Throughout the course of this series I have discussed harm reduction as a way to support people engaging in harmful behaviors who may not be ready to stop. Let's discuss a change model that may be helpful to understand how addicts (and anyone else for that matter) work through change and potentially find recovery.
Clinical psychologists James Prochaska and Carlo DiClemente developed a behavior change model in 1983 that has been useful in tailoring supportive services to people struggling with harmful behaviors. They describe behavior change as a cyclical process as illustrated above:
The nice thing about this model is that most of us can relate to it in some way. If you think about a time you attempted to make some change (quitting smoking, eating better, starting a new gym habit, etc.) you may be able to see yourself cycling through these changes and perhaps even exiting and re-entering the cycle multiple times. Although this model applies to any desired behavior change, I will use substance abuse and addiction in the examples below.
Harm reduction methods are appropriate for people in the precontemplation and contemplation stages of change described below.
Pre-contemplation: People at this stage are not thinking about change at all. They may have some consequences from their substance use, but they either do not want to quit or do not believe quitting is possible. We can help people at this stage of change by building trust and rapport, which fosters engagement and opens up opportunities for movement into the next stage. Appropriate interventions for this stage are harm reduction or simply engagement in other services such as healthcare or case management which may provide opportunities later.
Contemplation: People at this stage are becoming dissatisfied with the status quo and are wondering if things could be different. They are beginning to realize the disconnect between what they want and what they do. We can support people at this stage by eliciting pros and cons and exploring their strengths. Low self-efficacy is often an obstacle to change, so helping a person to increase their sense of effectiveness through small successes or focusing on one’s strengths can help move people into the next stage.
Appropriate interventions at this stage are harm reduction, individual counseling and brief interventions which can be done by healthcare providers, social workers and other points of contact in a person’s life. A specific style of brief intervention called motivational interviewing was developed to help people move from this stage to the next, and it can be a powerful tool to support change.
Preparation: People in this stage have decided they are going to change and are formulating a plan to do so. We can support people in this stage by providing resources and exploring which options are most consistent with their goals.
Appropriate interventions for this stage are individual counseling, social work, case management and support researching treatment options.
Action: People in this stage are actively making change. This stage is generally defined as the first six months after stopping the harmful behavior (i.e. getting clean and sober).
Appropriate interventions for this stage of change are inpatient or outpatient treatment, peer support groups such as AA (Alcoholics Anonymous), NA (Narcotics Anonymous), Smart Recovery and others.
Maintenance: Once a person has maintained the change for 6 months and has developed tools and routines to support the change, they are thought to be in maintenance.
Appropriate intervention at this stage are simply continued support, acknowledgement of the person’s success and respect of the person’s needs for maintaining their sobriety.
Relapse: It is important to note that most behavior change is cyclical. Some people have the constitution to set their mind to something and unwaveringly succeed, but most of us are not made of such grit. Change can take several tries. When relapse occurs, a person can re-enter the change cycle at any point. Some people re-enter at precontemplation again, while others throw themselves back into action. Prochaska and DiClemente described an “upward spiral” where people learn from their relapses and have improvements over time (with relapses becoming less severe and/or less frequent). (Prochaska, DiClemente et al. 1992)
Before harm reduction and motivational interviewing interventions were developed and implemented, we had little to offer people in terms of treatment or support until they were in preparation or action stages of change. People in earlier stages have traditionally been thought of as “resistant.” What I like about this model is that it accepts all levels of readiness to change as a normal part of the process. It also gives us tools to work with people who are not ready to change.
As a healthcare provider, I still find myself earnestly wanting a person to be ready for treatment (action) when they are not. If you have a loved one who is struggling with addiction, you can relate to this. Identifying which stage of change your loved one is in and adjusting your approach to match it can be more effective and less frustrating than trying to get your loved one to take action they are not ready to take it.
A good resource for locating local harm reduction services and getting more information about different harm reduction interventions is www.harmreduction.org.
For people further along in the change cycle, local resources for alcohol and drug treatment can be obtained here: https://www.samhsa.gov/find-help/national-helpline.
References:
Prochaska, J. O., et al. (1992). "In search of how people change. Applications to addictive behaviors." Am Psychol 47(9): 1102-1114.
#addiction #recovery #addictionrecovery #mentalhealth #rehab #methamphetamine #harmreduction #drugs #harmreductionsaveslives #harmreductionworks #humanism #humanist #dopamine #brain #neurotransmitters #compassion #love
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