Understanding Their Journey - Stages of Change Part 1

Stages of Change - The Healing Journey

Written by and for people with Lived Experience - Port Alberni Community Action Team - Families Helping Families

Today’s Learning Moment – 05 24 21 Issue: Understanding Their Journey – Stages of Change Part 1.

Yeap, we’re going to go through some theory in this article. Learning Moments is big on making it easy, so even though we’ll throw some technical terms into this article, they’re only there so you can research for additional information if you want to. Also, it will give you the lingo you'll need when discussing treatment options with Health Care Teams. We’ll explain everything as we go.

Folks with a family member suffering from Substance Use or Mental Health challenges can benefit greatly when they understand the stages of change a person goes through on their healing journey. In other words, understanding how they see themselves. When we understand, we can walk beside them, supporting them in their journey. When they become self-aware of their struggles and ready to change we can support their hope and possibility for change.

Professionals often use a model called Motivational Enhancement Therapy (MET). It’s been around for approximately 20 to 30 years. Often we combine MET with motivational interviewing (MI). I used these tools regularly in my professional counsellor career. Together they provided a hybrid understanding and communication model that can be key in producing a more effective relationship with people using substances and facing negative consequences in their lives.

Let's outline the stages of changes of MET so we can understand where a person might be on their journey of Mental Health or Substance Use (MHSU). Knowing which stage they’re at gives us the chance to connect with them and help them move to the next stage. The theory is that there are five stages of change that people move through. By the way – MET doesn’t just describe the journey of a person with (MHSU). It also describes your journey trying to come to grips with a family member with MHSU. 

1.     Precontemplation, sometimes known as denial:  — I don’t have a problem, I don’t need to change

2.    Contemplation: I might have a problem I am thinking of making a change but I don’t feel quite ready yet.

3.     Preparation:  I know I need to change and I am making plans.  I’m getting ready

4.     Action:  I am following through with the plans I made

5.     Maintenance:  I have established change in my life, it’s no longer new to me but part of my life 

One caution here. Sometimes people will get stuck and never progress from one stage to the next.

If they do progress through to stage five, it’s necessary to add one final stage. Relapse must be added, as it inevitably occurs as part of the process of addiction. While the journey is described as linear, like many concepts it is more fluid.  In fact, it’s usually portrayed as a circle or cycle of back and forths.

So I’ll briefly explain each stage and try to apply my own experience to the explanations. This will be a multi-part article. We’ll cover stage one here. The other stages will be detailed in future articles.

Precontemplation:  Problem? What problem?

So this is actually a state of unawareness.  In this stage, a person is unaware of any problems that might be occurring because of their substance use.  The best example I can think of is my history of smoking cigarettes.

I was brought up, like many in my age group and even younger, in an environment where almost everyone smoked.  Kids and adults alike were sparking up constantly, inside-outside, buses, theatres, planes, restaurants, bars, you name it and there was a haze of smoke everywhere you went. I even have a cigarette burn on the head of my guitar from putting a butt in between the strings while I was playing songs. Many of us wannabe rock stars had this badge of honour.

Everyone smoked, it was advertised and promoted as a way of life. If anyone said it was a problem in those times, they were “corrected” immediately with “what are you talking about?” as I would light up another smoke.  “I can quit anytime but I don’t want to right now, I don’t have a problem”.  This wasn’t denial. I legitimately did not see a problem.  No one was really aware of the consequences then and we were still in the social state of smoking is cool. So most of us did not see a problem. We were in precontemplation.

It is really important to recognize this state of mind.  It is usually someone else who begins to see or assume that there is a problem. It’s important what we say to the person at this point. This is where the language of motivational interviewing (MI) steps in.  It recognizes and validates precontemplation as a very real state of mind. The language itself helps eliminate the stigma and judgement that often accompanies someone’s realization that maybe (or definitely) my loved one has a problem with using substances.  So probably out of kindness, compassion and concern we jump in with both feet and tell the person they have a problem.  We tell them they need to quit, maybe “just stop” becasue it will ruin their life or worse.  We may even jump right into “your using substances so you must be an addict”.

The loved one then looks at us funny or angrily and legitimately wonders what we’re talking about (at least in the beginning). When someone told me I needed to quit smoking I got to the point where I would nod politely and light up a smoke.

It wasn’t until a close friend, okay girlfriend, who didn’t smoke, looked at me one day while we were out and about and said, “I noticed that every time you get stressed out, you have a smoke.  Did you know that?”  I stopped, lit a smoke, and realized that I didn’t really know that. Her statement of curiosity and awareness was the key that unlocked my journey to eventually quit.

