Behavioral change models in addiction recovery

An exclusive interview with Kathleen Sciacca, MA in which we explore some of the BEST WAYS to address substance abuse problems for a higher likelihood of change.

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Do you know a loved one who has a possible problem with drugs or alcohol? There are strategies and approaches to use and some to avoid.

More here on some of the BEST WAYS to address substance abuse problems for a higher likelihood of change. Then, we refer you to where you can find professional help.

Talking with a loved one about addiction?

It can help to recognize some effective approaches to communication and why they may work. So what are some of the communication skills considered effective by various models when talking to others about drug abuse or drinking?

We are joined today by expert, Kathleen Sciacca, MA to explore more. Kathleen is a Motivational Interviewing trainer, consultant, and practitioner for decades and is one of the country’s foremost experts and founder of Dual Diagnosis Treatment and Integrated Care (1984) and a teacher and supporter of the “Stages of Change”. Her experience extends into the realm of dual diagnosis cases…and we are grateful she has agreed to share her knowledge and experience on:

1. Effective models on: How to approach someone who is struggling with addiction

2. What effective strategies are used when trying to stimulate change in the ones we love

3. Dual Diagnosis treatment, Motivational Interviewing and the Stage of Change in addiction treatment.

Getting loved ones ready to quit

Motivational Interviewing (MI) works to facilitate and engage other’s intrinsic motivation so that people embrace change. MI helps those with problems with drinking or drug misuse explore and resolve ambivalence about change including getting help. The main goals of motivational interviewing are to engage clients, elicit change talk, and evoke intrinsic motivation to make positive changes.

We hope to provide insight in answer to your questions about how to (and how NOT to) talk with a loved one about addiction as demonstrated by these effective models. If you still have questions speaking to a friend or family member who needs addiction help, please use the section below. We will do our best to give you a personal and prompt answer.

ADDICTION BLOG: How do you first approach someone who may be struggling with drug or alcohol addiction? What’s the first step?

KATHLEEN SCIACCA, MA: In all three models of intervention to be discussed it is held that one addresses someone who is struggling with behavior change at the level of “readiness” that he or she presents regarding recognition that there is a problem, acceptance of the need for change and the change process itself.

Many treatment centers assume or approach those affected by drug and alcohol misuse as though he or she is ready and willing to participate in an “action” plan; hence the “action stage” in the stages of change. In fact, those who are not action ready, but rather view themselves as not having a problem or having a need for change are offered or required to participate in a behavior change plan; understandably they do not participate well or at all and are soon determined to be “non-compliant” or “resistant” clients. Programs or providers then proceed to terminate them. Many people go through this “failure scenario” repeatedly and avoid any further contact with behavioral health care services.

To begin with, one wants to listen for and “understand” the person’s perception and experience of their substance use and convey that understanding to him or her.

Examples: “So in your case you do not believe that drugs or alcohol use have any negative effect on any area of your life.”

Stages of Change “Pre-contemplation stage.”

Or, “So one side of your experience is that the use of drugs and alcohol is beneficial to you in a number of areas of your life; on the other hand you also experience negative effects physically and in several areas of your life.”

Stages of Change “Contemplation stage.”

Or, “So you have looked at many areas of the effects of substance use and the negative effects out way any benefits. You are ready to make a change.”

Stages of Change “Preparation stage.”

Or “You have considered a number of ways that you can approach this change and I have made recommendations that you would like to try.
Which shall be the first step you would like to take?”

Stages of Change “Action stage.”

If the client is at a different stage from the provider’s intervention there is a disconnect that may well result in discord in the relationship; at the very least there will not be a connection or conveyance of understanding on the part of the listener.

It is important to note that a person may be at different stages of readiness to change different behaviors.  For example, a poly substance user may be at the preparation stage regarding alcohol and the pre-contemplation stage regarding marijuana. In addition, if the person has co-occurring disorders he or she may be at the contemplation stage regarding mental health.  One needs to address these target areas at the correlating readiness stage. I have developed a tracking form that includes several different change areas for the same person for this purpose.

In sum, one must listen for and communicate with the person in a way that conveys understanding and is in keeping with the person’s readiness to change.

ADDICTION BLOG: What are some of the common mistakes people make when informally expressing their concerns?

KATHLEEN SCIACCA, MA: Common mistakes in expressing concerns frequently have to do with more “telling” than “listening.”

