Ebook Principles of addiction medicine the essentials: Part 2

Section 8: Behavioral Interventions C H A P T E R 54 Summary Author: John Young James O. Prochaska Enhancing Motivation to Change THE STAGES OF CHANGE Change is a process that unfolds through a series of stages: Precontemplation is a stage in which the individual does not intend to take action in the foreseeable future (usually measured as the next 6 months). Such individuals tend to avoid reading, talking, or thinking about their high-risk behaviors. Individuals in the precontemplation stage typically underestimate the benefits of change and overestimate its costs but are unaware that they are making such mistakes. As a result, many remain stuck in the precontemplation stage for years. Contemplation is a stage in which an individual intends to take action within the ensuing 6 months. Such a person is more aware of the benefits of changing but also is acutely aware of the costs. This balance between the costs and the benefits of change can produce profound ambivalence and thus can keep an individual stuck at the contemplation stage. Such individuals are not ready for traditional action-oriented programs. Preparation is a stage in which an individual intends to take action in the immediate future (usually measured as the ensuing month). It is these individuals who should be recruited for action-oriented treatment programs. Action is a stage in which the individual has made specific, overt modifications in his or her lifestyle within the preceding 6 months. Maintenance is a stage in which the individual is working to prevent relapse, but does not need to apply change processes as frequently as one would in the action stage. Such a person is less tempted to relapse. Main-tenance lasts from 6 months to about 5 years. Termination is a stage at which individuals have zero temptation and 100% self-efficacy. Although the ideal is to be cured or totally recovered, it is important to recognize that, for many patients, a more realistic expecta-tion is a lifetime of maintenance. USING THE STAGES OF CHANGE MODEL TO MOTIVATE PATIENTS The stages of change model can be applied to identify ways to motivate more patients at each phase of planned interventions for the addictions. The five phases are (a) recruitment, (b) retention, (c) progress, (d) process, and (e) outcomes. Recruitment Fewer than 25% of persons with addictive disorders enter professional treatment in their lifetimes. How can more people with addictive disorders be motivated to seek the appropriate help? There are two paradigms that need to be changed. The fi rst is an action-oriented paradigm that construes behavior change as an event that can occur quickly, immediately, discretely, and dramatically. Treatment programs that are designed to have patients immediately quit abusing substances are implicitly or explicitly designed for the portion of the population in the preparation stage. The problem is that, with most unhealthy behaviors, fewer than 20% of the affected population is prepared to take action. To meet the needs of the entire addicted population, interven-tions must meet the needs of the 40% in the precontemplation and the 40% in the contemplation stages. The second paradigm change that is required is movement from a passive-reactive approach to a proactive approach. The passive-reactive paradigm is designed to serve populations with acute conditions. The pain, 289 290 SECTION 8 | Behavioral Interventions distress, or discomfort of such conditions can motivate patients to seek the services of health professionals. But the major killers today are chronic lifestyle disorders such as the addictions. To treat the addictions seriously, professionals must learn how to reach out to entire populations and offer them stage-matched therapies. Retention What motivates patients to continue in therapy? At least five studies are available on dropouts from a stage model perspective. These studies found that stage-related variables were more reliable predictors of dropout than demographics, type of problem, severity of problem, and other problem-related variables. Figure 54.1 presents the stage profiles of three groups of patients with a broad spectrum of psychiatric disorders. The before-therapy profile of the entire group who dropped out quickly and prematurely (40%) was a profile of persons in the pre-contemplation stage. The 20% who finished quickly but appropriately had a profile of patients who were in the action stage at the time they entered therapy. Those who continued in long-term treatment were a mixed group, with most in the contemplation stage. The lesson is clear: persons in the precontemplation stage cannot be treated as if they are starting in the same place as those in the action stage. With patients who begin therapy in the precontemplation stage, it is useful for the therapist to share key concerns: “I’m concerned that therapy may not have a chance to make a signifi cant difference in your life, because you may be tempted to leave early.” The author and others have conducted four studies with stage-matched interventions in which retention rates of persons entering interventions in the precontemplation stage can be examined. What is clear is that, when treatment is matched to stage, persons in the precontemplation stage will remain in treatment at the same rates as those who start in the preparation stage. Progress What moves people to progress in therapy and to continue to progress after therapy? Figure 54.2 presents an example of what is called the stage effect. The stage effect predicts that the amount of successful action taken during and after treatment is directly related to the stage at which the person entered treatment. The stage effect has been found across a variety of problems and populations. One strategy for applying the stage effect clinically involves setting realistic goals for brief encounters with patients at each stage of change. A realistic goal is to help patients progress one stage in brief therapy. If a patient moves relatively quickly, he or she may be able to progress two stages. One result for health professionals trained in this approach to the addictions can be a dramatic increase in the morale of the health professionals involved. FIGURE 54.1 Pretherapy stage profiles for premature terminators, appropriate terminators, and continuers. (Data from Brogan ME, Prochaska JO, Prochaska JM. Predicting termination and continuation status in psychotherapy using the Transtheoretical Model. Psychotherapy 1999;36:105–113.) CHAPTER 54 | Enhancing Motivation to Change 291 FIGURE 54.2 Percentage of smok-ers who maintained abstinence over 18 months. Note: Groups were in the following stages at the time of entry into treatment. PC, precontemplation; C, comtemplation; C/A, preparation (n = 570). They