not end at Maintenance.
In addition to handling problems that can
Triggers
interrupt treatment prematurely, work to
stabilize actual change in the problem
behavior. This requires considerable
interactive planning, including conducting a
functional analysis, developing a coping plan,
and ensuring family and social support.
Start with identifying Triggers and Effects
Effects
Maintenance Strategies:
Functional Analysis
Conducting a Functional Analysis:
Although a functional analysis can be used at various points in treatment, it can be
particularly informative in preparing for maintenance. A functional analysis is an
assessment of the common antecedents and consequences of substance use.
Through functional analysis, you help clients understand what has "triggered" them
to drink or use drugs in the past and the effects they experienced from using
alcohol or drugs. With this information, you and your clients can then work on
developing coping strategies to maintain abstinence.
"Tell me about situations in which you have been most likely to drink or use drugs in
the past, or times when you have tended to drink or use more. These might be
when you were with specific people, in specific places, or at certain times of day, or
perhaps when you were feeling a particular way." Make sure to use the past tense
because the present or future tense may unsettle currently abstinent clients.
Miller and Pechacek, 1987
Maintenance Strategies:
Functional Analysis
•
Once the client has finished giving antecedents and consequences, you can point
out how a certain trigger can lead to a certain effect. First, pick out one item from
the Triggers column and one from the Effects column that clearly seem to go
together. Then ask the client to identify pairs, letting the client draw connecting
lines on the paper or blackboard.
•
For trigger items that have not been paired, ask the client to tell you what alcohol
or drug use might have done for her in that situation, and draw a line to the
appropriate item in the Effects column. Sometimes there is no corresponding item
in the Effects column, which suggests that something has to be added. Then do
the same thing for the Effects column. It is not necessary, however, to pair all
entries.
•
With this information, you can develop maintenance strategies. Point out that
some of the pairs your client identified are common among most users. Next, you
can say that if the only way a client can go from the Triggers column to the
Effects column is through substance use, then the client is psychologically
dependent on it. Then make clear that freedom of choice is about having options-different ways--of moving from the Triggers to the Effects column. You can then
review the pairs, beginning with those the client finds most important, and
develop a coping plan that will enable the client to achieve the desired effects
without using substances
Miller and Pechacek, 1987
Determining a Client’s Stage of
Change using SOCRATES
The Stages of Change Readiness and Treatment Eagerness Scale
(Miller & Tonigan)
“The Stages of Change Readiness and Treatment Eagerness Scale was
originally developed as a parallel measure of the stages of change described
by Prochaska and DiClemente with item content specifically focused on problem
drinking.”
Miller, Tonigan (1996) p. 82
• Contains 19 items
• Client responds based on a lickert scale from:
(1 - NO! Strongly Disagree) to (5 - YES! Strongly Agree)
• 10 minutes to complete
• Reports on 3 factors
– Recognition
– Ambivalence
– Taking Steps
• SOCRATES in pdf format
• SOCRATES in Excel Format
Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.62203#62297
Determine the stage of change:
Case Study 1
Leeann is a 17 year old female brought to a local community counseling
agency by her parents for treatment of her drug and alcohol use. Leeann
has been experimenting with various drugs since the age of 14. She reports
using marijuana on a daily basis and drinking alcohol every weekend. On
occasion, she has experimented with ecstasy, as well as some prescription
medications (Klonopin, Xanax). Leeann’s parents report that she has been
suspended twice this academic year; once for bringing alcohol to the
homecoming dance, and the second time for getting caught with marijuana
paraphernalia. Her parents are concerned that Leeann is seriously
jeopardizing her chances of attending college or obtaining a scholarship.
During her initial session, Leeann presented as disinterested and somewhat
oppositional. She reported that she was only attending the session “to keep
my parents off my back”. She denied a problem with her use and stated that
“everyone I know smokes marijuana and they are fine”. She indicated no
motivation to change her pattern of use and stated that she was just “biding
my time until I’m 18”.
Hoffman, R. (2005).
Case Study 2
Craig is a 42 year old male who has been participating in counseling for
three months. He was initially referred by his Employee-Assistance
Program for concerns about his alcohol consumption. Craig initially
presented as ambivalent about achieving sobriety and demonstrated
resistance to giving up his lifestyle of social drinking. However, after
several sessions, Craig seemed to realize the impact of his drinking
behaviors. He reported that he did not want to lose his job and since he
had been referred by EAP, he was concerned that this was his one and
only chance to change his behavior. Craig also indicated that alcohol had
become so much a part of his life that he didn’t know how to begin to live
without drinking. Craig decided to take small steps to eradicate alcohol
from his life. He stated that he would no longer order a drink with his
meals, nor would he order a cocktail after work with his friends. Craig
stated that both of these tasks would be difficult for him, but identified a
commitment to change his behavior.