Providers, friends, relatives and others are poised to give advice to those we perceive are in need of some guidance. “Persuasion” is a common response to those whom we perceive are in need. Persuasion includes trying to convince others with logic, key arguments, It is a provider directed approach that includes confronting the client with reality; providing solutions; If they experience the person is resistant they may turn up volume.

Persuasion includes:

  • Asking the right question
  • Finding the right arguments
  • Giving critical information
  • Pursuing the correct logic
  • Provoking decisive emotions

These interactions are provider or listener driven and do not elicit the person’s side.

The communication principles in the models we will review here are “client-centered.” This means that the listener is listening to, eliciting and expressing understanding of the person’s thoughts, ideas, feelings, motivation, etc. regarding a particular target behavior.
Client-centered communication holds that the client has many of the answers inside him or herself including reasons to make a change that are the necessary motivators to move forward.

ADDICTION BLOG: What are some better, more effective strategies that CAN work? What are some of the core communication skills and principles of Dual Diagnosis Treatment, Motivational Interviewing and the Stages of Change that have demonstrated effectiveness?

KATHLEEN SCIACCA, MA: To begin with one wants to understand the client’s stage of readiness and listen, respond and communicate with the person on their level of readiness or stage of change.

The listener wants to do more listening than telling; wants to convey understanding of why the person, thinks, feels and what he or she may mean by what is being said.

Through the listening process the listener wants to elicit from the client experiences that will move the person incrementally from one stage to the next. For example, for a pre-contemplator the listener would intently listen for any thing that may be negative regarding the person’s substance use experience.

It may be that it bothers him or her that others bring up the behavior. That would be a peripheral concern, but one that is brought on by the client’s substance using behavior non-the-less. One would reflect the negative side of the client’s experience as a means of reinforcing it.

Example: “So even though you believe that the use of drugs and alcohol are not a problem in general, it bothers you that others think so and they nag you about it.”

To further reinforce this negative experience the listener might ask the client to discuss what the experience of the nagging is like -elaboration.

In addition to listening for negative elements of the person’s experience, one might also “elicit” possible problems, concerns, etc. from the client.

Example: “What concerns you the most about this.” This is an “evocative” question. It is one of a number of strategies to elicit “change talk.”

If the client gives a response to this question or other questions like it the listener has elicited “change talk”. Change talk equals reasons to change or the negative side of the consequences of substance misuse.

When the client has acknowledged and accepted both positive and negative sides of the behavior, he or she has moved to the “contemplation stage.” Here the client sees both positive and negative experiences and may be “ambivalent” or “stuck” regarding moving forward.

In dual diagnosis treatment the provider matches the client’s readiness to accept symptoms and behaviors and interacts with him or her based upon the readiness level. In addition, movement occurs for clients when “shame,” “self-blame,” and “guilt” are diminished.

Group treatment is the primary treatment and “exposure to information” is the strategy for alleviating these negative self-perceptions and freeing people to talk about their experiences. Exposure to information includes multi-media and participation is client-centered. For example, clients are “critics” not “students” of the information presented or discussed.

Information is geared toward providing the real elements and properties of mental health, alcohol and drug misuse and addiction.
For example, the presentation of the component of chemical imbalance in some forms of mental illness and the ways that medication may work to restore that balance; and the physiological aspects of alcohol misuse including physical addiction, effects upon brain chemistry, withdrawal and addiction/loss of control; the same kind of information for a variety of drugs such as cocaine, opiates, stimulants, etc.

As clients learn about the real properties of these chemicals they begin to discuss their own knowledge and observations in relationship to the information and progress to discuss their own personal experiences.

This process emphasizes a clear distinction from popular beliefs that a person is in control of their substance misuse behavior and simply chooses not to make a change and thereby is to blame for the consequences. In contrast, a client could understand that he or she approached the effort to stop using in good faith, achieved it for a short time and then returned to using not because they were negligent or didn’t care; but because chemical withdrawal symptoms kicked in and the discomfort was too great to tolerate, hence the drug would curb the uncomfortable or in some cases dangerous withdrawal effects.

In addition the dangerous interaction effects of chemical misuse with the chemical imbalance and sensitivity of mental illness can be determined by understanding how different substances effect brain chemistry and symptoms.

