Advancing the Concept of Stages of Change & Treatment for Individuals with Co- Occurring Disorders MEETING PEOPLE WHERE THEY ARE Presented by Erwin Concepcion, Ph.D. LP 1 Objec,ves 1. Describe one primary way in which Stages of Change and Stages of Treatment differ 2. Iden,fy two new ideas related to resistance and change 3. Describe two ways in which Stage of Treatment can be used to help in the change process 2 Clear Difference Between Pre- Ac,on & Ac,on Stages From Patrick Boyle, 32009 based on Di Clemente 1
Pre- Contempla,on Advantages of Use Disadvantages of Use Cope Sleep Socialize Fight boredom Legal problems Family conflict Cost 4 Contempla,on Advantages of Use Disadvantages of Use Cope Sleep Socialize Losing Children Legal problems Family conflict Fight boredom AMBIVALENCE Cost 5 Components of Change Resistance Ambivalence Mo,va,on 6 2
Ac,on Advantages of Use Disadvantages of Use Losing Children Legal problems Cope Fight boredom Family conflict Cost Course of dual (co- occurring) disorders Both substance use disorders and severe mental illness are chronic, waxing and waning Recovery from mental illness or substance abuse occurs in stages over,me Precontempla,on Contempla,on Prepara,on/Determina,on Ac,on Relapse preven,on 8 8 Staging Approach to Treatment Identifying the individual s stage of change and the approach most likely to succeed in helping the person move forward in being ready for change Pre-contemplation Contemplation Preparation Action Maintenance Relapse, if it occurs, is another stage but does not require the patient automatically go back to the beginning 9 3
Real Change Always Creates Resistance Understanding resistance and addressing what you learn is central to managing it. Resistance can be a valuable tool in the successful accomplishment of change if we are willing to consider two new ideas about resistance to change: 1. We tend to see resistance as part of the problem of change, and we focus on overcoming it rather than engaging it. 2. Resistance is a form of feedback and, as such, it provides poten,ally valuable informa,on that may not be available any other way. - Jeffrey D. Ford & Laurie W. Ford 10 Staged Approached to Treatment STAGES OF CHANGE STAGES OF TREATMENT PrecontemplaXon ContemplaXon AcXon Maintenance Pre- Engagement Engagement Early Persuasion Late Persuasion Early Ac,ve Treatment Late Ac,ve Treatment Relapse Preven,on In Remission or Recovery 11 Staging Multiple Problems Substance Abuse Bipolar Disorder 12 Employment 4
Life - Work Mental Health Treatment Chemical Dependency Treatment - School - Housing 13 Life - Work - School - Housing Chemical Dependency Treatment Mental Health Treatment 14 15 5
SUBSTANCE ABUSE TREATMENT SCALE- REVISED PRE- ENGAGEMENT (pre- contemplaxon) The person (not client) does not have contact with a counselor and meets the criteria for substance abuse or dependence ENGAGEMENT (pre- contemplaxon) The client has had only irregular contact with a counselor and meets criteria for substance abuse or dependence EARLY PERSUASION(contemplaXon) Regular contact with a counselor conxnues to use the same amount of substances or has reduced substance use for less than 2 weeks and meets criteria for substance abuse or dependence LATE PERSUASION (preparaxon/planning) Regular contact with a counselor, shows evidence of reducxon in substance use for the past 2-4 weeks but sxll meets criteria for substance abuse or dependence EARLY ACTIVE TREATMENT (AcXon) Client is engaged in treatment has reduced substance use for more than the past month but sxll meets criteria for substance abuse or dependence during this period of reducxon LATE ACTIVE TREATMENT(acXon) The person is engaged in treatment and has not met criteria for substance abuse or dependence for the past 1-5 months RELAPSE PREVENTION (maintenance) The client is engaged in treatment and has not met criteria for substance abuse or dependence for the past 6-12 months REMISSION The client has not met criteria for substance abuse or dependence for over one year 16 Janice Is a young single woman who has been diagnosed in the past as having schizophrenia, occasionally shows up at the mental health center demanding to see someone. She knows she has a case manager but cannot remember her name. She last saw her case manager three months ago when she wanted to get energy assistance. Her contacts are