Case Study 3
Marianne is a 26 year old female who has been in
counseling for five months due to substance abuse and
dependency. For the past month she has been actively
involved in attending AA meetings and participating in
intensive outpatient treatment for her dependency on
barbiturates. Marianne reports having a break through during
an individual counseling session where she realized that she
would risk losing her friends and family if she did not change
her behavior. Marianne reports that this is her time to turn
her life around and get things “in order”. She has made
several friends in both her IOP treatment as well as within
her AA group. She also reports feeling comfortable and
secure with her current AA sponsor.
Case Study 4
Mark is a 34 year old male who has sought individual counseling for
work-related stressors. Mark is a police officer and admits that
sometimes his job “gets to him”. Recently, Mark’s partner was shot in the
line of duty during a routine traffic stop. Fortunately, his partner sustained
only minor injuries, however, Mark reports that he has experienced
difficulty sleeping, concentrating, and relaxing since the incident. He
reports that he has recently began to use his wife’s prescription sleep aid
to help him fall asleep at night. However, the sleep aid has begun to lose
its efficacy and Mark reports that he has recently began drinking in the
evening, after he gets off of work to “help calm me down”. Mark reports
drinking approximately a six-pack of beer each evening for the past two
weeks. Mark admits that he is concerned about his reliance on
substances to help control his stress. However, Mark states that he is
also concerned about the effects of seeking treatment for his alcohol use
because of possible ramifications to his career.
Questions for vignettes
1. What stage of change is the client in?
2. What facilitate movement to the next stage?
3. What would be some pitfalls or problems that
may be encountered at this stage?
4. What would be the goals of this stage?
References
Davis, T. E. & Osborn, C. J. (2000) The solution focused school counselor: Shaping
professional practice. Philadelphia, PA: Accelerated Development.
DiClemente, C.C. (1991). Motivational interviewing and the stages of change. In
W.R. Miller & S. Rollnick (Eds.) Motivational interviewing: Preparing people to
change addictive behavior (pp. 191-202). New York: Guilford Press.
Lewis, T.F., & Osborn, C.J. (2004). Solution-focused counseling and motivational
interviewing: A consideration of confluence. Journal of Counseling &
Development, 82, 38-48.
Miller, W.R., & Pechacek, T.F.(1987). New roads: Assessing and treating
psychological dependence. Journal of Substance Abuse Treatment,4, 73-77.
Miller, W.R., Tonigan, J.S., Montgomery, H.A., et al. (1990). Assessment of client
motivation to change: Preliminary validation of the SOCRATES (Rev) instrument.
Albuquerque , NM: University of New Mexico
Miller, W.R., & Tonigan, J.S. (1996). Assessing drinkers' motivation for change: The
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES).
Psychology of Addictive Behaviors 10, 81-89.
References continued
Miller, W.R., & Sanchez, V.C.(1994). Motivating young adult’s for treatment and
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Miller, W. R., TIP 35: Enhancing Motivation for Change in Substance Abuse
Treatment Retrieved from
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a
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Practice, 19, 276-287.
Prochaska, J.O.,& DiClemente, C.C.(1984).The transtheoretical approach: Crossing
traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin.
Prochaska, J.O., & DiClemente, C.C. (1992). The transtheoretical approach. In J.C.
Norcross & M.R. Goldfried (Eds.) Handbook of psychotherapy integration. NY:
Basic Books.
References continued
Prochaska, J.O., Redding, C.A., & Evers, K.E.(1997). The transtheoretical model and
stages of change. In K. Glanz, F.M. Lewis, & B.K. Rimer (Eds.),
Health
nd
behavior and health education: Theory, research, and practice (2 ed.) San
Francisco: Jossey-Bass.
Rollnick, S., Heather, N.,& Bell, A.(1992). Negotiating behavior change in medical
settings: The development of brief motivational interviewing. Journal of Mental
Health,1, 25-37.
Sobell, L.C., Cunningham, J.A., Sobell, M.B., Agrawal, S., Gavin, D.R., Leo, G.I., &
Singh, K.N.(1996). Fostering self-change among problem drinkers: A proactive
community intervention. Addictive Behaviors 21, 817-833.
Walter, J.L. & Peller, J.E. (1992). Becoming solution focused in brief therapy.
Levittown, PA: Brunner/Mazel.