In sum, approaching people with incorrect perceptions and beliefs about their behavior can be damaging and wasteful and in many cases perpetuate the dilemma. Here the perception of the person’s behavior goes from “unacceptable” to understood empathically and thereby acceptable under the circumstances.

As Carl Rogers noted: When people view themselves as unacceptable they are immobilized; When they experience acceptance they are freed to change.

ADDICTION BLOG: When do addicts or alcoholics decide to change? What are some of the ways that we can help an addict or alcoholic be ready for change?

KATHLEEN SCIACCA, MA: People decide to embark upon change when they have reached their personal source of motivation and conviction that is genuine and propelling. Changing one’s behavior requires determination. Self-motivation is one of the most important prerequisites for behavior change. This is in contrast to external motivators such as bribery or coercion.

Change is difficult, change requires determination, for every individual the reasons to embark upon these efforts may be very different; but it will be their own reasons that will mobilize
and sustain their efforts.

This requires client-centered communication once again, whereby the listener is eliciting from the person reasons why he or she would embark upon a particular change. This “change talk” would be reinforced, elaborated upon, explored. Change talk frequently includes a person’s values.

Example: “I really want to be a better parent.”

Elaboration: “What would your parenting be like if you could change and improve it? How would that be different for your children?”

Elaboration brings change talk into more specific focus and makes it more salient for the person and less likely to recede as an important motivator for change.

From the perspective of the contemplation stage the person strengthens change talk and identifies more reasons to change until they out weigh the reasons to not to change and ambivalence is resolved; the person moves towards the preparation stage which is how will I do this?

ADDICTION BLOG: When should family members seek the help of a professional trained psychotherapist, licensed clinical social worker, or psychiatrist in order to help a loved one? Should ALL cases of substance abuse be referred to a mental health professional?

KATHLEEN SCIACCA, MA: The best efforts of family members would be to seek professional help or at minimum peer support for their relative. It is not appropriate or recommended that relatives attempt to provide therapy or counseling with their relative.
Finding a professional for their relative to talk to would be the more appropriate and useful place to extend their energy.

However, the relative would need to be some where along the continuum of readiness to be willing to speak to a professional or a peer about their situation.

A relative who is in pre-contemplation and sees no need to address his or her substance use is not a likely candidate to meet with a professional. However, that may be where a compromise may be reached.

Rather than the relative attempting to convince their relative through persuasion that he or she has a problem or a need for behavior change; he or she might instead discuss the possibility or willingness for the person to discuss their stance regarding substance use with a professional counselor, a therapist or a peer.

ADDICTION BLOG: What are some very basic considerations that family/friends need to know about change?

KATHLEEN SCIACCA, MA: Primarily that we cannot make other people change. Only the person him or herself can make that decision and do that for themselves.

In some cases it is important to emphasize personal choice and control. Example: “It really is up to you to decide to make this change. No one else can do it for you or make you do it.”

It is a futile struggle to relate to another within the belief that we can make them change. It can result in unnecessary frustration, anger and hardship for both parties. Acceptance facilitates change. Acceptance that this will be the person’s decision and choice.

Conveying understanding of the person’s situation, thoughts, ideas is the inroad for establishing a safe place to talk and for the person to get in touch with his or her own experiences, thoughts, feelings, decisions, etc. If there are life threatening substance misuse conditions relatives would do best to expend their energy in finding professional assistance for themselves and for their relative.

ADDICTION BLOG: When do addicts or alcoholics decide to change? What are some of the ways that we can help an addict or alcoholic be ready for change?

KATHLEEN SCIACCA, MA: Throughout the process of change “the action stage” the person may well need support from various sources in order to stay focused and on track.

If one would like to lend support it would be best to ask the person if there is any way one could be of any assistance or provide support during the change process. One would listen carefully to the person’s ideas and requests and convey understanding of the request and either agree to provide it or negotiate what he or she can actually provide. There needs to be a mutual agreement of how each of you will proceed in this supportive endeavor.
It will be best to stay within the parameters of what the person believes may be useful to him or her and not interfere with other areas of the person’s change plan.

ADDICTION BLOG: What is reflective listening and how can it be used to help people build empathy in a conversation with an addict?