can see progress with most of their patients, where they once saw failure when immediate action was the only criterion for success. Process To help motivate patients to progress from one stage to the next, it is necessary to know the principles and processes of change. Principle 1 The rewards for changing must increase if patients are to progress beyond precontemplation. A technique that can be used in population-based programs involves asking a patient in the precontemplation stage to describe all the benefits of a change such as quitting smoking or starting to exercise. Most persons can list four or five. The therapist can challenge the patient to double or triple the list for the next meeting. Principle 2 The cons of changing must decrease if patients are to progress from contemplation to action. Principle 3 The relative weight assigned to benefits and costs must cross over before a patient will be prepared to take action. Principle 4 The strong principle of progress holds that, to progress from precontemplation to effective action, the rewards for changing must increase by one standard deviation (SD). Principle 5 The weak principle of progress holds that, to progress from contemplation to effective action, the perceived costs of changing must decrease by one-half SD. Because the perceived rewards for changing 292 SECTION 8 | Behavioral Interventions TABLE 54.1 Stages of Change in Which Change Processes are Emphasized Stages of change Precontemplation Processes Consciousness raising Dramatic relief Environmental reevaluation Contemplation Self-reevaluation Preparation Self-liberation Action Maintenance Contingency management Helping relationships Counterconditioning Stimulus control must increase twice as much as the perceived costs decrease, twice as much emphasis must be placed on the rewards than the costs of changing. Such principles can produce much more sensitive assessments to guide interventions. Principle 6 It is important to match particular processes of change with specifi c stages of change. Table 54.1 presents the empirical integration found between processes and stages of change. 1. Consciousness raising involves increased awareness of the causes, consequences, and responses to a particular problem. Consciousness raising should be designed to increase the perceived rewards for changing. 2. Dramatic relief involves emotional arousal about one’s current behavior and the relief that can come from changing. Fear, inspiration, guilt, and hope are some of the emotions that can move persons to contemplate changing. Psychodrama, role playing, grieving, and personal testimonies are examples of techniques that can move people emotionally. 3. Environmental reevaluation combines both affective and cognitive assessments of how an addiction affects one’s social environment and how changing would affect that environment. Empathy training, values clarifi-cation, and family or network interventions can facilitate such reevaluation. 4. Self-reevaluation combines both cognitive and affective assessments of an image of one’s self free from addiction. Imagery, healthier role models, and values clarification are techniques that can move individuals in this type of intervention. 5. Self-liberation involves both the belief that one can change and the commitment and recommitment to act on that belief. Techniques that can enhance such willpower include public rather than private commitments. Motivational research also suggests that individuals who have only one choice are not as motivated as if they have two choices. Three choices are even better, but four choices do not seem to enhance motivation. Wher-ever possible, then, patients should be given three of the best choices for applying each process. 6. Contingency management involves the systematic use of reinforcements and punishments for taking steps in a particular direction. Because successful self-changers rely much more on reinforcement than punishment, it is useful to emphasize reinforcements for progressing rather than punishments for regressing. Contingency contracts, overt and covert reinforcements, and group recognition are methods of increas-ing reinforcement and incentives that increase the probability that healthier responses will be repeated. CHAPTER 54 | Enhancing Motivation to Change 293 To prepare patients for the longer term, they should be taught to rely more on self-reinforcements than social reinforcements. Many patients expect much more reinforcement and recognition from others than they actually receive. 7. Helping relationships combine caring, openness, trust, and acceptance, as well as support for changing. Rap-port building, a therapeutic alliance, counselor calls, buddy systems, sponsors, and self-help groups can be excellent resources for social support. If patients become dependent on such support to maintain change, the support will need to be carefully faded, lest termination of therapy becomes a condition for relapse. 8. Counterconditioning requires the learning of healthier behaviors that can substitute for addictive behaviors. Counterconditioning techniques tend to be quite specific to a particular behavior. They include desensitiza-tion, assertion, and cognitive counters to irrational self-statements that can elicit distress. 9. Stimulus control involves modifying the environment to increase cues that prompt healthy responses and decrease cues that lead to relapse. Avoidance, environmental reengineering (such as removing addictive sub-stances and paraphernalia), and attending self-help groups can provide stimuli that elicit healthy responses. Outcomes What is the result when all of these principles and processes of change are combined? A series of clinical trials applying stage-matched interventions offers lessons about the future of behavioral health care generally and treatment of the addictions specifically. In a large-scale clinical trial, the author and colleagues compared four treatments: (a) a home-based action-oriented cessation program (standardized), (b) stage-matched manuals (individualized), (c) a computerized expert system plus manuals (interactive), and (d) counselors plus an expert system and manuals (personalized). Patients were randomly assigned by stage to one of the four treatments. Figure 54.3 presents point-prevalence abstinence rates for each of the four treatment groups over 18 months, with treatment ending at 6 months. Results with the two self-help manual conditions were parallel for 12 months, but the stage-matched manuals achieved better results at 18 months. FIGURE 54.3 Point-prevalence absti-nence (%) for four treatment groups at pretest and at 6, 12, and 18 months. ALA+, standardized manuals; TTT, indi-vidualized stage-matched manuals; ITT, interactive computer reports; PITT, personalized counselor calls. ... - tailieumienphi.vn