Tools for addictions care: A community learning perspective

Recovery from addiction might be facilitated by using the Stages of Change model in conjunction with motivational interviewing. The patient and his or her addiction problem are viewed nonjudgmentally, and motivation is developed through the partnership of patient and support worker, rather than by assigning this task solely to the patient.

Stages of Change model

The Stages of Change model involves five stages of change originally defined by Prochaska and colleagues in 1982.[1] The model is also known as the Transtheoretical model, and its application is referred to as transtheoretical therapy. Using multiple studies of people who successfully achieved abstinence from their addictions, the authors found a common process by which a person moves nonlinearly through five stages—the nonlinear pattern being due to varying points of relapse and then re-entry into one of the five stages. A key point is that relapse in this model is defined as the rule more often than the exception, and thus time is not lost punishing or judging oneself for the relapse, and the focus instead is on recognizing how and why a relapse occurred, and then moving forward. In a recent book, Prochaska and Norcross define a sixth stage—the termination stage, in which the person no longer has any desire whatsoever to return to past addictive behavior.[2]

The five stages in Prochaska’s original model are precontemplation, contemplation, preparation, action, and maintenance. Each stage is defined by unique thoughts, feelings, and actions. A person in the precontemplation stage does not think that he or she has an addiction, whereas a person in the contemplation stage recognizes that an addiction exists but doesn’t necessarily want to change the addictive behavior. In the preparation stage, the person begins to decrease the addictive behavior. In the action stage, the person follows an action plan with the goal of abstinence. And in the maintenance stage, the person works on maintaining the state of abstinence. By understanding the different states of mind of a client at each stage in the model, a counselor, i.e., health care provider (physician, therapist, etc.) is able to recommend services and support that are best suited to that specific stage (see Table 1).

The tasks of a counselor trained in the Stages of Change model are specific to each stage. For example, the counselor raises doubts when a client is precontemplative, versus helping to avert relapse when a client is in the maintenance stage. Throughout the period of intervention, the counselor is aware of what the client is undergoing at each stage (see Table 2). For instance, the precontemplation and contemplation stages can involve “dramatic relief,” a process of experiencing and expressing feelings. To further specify the treatment needed for each stage of change, I worked with Dr Chris Fraser of the Cool Aid Community Health Centre to identify key services. By consulting various community service providers in Victoria, we developed a preliminary chart listing the most appropriate services for each stage of change (see Table 3: Part 1 and Part 2). We also developed a chart detailing gaps in services (see Table 4).

Motivational interviewing

Motivational interviewing is a technique based on the Stages of Change model, but focusing mainly on the area of motivation.[3] Motivation to change is defined as a behavioral probability—something that can be developed rather than something that is either present or absent in a person. The process of developing motivation is clearly delineated in eight skill sets:

• Giving advice

• Removing barriers

• Providing choice

• Decreasing desirability

• Practising empathy

• Providing feedback

• Clarifying goals

• Active helping

At the Victoria Youth Clinic, Dr Doug McGhee combines the Stages of Change model with motivational interviewing. He identifies key interview questions for each stage in his draft of clinician guidelines. Dr McGhee works to understand an addiction from the patient’s point of view: “I invite them to hold things that are in discord in their head simultaneously. I put words to the difficulties they are facing. I am on their side, and look at their struggle with them.”

Motivational interviewing is especially useful in emergency interventions, which has made it popular in the area of adolescent medicine. A recent study found significant reductions in alcohol consumption by adolescents in response to brief motivational interviewing in emergency department settings.[4] In follow-up interviews, 70% of alcohol-positive young adults were in favor of motivational interviewing.[5] Furthermore, motivational interviewing has been found useful for cocaine and heroin abuse. In another recent study, clients receiving motivational interviewing treatment had higher rates of drug abstinence than control groups, with ratios of 17.4% to 12.8%, 40.2% to 30.6%, and 22.3% to 16.9%.[6] Thus, several studies support the efficacy of using motivational interviewing for intervention in addictions medicine.

In addition, motivational interviewing has shown efficacy for people with substance-abuse rather than substance-dependence issues. In a systematic review, Dunn and colleagues found 11 of 15 studies significantly supported the use of motivational interviewing in brief interventions.[7] A meta-analysis conducted by Burke and colleagues found efficacy for techniques adapted from motivational interviewing for problems with alcohol, drugs, diet, and exercise.[8] In addition, approximately 75% of 72 randomized controlled trials support the efficacy of motivational interviewing in facilitating clinically important effects in physiological and psychological diseases.[9]

Research needed

Further research regarding the interventional efficacy of the Stages of Change model and motivational interviewing is needed. In particular, the physicians treating addictions in Victoria are interested in studying the application of these tools in order to balance the large volume of descriptive research that dominates the field of addictions medicine at present. Using the Stages of Change model to structure addictions medicine services as suggested by Dr Fraser may integrate community services in a way that maintains the focus on the kind of care the client is receiving. Also, further development of the definitions within these models can address problems in caring for the subpopulation of intravenous drug users. For this subpopulation, achieving abstinence from the substance is often quite difficult to attain. However, achieving abstinence from sharing needles can have a significant health impact on this subpopulation. Thus further development of these models, supported by research as to the application of these models, can improve community health.

Acknowledgments

For their assistance in editing the article, thank you to Dr Mary Kay Nixon, the Doctor Patient and Society Course director at the Island Medical Program, and Dr John Anderson, a PBL tutor and addictions medicine researcher. In addition, many thanks to several people working in the field of addictions medicine in Victoria: Dr Chris Fraser, Dr Doug McGhee, Ms Kris Bolton, Ms Jody Pickard, Mr Jeff McIndoe, and Ms Jody Paterson. These people took considerable time out of their busy schedules to share their valuable knowledge with me.

Competing interests
None declared.

Resources

References

1. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. Am Psychol 1992;47:1102-1114. PubMed Abstract Full Text 
2. Prochaska JO, Norcross JC. Systems of Psychotherapy: A Transtheoretical Analysis. Pacific Grove, CA: Brooks/Cole Publishers; 2003. 624 p. 
3. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press; 1991. 348 p. 
4. Spirito A, Monti PM, Barnett NP, et al. A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department. J Pediatr 2004;145:396-402. PubMed Abstract Full Text 
5. Hungerford DW, Williams JM, Furbee PM, et al. Feasibility of screening and intervention for alcohol problems among young adults in the ED. Am J Emerg Med 2003;21:14-22. PubMed Abstract Full Text 
6. Bernstein J, Bernstein E, Tassiopoulos K, et al. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend 2005;77:49-59. PubMed Abstract Full Text 
7. Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: A systematic review. Addiction 2001;96:1725-1742. PubMed Abstract Full Text 
8. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843-861. PubMed Abstract Full Text 
9. Rubak S, Sandibaek A, Lauritzen T, et al. Motivational interviewing: A systematic review and meta-analysis. Br J Gen Pract 2005;55:305-312. PubMed Abstract Full Text
  

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Maia Love, BSc, BGS

Ms Love is a third-year medical undergraduate student at the University of British Columbia. As a student in the Doctor, Patient and Society course offered through the University of British Columbia’s Island Medical Program, she conducted research in addictions medicine in Victoria, BC, under the supervision of Dr Mary Kay Nixon and Dr Chris Fraser. Her research focused on the Stages of Change—a model widely used to provide support in a number of clinical settings.