INTEGRATING STAGES OF CHANGE IN DAY TO DAY PRACTICE Judith Magnon RN-BC, BS, CAC APNA Conference, Hartford, CT IDDT/Stages of Change BASED ON Recovery Thinking The person is a partner in the treatment process and The provider is a guide with knowledge and experience to share, discuss, educate, explore, coach, advise, assist, encourage, negotiate, role model, validate, etc. 1 4 Conflict of interest note: This presenter has no conflict of interest, commercial support, or off label use to disclose. 10% of Programs Address The 80% Who are in: Precontemplation, Contemplation, STAGES OF CHANGE What Process and techniques are helpful in what stage? What is the focus of each stage? What are the Tasks of each stage? 2 5 Learning Objectives: Gap: Skill-How to integrate Stages of Change into mental health and substance abuse treatment with individuals experiencing serious mental health disorders and substance abuse disorders. By the end of this presentation the learner will be able to: Understand Stages of Change and how to integration of Stages of Change into mental health and substance abuse treatment with individuals experiencing serious mental health disorders and substance abuse disorders. List the Stage of Change Process and Techniques that need to be incorporated into nursing practice. Cite examples of nursing practices that can effectively incorporate Stages of Change. READINESS TO CHANGE Individual STAFF Not interested Very interested in change 1 2 3 4 5 in change (Precontemplation) () 3 6 Judith Magnon, RN-BC, BS, CAC 1
Stages of Change in which particular CHANGE PROCESSESS are most useful Precontemplation Contemplation Maintenance Consciousness-Raising Social Liberation Emotional Arousal Self-Reevaluation Commitment ACTION Reward Countering Environment Control TASKS: Become aware of self defeating defenses what they are and how they operate Develop insight-- Increase information/knowledge about the problem Explore barriers to change Be willing to talk, hear feedback, feel cared for Find hope, Gain confidence Helping Relationships 7 10 Precontemplation Characteristics: Unaware of Problem Problem is external Resistant, Hopeless Demoralized, Defenses: Denial, minimize, Thinking Stage Internalize, Projection, Rationalization Displacement Present as Depressed, Anxious, Afraid to risk, Believe they are in control How to help Precontemplators Make therapy a safe and supportive place, encourage them to ask someone they trust to share with them their defenses. Use education to show them how defeating defenses can be. Give them permission to be human, encourage participant to be open about their defenses. Help them get control over their defenses. Remind them that they are not ready for action, that they need to talk, get feedback, and feel cared for. They need to communicate with others what their goals are to change. Remind them that this is a process and that each step builds toward the next and that it will not happen overnight. 8 11 Precontemplation GOAL: Shift the focus to THINKING and INSIGHT Increasing information about self & problem Change Process: Consciousness Raising Social Liberation Techniques: Observations, confrontations, interpretations, How to help Precontemplators DO Recognize that participants need assistance to change Provide feedback on participant defenses Assess for shame, guilt, embarrassment DON T Push someone into action, Nag, Give up, Enable 9 12 Judith Magnon, RN-BC, BS, CAC 2
DATA COLLECTION: (Nursing process) Psych/Social Evaluation: Comprehensive Eval includes biological Mental Status Legal History SA & MH Substance Abuse Profile: Identify Risk Factors, Triggers, strengths, and Stage of Change Collateral Resources: Family, Law Enforcement, Employers, Healthcare Workers, Friends, Lawyers Medical Profile, LABS QUESTIONNAIRES: Alcohol Expectancy Questionnaire Alcohol Effects Questionnaire CAGE Questionnaire Comprehensive Drinker Profile The Drinker Inventory of Consequences Addiction Severity Index Substance Abuse Subtle Screening Inventory DATA to give feedback from your assessment 13 Providing Feedback Target the person s present situation and its risks or consequences. Journals Family Input Friend s input Objective tests Blood Work/Medical tests Probation Input Work Performance 16 Consciousness-Raising The first step to fostering intentional change is to become conscious of the self-defeating defenses that get in the participant s way. KNOWLEDGE IS POWER so provide EDUCATION Help them Become aware of defenses Help them transform defense's into coping (Rationalization- explaining away problems to Logical Analysisthoughtfully and carefully analyzing problem behaviors without becoming overwhelmed by emotions Checking the participant s defenses Increased awareness and practice can help a participant turn a maladaptive defense into a positive behavior. 