KATHLEEN SCIACCA, MA: Reflective listening is inherently empathic. It is an intervention that was developed by Carl Rogers and was studied by him and his colleagues extensively. It is a very potent intervention that leads people to examine their internal references and in many cases reach a deeper understanding of their experiences. It is a therapeutic intervention that can lead to underlying and new revelations. As with all of the interventions discussed here reflections are “non-judgemental.”

Reflective listening is a response that is in the form of a statement as opposed to asking questions. The main intention of a reflection is to convey understanding. Conveying that one understands another’s thoughts, feelings, meaning, etc. it is inherently empathic. Empathic reflective listening. A reflection leaves off with the expectation that the speaker will consider if what he or she said originally is what was he or she meant to say or if the listener is accurate or inaccurate in his or her understanding.

Example: Client states “I cannot imagine what my life would be like without alcohol. It helps me relax and forget about my problems.”
Listener reflects: “You have come to depend upon alcohol to avoid thinking about your problems and you cannot imagine how else you could achieve that.”

This would be referred to as a complex reflection. A reflection that has paraphrased the client’s statements and inferred new or additional meaning to them. This conversation may continue.

Client: “I would not say that I depend on alcohol. I prefer to have a few drinks to relax. It is my choice.”

Listener reflects: “Drinking alcohol is a form of relaxation that you prefer over other ways to relax and it has the added benefit of helping you to avoid thinking about your problems.”

Client: “That sounds more accurate.”

Reflective listening stays with the speaker and follows rather than leads the discussion.

When one is asking questions he or she is leading the discussion. When one follows the client’s thoughts, ideas and feelings with reflective listening he or she is following the client’s ideas, conveying understanding and eliciting further thoughts and ideas. Discussions that include reflections are often preceded by open questions. In the above example an open question might have been, “How would you describe your drinking?” Open questions are also dispersed among reflections.

For example: “Tell me more about that?”

This allows one to stay on the topic and explore it further. Based upon the client’s response it may lead to other areas of the topic.

ADDICTION BLOG: What is your best method to boost up motivation in people willing to change?

KATHLEEN SCIACCA, MA: It is important that a client take steps in a change plan that lead to confidence building and success (the action stage). For example if the plan includes six possible actions to embark upon change, the one that is least threatening or complicated and the one that the client most believes he or she can achieve, would be recommended as the first step.

It is also important that people who have developed a plan always have the option to change it if they decide that an element of the plan is no longer comfortable for them. The change plan must include the client’s ideas and steps and the provider’s ideas and steps, but only those that the client agrees with. One would not include anything in the plan that the client does not want to do.

I recommend that the plan includes a functional analysis whereby the client identifies triggers that precede the unwanted behavior and coping skills to respond to those triggers and avoid relapse. As the person takes steps and changes his or her behavior incrementally he or she is achieving success. In a carefully executed change plan, with each step along the way the client is building confidence and achieving success; this would be important in sustaining and enhancing motivation.

ADDICTION BLOG: Is there anything else you would like to share with our readers?

Following a successful plan that results in behavior change there would follow a relapse prevention plan – the “maintenance stage.” This plan would collaboratively identify activities and supports that would sustain the person’s adjusted life style and environment and thereby prevent relapse into the unwanted behavior.

Despite this effort relapse is not always prevented.

If the person relapses or returns to the unwanted behavior this is not considered failure nor is the person to be scorned. One would communicate to the person that this happens to many people who embark upon change. Something may have gone wrong or was not working in the maintenance plan. Let’s review that plan and figure out how to adjust it and address any short coming or omission. The goal will be to minimize the return of the unwanted behavior and facilitate the person’s getting back on track (action/maintenance) as soon as possible.

However, it is understood that once there is a relapse the client can enter back into the stages of change at any stage, including the early stage of pre-contemplation. If so, we will need communicate on that level and proceed until the client reaches action and maintenance once again.

About the Interviewee: You can learn more about Kathleen and her prolific work by visiting the following links:
Dual Diagnosis Website
Motivational Interviewing Training
Dual Diagnosis Webinar
Training videos – Motivational Interviewing Core Skills
Change Talk
Giving Info – Advice
“The Family and the Dually Diagnosed.”
Additional publications
Recent Behavioral Healthcare Magazine article “A language for integrated care”
About the author
Lee Weber is a published author, medical writer, and woman in long-term recovery from addiction. Her latest book, The Definitive Guide to Addiction Interventions is set to reach university bookstores in early 2019.
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