Stages of change and motivational interviewing in addiction treatment

Change Model and Addiction

In our society physicians fill the roles of diagnostician and healer but another role equally important is that of aiding patients to understand and take ownership of their own health and guide them in making decisions and any necessary changes to improve that health. Dietary restrictions, stress management, and exercise programs are common interventions prescribed by physicians but none of these will be successful without a change in the patient's behavior. Without that relapses are common and consistent, life-long behavioral changes are difficult to implement.

We need only to look at the rows of books in stores or the numerous resolutions made at the beginning of every year to know that change is a popular topic, but it is often easier said than done. Physicians can promise a patient improvement in health and back it with scientific evidence but that does not guarantee patients will be motivated to change. Many patients want to change but if the physician uses a confrontational approach the patient may feel criticized instead of supported.

Often seen as failure by both physician and patient relapses may cause the patient to give up, avoiding contact with his or her doctor to avoid further humiliation until forced to visit due to illness. Many physicians have found that having a caring and supportive attitude and working alongside the patient in a partnership, particularly during treatment for addictions, may have a more lasting effect on the patient's future health. This paper takes a look at the Stages of Change Model and Motivational Interviewing, two methods of diagnosing and supporting the patient on the path of treatment and recovery.

Stages of Change Model

For most people changes occur gradually and that is reflected in the Stages of Change Model. The model shows behavioral changes occurring in stages, beginning with the patient having little interest in change, going through all phases and finalizing with working toward habits that will bring about life-long change.

Stage One: Pre-contemplation

In this first stage people do not see themselves as having a problem. Patients are not seriously considering making any changes. They may be defensive if anyone mentions improvements are needed, they may not feel that health advice applies to them but is for 'other people' or they have simply given up due to past experiences of attempts and failures.

Stage Two: Contemplation

Ambivalence is the operative word in this stage. Patients are more open to discussing their bad habits and have come to realize that a change should be made but are not yet convinced to make that change. They may understand the benefits that the changes will bring but do not really want to give up the behaviors that have brought on the trouble; in a sense it feels like losing an old friend. A patient may go through this stage fairly quickly or may linger here indefinitely, contemplating but never moving forward.

Stage Three: Preparation

Patients have made a commitment and are preparing to make specific changes. They realize that they must do something about the problem because it is serious. If nothing is done their bad behavior or habit may cause irreparable harm or even death. The patient usually begins by reading and gathering information on the problem and may then experiment with small changes.

Stage Four: Action

In this stage people believe they have the knowledge and ability to make the necessary changes to their behavior and they are actively taking steps to end the old behavior and make the new ones a habit. Various techniques can be used in this stage depending on the behavior being changed but willpower is often viewed as being the most important tool used.

Stage Five: Maintenance

Changes have been made and are kept up. This is a life-long stage and patients are in it for the long-haul. There are temptations to return to old habits but they are successfully avoided and progress can be measured.

Relapse

Most people experience a relapse at one time or another on the path to permanent change. Usually having been tempted and drawn back into the old life the patient feels discouraged and may feel a failure.

Necessary Counseling Skills

Truly caring and having empathy is at the heart of MI. Feldstein & Forcehimes (2007) state "Since the 1960s, studies have shown that empathy is an important force in effecting positive therapeutic change. As in the Rogerian framework, in MI, empathy is the skillful and deliberate ability to convey a sense of being present, understanding the client's words, emotions, and underlying meaning. The use of empathy is fundamental to MI."

Using empathy there are four basic techniques used in Motivational interviewing: reflective listening, asking open-ended questions, affirming, and summarizing. Reflective listening has the therapist respond to what a patient says by restating the essence of what the patient has just said. Asking open-ended questions encourages a discussion of what changes need to be made and the reasons for doing so. By doing this the therapist acknowledges the patient's thoughts and feelings and both parties will know if the therapist has understood what the patient is saying.

CAGE AUDIT and MAST Assessment Tools

The Michigan Alcohol Screening Test (MAST) is a 25 question screening tool, widely used by courts to diagnose alcohol abuse or dependence and aid in determining the appropriate sentence for those convicted of alcohol-related offenses. Problems with the test include making assumptions about the test-taker that may relate to another problem not being addressed.

Used for the detection of alcohol related problems the CAGE is favored by physicians due to its brevity. Subjective in form it does not screen for drug-related problems nor does it discriminate between alcohol dependence and abuse.

The AUDIT (Alcohol Use Disorders Identification Test) is another screening tool. Developed by the World Health Organization to identify people whose consumption of alcohol has grown to such an extent that it has become harmful or dangerous to their health, but it does not test for other drugs.

Client Involvement

Without client involvement, change will not occur. As seen in the Change Model a patient will not necessarily see or feel a need for change in the beginning. At this time a physician or therapist must be patient and non-threatening in presenting information to the client. If the patient at any time feels as though he is being scolded or treated as a child he will likely stubbornly dig in and refuse to acknowledge the need for any change.

If on the other hand the patient feels he is being treated as an equal and with understanding he will then move to the next stage of contemplation. Here he acknowledges the need for change and considers his options, moving toward a belief that change is possible and a commitment to do so.

Strengths and Weaknesses

Thorough diagnostic testing will establish a definite diagnosis of a disorder; however AUDIT, CAGE, and MAST are simple screening tools that cannot take the place of full diagnostic testing. Screening will only identify those who may be likely to have a drug-related problem.

Screening for alcohol or other drug-related problems will vary from test to test. A patient may be asked a myriad of extensive questions or just one. The reasons for this are varied. A physician or therapist will choose which screening tool to use depending on time constraints, whether the patient has other problems, and the characteristics with which the patient presents.

These screening tools only relate to and identify drinking behavior and alcohol-related problems and have not been adapted to identify other substance abuse problems.

Critical Analysis

Heather (2005) states "While MI does not attempt to prescribe the goal of intervention, in the area of opportunistic intervention among low dependence individuals, it allows the great majority of clients to attempt moderate use rather than abstinence, thus engaging more problem users in the effort to reduce harm."

The combination of the Stages of Change Model and Motivational interviewing is a powerful one. Understanding how people think, feel, and respond to change is vital for the therapist and must happen before undertaking any type of change action. Many physicians and therapists believe that addictions are motivational disorders, implying that patients with addictions have a preference, whether consciously or not, for behavior that is against their better interests. Self-destructive behavior that leads to addiction affects not only the patient's health and well-being but that of those close to the patient as well. Still, many addicts do not understand their own behavior, often disapprove of it and want to make changes to end their addictions. Benjamin Rush described habitual drunkenness as a "disease of the will" and, although we may not now accept this way of putting it, this summarizes in a nutshell the addict's predicament (Heather 2005).

Conclusion

Making changes in one's life is a complicated issue and requires understanding of all issues involved by not only the patient or client but by all involved, including professionals, family, and friends. The patient will need empathic support and positive reinforcement through all phases of the Change Model. Faith and hope are also large contributors to facilitating change. If a patient believes he or she is capable of making necessary changes and will succeed that person has a greater chance for actual success.

The therapist or physician also has beliefs about the abilities and chance of success for each patient and that attitude is communicated to the patient through words and actions. Even facial expressions will tell a patient what the professional believes about the ability of the patient to bring about change. The mind is the most powerful tool involved and the beliefs from the treatment professional and patient can lead to self-fulfilling prophecy.

No matter the diagnostic tool or screening device used and no matter the need for change, if the patient does not feel supported, respected, and viewed as capable by the physician or therapist he or she will remain unconvinced of the need for change. The interaction between the professional and patient not only influences but feeds the need for change. From the initial meeting a relationship develops between the two and a rapport must be built.