14 Treatment Planning --- Integrating S of C Precontemplation Goal: Shift in Focus Target participant s perception Educate to develop insight Increase Hope Consciousness Raising Nurse Objectives: Complete Assessments Review Assessments Provide Education Stress Management Coping/Wellness information Assess for Depression Assess Lifestyle Interventions: Assessment Tools Medical Evaluation Education Groups Social Alternatives Encourage use of Journaling Coping/Stress Management Skills Use of Timeline Lifestyle Awareness Encourage Wellness and healthy diet through education Encourage Exercise 17 Social liberation involves utilizing community resources, social norms to create more alternative and choices for problem behavior. Examples include: No Smoking sections Fat free foods Designated drivers Public service messages Employee wellness programs Reimbursement for exercise equipment Lower insurance rates for non-smokers. Self-help groups Precontemplators can perceive these forces as positive and helpful, in which case they will progress to contemplation. They may also perceive these forces as coercive, believing that their rights are being infringed upon by society. Contemplation Characteristics: Thinking Stage Increase awareness causes ambivalence (Normal) There is a resistance to change, The desire to change exists simultaneously with an unwitting resistance to it. Open to information about problem, May feel stuck, may be avoided, Await some type of external intervention, Analysis causes paralysis, Fear of failure, Fear of new self, Threatened identity or security, Wait for the magic moment. 15 18 Judith Magnon, RN-BC, BS, CAC 3
Contemplation GOAL: Shift the focus to awareness of the problem and the solutions Techniques: Consciousness Raising & Social Liberation Emotional Arousal Self-Reevaluation TASKS Increase awareness of problem and solution, Self-appraisal, Resolve fear and ambivalence, Make an informed decision to change problem behavior, Pros and cons of changing, Skill building, exercise, functional analysis Chronic Contemplators Substitute thinking for acting Will make statements about taking action in the future or someday Conflicts and problems are suspended Decisions are never completed is avoided Await some type of type of external intervention 19 22 Contemplation COMMENTS: Shift in perception, Learn to make an informed decision, Positive attitude, hope, self-esteem, Need a support system, Dual disorders--tx both!, Environmental control Contemplation is essential prior to preparation. Ambivalence is a natural part of the change process. Contemplators may present as: Depressed Passive Serious about solving their problem Eager to talk about themselves and their problem Open to any information about their problem Characteristics Practice behavior change Stage Ambivalence is resolved, Self-reevaluation, anticipate roadblocks, Make a decision to take action By end of stage: Make a commitment to change Have self-confidence, Hopeful about future, careful planning, rehearsing for action, Self pride, Become responsible for behavior. 20 23 Emotional Arousal Experiencing and expressing feelings about one s problem and solutions Emotions can be harnessed to provide the energy to move from contemplation to preparation. Not the same as fear arousal, Serves as a cleansing function Do not confuse emotions with change TECHNIQUES: Psychodrama, grieving losses, role-playing Self-Reevaluation Assessing feelings and thoughts about self with respect to a problem This reevaluation should leave the participant thinking, feeling and believing that life would be much better if his behavior was changed. Develop techniques that focus on: Abandoning the hope of finding an easy route to change Confronting difficult questions regarding the outcome of change Looking at how change will effect self-image Value clarification, imagery, corrective emotional experience 21 GOAL: Using the decisions made in Contemplation Stage to develop specific steps to solve the problem for implementation during Stage Change Process: Social Liberation, Emotional Arousal, Self- Reevaluation Commitment: Choosing and committing to act coupled with a belief in the ability to change, which reinforces the will to act. 24 Judith Magnon, RN-BC, BS, CAC 4
TASKS: List benefits of changing, Focus on positive outcomes, Let go of past, Work on New self-image, Belief in ability to change, Anxiety is a normal reaction to change, Skill building (anger management, assertiveness training, 12 step groups) For Commitment: Take small sets, Set a date, Go public, prepare for a major operation, Create your own plan of action, Ask for help, Use support network GOAL: Purposefully modify lifestyle in order to alter behavior based on commitment. Change Process: Countering Substituting healthy responses for problem behaviors Active diversion: keeping busy Exercise, Relaxation 10 to 20 Min. per day Positive self-statements Assertion, Desensitization 25 28 COMMENTS: Recovery is a process not an event, [A marathon not a sprint] Help them Identify strengths, Help them Learn new skill to succeed, Stress the Need for a sober support system, Be aware that Relapse may occur and it is learning opportunity. Countering (Cont d.) Counter thinking: substituting positive thoughts for negative/b&w thoughts (I would like rather than I need to) Assertiveness: exercising right to communicate your thoughts, feeling, wishes, and intentions clearly, thereby countering feelings of helplessness. 26 29 Characteristics: Modified lifestyle to alter behavior, Need to be committed to change, Understand-- No guarantees that action will be successful, Prepared Have an action plan, Aware of pitfalls, May be active in 12 step program Change Process: Environmental Control: Restructuring the environment so that the likely occurrence of a problematic stimulus is significantly reduced. Avoiding stimuli that elicit problem behaviors. Techniques: Assist with Avoidance: (i.e. bars, street drug dealer lives on); Deal with cues & develop a plan; Assist with Reminders: To do list, including use of relaxation & exercise, hobbies, appointments, etc. 27 30 Judith Magnon, RN-BC, BS, CAC 5
