Substance AbuseNov 21st, 2005

The Stages of Change Model, and Treatment Planning

Kevin Glavin – Kent State Universitykglavin@kent.edu

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

Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.62561

No intention of changing behavior

Intends to change in the next 6 months, but may procrastinate

Intends to take action soon, for example next month

Has changed behavior for less than 6 months

Has changed behavior for more than 6 months

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: PrecontemplationDescription 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).

It is also possible these individual’s may not fully realize the negative consequences of their behavior.

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 change as a possibility.

Ultimately, we are trying to move the client to the next stage of change, contemplation.

• Validate client’s feelings and thoughts regarding lack of readiness

• Make client aware it is her/his decision whether or not to change.

• Encourage re-evaluation of current behavior

• Self exploration, not action, should be the goal

• Raise awareness and doubt

• Explain and personalize the risk

• "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?“

• “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 Precontemplationto 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 Precontemplationto 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 Precontemplationto 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)

CostsBenefits

Costs of Use

Costs of Sobriety

Benefits of Use

Benefits of Sobriety

CostsBenefits

Contemplation: Strategies

Figure 8-3Deciding 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 Questions to ask

Individuals in the preparation stage intend to take action (within the next month) and may already have had previous failed attempts at trying to change. Some may have already ‘tested the waters’ by engaging in small changes, e.g. going without a drink for a night.

Client may have an initial plan.

• Identify and assist in problem solving, e.g. identify barriers and brainstorm solutions

• Help identify client resources such as social supports

• Encourage and support small initial steps

• 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 Questions to ask

Individuals are actively changing their behavior and/or environment in a positive manner in order to address their problem(s). Client has changed behavior for less than 6 months.

• Focus on restructuring cues and social support

• Bolster self-efficacy for dealing with obstacles

• Combat feelings of loss and reiterate long-term benefits

•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 proactively working to prevent relapse. Change is continuous, it does not end at Maintenance.

• Conducting a Functional Analysis • Developing a Coping Plan• Plan for follow-up support

Triggers EffectsIn addition to handling problems that can 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

Maintenance Strategies: Functional AnalysisConducting 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)

• 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

“The Stages of Change Readiness and Treatment Eagerness Scale was

originally developed as a parallel measure of the stages of change describedby Prochaska and DiClemente with item content specifically focused on problem drinking.”

Miller, Tonigan (1996) p. 82

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 lifestyle change. In G.Howard (Ed.), Issues in alcohol use and misuse by young adults (pp. 55-81). Notre Dame, IN: University of Notre Dame Press.

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 more integrative model of change. Psychotherapy: Theory, Research and 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 behavior and health education: Theory, research, and practice (2nd 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.