infrequent, and usually involve wan,ng money, food or cigare^es. Jeanne smokes marijuana on a daily basis but does not speak to her case manager about it. 17 MENTAL EHALTH STAGE OF TREATMENT ENGAGEMENT (pre- contemplaxon) Has had irregular or no contact with community provider Has not self- idenxfied prior to admission as having mental health problem Does not idenxfy as having mental illness No readiness to engage in treatment Shows li#le or no desire to address the impact of mental illness on quality of his/her life EARLY PERSUASION (contemplaxon) Has had regular contact with community provider Ambivalent about accepxng treatment for mental illness TherapeuXc alliance is developing or present Mental illness can be discussed Has some readiness to discuss the impact of mental illness on the quality of his/her life LATE PERSUASION (preparaxon) Has been engaged in relaxonship with community provider Willing and able to parxcipate in a discussion/group about mental illness TherapeuXc alliance is present Discussing psychiatric symptoms Evidence of symptom reducxon for 2 to 4 weeks ACTIVE TREATMENT (acxon) Has engaged in community treatment Has had an acxve working relaxonship with a community provider Discusses mental illness openly with treatment providers/team Is working toward stability as a goal but sxll may be experiencing psychiatric symptoms Is exploring ways to enhance quality of life through recovery planning RELAPSE PREVENTION (maintenance) Engaged in treatment Acknowledgement that psychiatric symptoms are problemaxc Aware that an occasional return of mental health symptoms may occur Has developed and uses knowledge and skills to support recovery from mental illness Has idenxfied and connected with a support network Management of mental health symptoms for more than 6 months 18 6
Ready? Willing? Able? Mo,va,on for Change 19 Readiness Ruler One thing they would like to try to do new or different Turn to a neighbor and do a readiness ruler that includes: What is the change? How important it is to you? Why isn t it a (1 or 2 numbers lower) How confident are you that you ll be able to do this? What might hold you back? What s your plan for doing this? 20 21 7
Pay- off Matrix Status Quo (Using) Change (Not Using) Advantages Disadvantages 22 + Status Quo (Using) Janice s Pay- off Matrix I thought it was going to solve things or at least I wouldn t be bothered by them Hanging out with my friends Cope ager work Cope with my parents Cope with my ex- husband Cope with life and pain Cope with everything! Change (Not Using) More clear thinking Having money now to spend. Not waking up broke in the morning No more legal troubles. I would not be in this situa,on if I didn t use. Being close to my parents Go back to work be successful! _ Not having money Not having a place to live Losing my family Not having a good job Losing my belongings Not having friendships Not having true friendships Having pain. Broken tooth I s,ll have some feelings like depression Maybe losing what li^le friends I ve got Facing reality and problems Can t sleep Bored with nothing to do 23 OBJECTIVES (Desired Behaviors & Outcomes) Build a therapeu,c rela,onship Develop a crisis plan (ogen a program goal) Establish peer supports or healthy supports Further assessment and collateral informa,on Iden,fy triggers for use Manage triggers, cope with triggers, or avoid triggers using replacement ac,vi,es (sober friends, places, or ac,vi,es) Understand the rela,onship between use & symptoms and symptoms & use Manage stress/triggers that leads to use (iden,fying, learning, prac,cing, and using skills) Manage cravings (an,- craving medica,ons) Manage urges (thoughts about use) Learn refusal skills Address grief and loss issues Par,cipate in self- help Develop a relapse preven,on plan Conduct further or ongoing assessment 8
Stagewise Interven,ons Engagement Support & Mo,va,onal Approaches Persuasion Mo,va,onal, Payoff Matrix, Persuasion Group, Educ AcXve Tx Skill Building, Cogni,ve Behavioral Relapse Prev Skill Prac,ce, Cogni,ve Beh & Self- Help 25 26 27 9
28 29 Mo,va,on People ogen say that mo,va,on doesn t last. Well neither does bathing That s why we recommend it daily. Zig Ziglar 30 10
Puong it All Together Resistance is a product of change Our ability to establish a therapeu,c rela,onship is cri,cal to helping people advance into ac,ve treatment 32 11