Change Process: REWARD: Rewarding self, or being rewarded by others, for making changes Environmental control modifies the cues that precede & trigger problem behavior, Reward modifies the consequences that follow and reinforce it. Techniques: Encourage use of Positive thoughts: Nice job relaxing. A way of re-parenting self! Contingency Contracts, Overt and covert reinforcement Maintenance/ Recovery Management Change Process and Techniques: Commitment, countering, Environment control, Reward as reviewed earlier Relapse Prevention tools Encourage use of Hobbies, ensure that identified Skills that need to be in place are and look for new areas that may come up requiring new skills, Social Alternatives, Exercise, etc 31 34 Tasks Be aware of time, effort and energy needed to change, Relapse prevention skills No simple solutions to complex problems COMMENTS: Relapse may occur, Need to have support system in place already, Change in lifestyle, Treat core issues. HELPING RELATIONSHIPS Helping relationships: Provides a supportive context to process events and see self as others do Assist to break down defenses and move to next stage Provide empathy, warmth, and feedback, especially positive as a motivator Be aware of the difficulty to change behaviors Respond to their requests for support 32 35 Maintenance/ Recovery Management Goal Maintain new behavior FOCUS On Behavior and Lifestyle Relapse Prevention: Task Continue integration and utilization of new coping skills Goal Abstinence 33 Nursing practices that can effectively incorporate Stages of Change Use of nursing Knowledge: Knowing the right Stage of Change means Providing the right stage based interventions Increased ability to Assess, Educate, partner, collaborate, assist, coach, assess, Plan, Implement, Evaluate and Document Increased skill building abilities to enhance quality of life by addressing both illnesses in the correct Stage of Change at the same time 36 Judith Magnon, RN-BC, BS, CAC 6
Nursing practices that can effectively incorporate Stages of Change Enhances your Nursing skills: Increases ability to be team player, Increases ability to have compassion for both illnesses, Increases willingness to be on the journey over a long period of time, Increases ability to share your medial knowledge about both illnesses, etc Increases your ability to improve outcomes Increases job satisfaction Objectives-- Precontemplation: I will explore how my day to day choices impact my reaching my goals. Contemplation I will explore how my day to day choice to drink impacts my reaching my goals. 37 40 Goals---- Precontemplation Stage S. A. Sample: I will explore how my choices impact my reaching my goals. Contemplation Stage S.A. Sample: I will explore how my choice to drink alcohol impacts my reaching my goals. Objective--- Stage I will explore the consequences of my use by not using for a 3 day period, than a 7 day period and than a 14 day period over the next 3 months. Stage I will not use any alcohol or drugs. 38 41 Goals-- Stage S. A. Sample: I will explore how my use negatively impacts my reaching my goals. Stage S. A. Sample: I will be sober and clean. Interventions: Remember to list the stage appropriate intervention/techniques for each issue. This keeps you focused on stage appropriate tools and aligned with them. It will decrease your frustration and theirs. 39 42 Judith Magnon, RN-BC, BS, CAC 7
Progress Notes, etc. Document the Stage of Change that the person is in for each issue:i.e. Mental Health recovery Substance Abuse Use the words that explain their characteristics from the stage you decide matches them. This keeps you focused on the appropriate tasks and interventions. 43 References: Mueser, K. T., Noordsy, D. L., Drake, R. E., Fox, L (2003). Integrated treatment for dual disorders: A guide for effective practice. New York: Guilford Press. Miller, W. R., & Rolnick, S. (2002) Motivational Interviewing (2nd ed.): Preparing People for Change. New York: Guilford Press. Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994) Changing for Good. New York: Avon Books. TIPS: #35 Enhancing Motivation for Change in SA TX #42 SA TX for Persons With Co- Occurring Disorders Order FREE at Webb site: WWW.ncadi.samhsa.gov (National Clearing house for alcohol & drug information) 44 Presenter Information Judy Magnon, RN-BC, BS, CAC WestBridge 7300 Grove Road Brooksville, FL 34613 jmagnon@westbridge.org Office (352) 678-5553 Cell(727) 277-6094 45 Judith Magnon, RN-BC, BS, CAC 8