Read those last two paragraphs again.  Now notice the difference in how the language is used.  Out of concern, we jump to assumptions about the person using substances.  Often we get frustrated when the person doesn’t respond the way we would like them to. The person gets frustrated and resistant to us. This is what traditional approaches would consider denial. 

MI does not.  MI recognizes this as a state of unawareness of any problems at this point.  “Denial” implies judgement, “unaware” implies a need to find a solution to reach an awareness.  

Now notice my girlfriend’s statement. Even though I likely did spark up at that point, we actually had a decent conversation about what she noticed. She stated a noticeable fact, something she observed over time, and introduced it to me as a kind of a challenge or constructive confrontation, without judgment or advice.  Just the observation. This is what is known in MI as “raising discrepancy or doubt”. I didn’t suddenly stop smoking, but I did move from precontemplation to contemplation.

So language is important in all stages. Advice giving or developing strategies can be useful in one of the later stages. The language used at this stage can mean the difference between raising awareness or raising resistance. At this stage, the goal is to create awareness and begin to create motivation. It is not the stage to expect sudden change. It is not a stage for promises or commitments (they will be broken at this point). So what do we say? What can we expect?

Establish rapport, ask permission, and build trust. 

People won’t change unless they believe it is safe for them to do so. They won’t engage in conversation or interactions if blame, judgement and unrealistic consequences are imposed at this point. Ask permission to speak of what you have noticed. Reassure that you will listen even if you don’t agree on everything.

Raise doubts or concerns about substance-using patterns by:

Exploring what you have observed (like my girlfriend did) without blame or judgement

Asking your loved one what their experience of using is like for them.

Exploring the pros and cons of substance use: If you continue to use in the same way, what’s good, what’s bad; If you made a change to your use, what’s good, what’s bad (either beginning with harm reduction, reducing use, or abstinence. Don’t assume the change will be abstinence right off the bat)

Examining discrepancies between with the person’s use. E.g. So help me understand why you never have any money after getting paid….help me understand why you just lost your job…etc.  Remember no judgement. Take the “Colombo Detective” approach, be curious, try to help them put together missing pieces and inconsistencies.

Offering factual information about the risks of substance use and always ask permission to do so.

Express concern and keep the door open.

Practice using “I” statements:  I’m afraid that, I’m concerned for you,  I get scared when, I get angry when, I’m relieved when…   and so on.

Notice that no one is pointing a finger and saying “you’re an addict or you’ve got a problem”  All that will get you is resistance, lack of trust, lack of rapport and usually contributes to an increase in the use. It is never up to anyone other than the person to establish and acknowledge a problem.

So I have adapted the above points from the sources below to fit more for families rather than a counsellor or clinician. But this is what many of us do as counsellors. Many people come in for counselling not feeling ready or even recognizing the issues. There’s no reason that family members can’t adapt their communication and interactions to include MI language and strategies from stages of change.

Precontemplation and contemplation are the typical stages that most of us are seeing with our loved ones. Next article, I will write about contemplation. In the meantime, there a few resources listed below and the internet is flooded with information about Motivational Interviewing techniques and information on the stages of change. I highly encourage everyone to study up. As I said before, this is likely the most effective tool kit I have used as a clinician.

All our past articles can be found here: https://ptalbcat.blogspot.com/
The link to this specific article is: https://ptalbcat.blogspot.com/2021/05/stages-of-change-part-1.html SHARING is best done by copying and pasting this link everywhere you want.

Author: Ben Goerner— Ben is a retired BSW MHSU Clinician. He advocates for people with substance use or mental health challenges.

Families Helping Families is an initiative of the Port Alberni Community Action Team. We send out “Learning Moment” articles regularly to help folks understand substance illness. Knowledge is vital in understanding the illness of our family members. You may copy, distribute or share our articles as long as you retain the attribution. You can be added to our distribution list by dropping us a note at - albernihelp@gmail.com

Go here for Part 2 in the series

This article was written using info from the following sources:

References

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviour. The Guilford Press.

Prochaska, J. O., & Norcross, J. C. (2001). Stages of change. Psychotherapy: Theory, Research, Practice, Training, 38(4), 443–448. https://doi.org/10.1037/0033-3204.38.4.443

https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies/motivational-enhancement-therapy 

Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35.) [Table], Figure 2-2: Appropriate Motivational Strategies for Each Stage of Change. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64963/table/A62587/