Readiness to change

Transcript

RyanSAMHSA, the federal Substance Abuse and Mental Health Services Administration, tells a story about a seventeen-year-old it calls Myra. She's in foster care and visits a clinic three times in one year. Each time, someone talks with her about her cannabis use.

SoheeAnd the first time, she says quitting matters. But she's not ready to make a plan. The second visit, still no plan. Then on the third visit she says she's ready to quit, and she picks the people who'll support her.

RyanWelcome to EPPP Prep, the podcast. I'm Ryan.

SoheeI'm Sohee. Myra's story is the heart of today's topic: readiness to change. The blueprint lists it as a treatment decision factor, and it runs straight into health promotion too.

RyanNotice what the clinic didn't do. They didn't decide she was a lost cause after visit one. They met her where she was, three times.

SoheeAnd the best-known map of where people are is the transtheoretical model, often called the stages of change. A systematic review by Hashemzadeh and colleagues describes the core idea: changing a behavior isn't a coincidence, it's a process, and different people are in different stages of change and readiness.

RyanFive stages. Precontemplation, contemplation, preparation, action, and maintenance. And the same review notes it's possible to return to a previous stage.

SoheeLet's define each one carefully, because the exam gives you a client's words and asks for the stage. I'll use the definitions in an appendix to a Cochrane review by Mastellos and colleagues.

RyanPrecontemplation. The person has no intent to change in the near future, usually measured as the next six months. They may not have the information, or they may have tried and failed and feel demoralized.

SoheeAnd here's a line worth remembering. These people are often characterized as resistant or unmotivated, and tend to avoid information or discussion about the behavior.

RyanContemplation. Individuals openly state they intend to change within the next six months. They see the benefits but are still weighing the costs. The appendix says they can get stuck here a long time. It even calls them procrastinators, and says they're often not ready for traditional action-oriented programs.

SoheePreparation. The person intends to take steps soon, and most often has a plan, like signing up for a class or talking to a counselor. The appendix says these are the people who should be recruited for action-oriented programs.

RyanAction. People have made overt changes within the past six months. It's the most visible stage, and it takes real commitment of time and energy.

SoheeAnd maintenance. People work to avoid relapse, and grow more confident. The appendix makes a point I love: maintenance isn't static. It's a continuation, not merely an absence of change.

RyanPause and think. A client says: I know my drinking is hurting my marriage. I'll probably cut back sometime this year. But honestly, I like how it relaxes me. Which stage?

SoheeContemplation. He openly intends to change within months, and he's still weighing benefits against costs. Not precontemplation, because he sees the problem and intends to act. Not preparation, because there's no plan and no first steps.

RyanSo why does the stage matter for treatment? Because the right tool depends on it.

SoheeA study by Zink and colleagues in the Annals of Family Medicine, on helping survivors of intimate partner violence, summarizes it well. Prochaska and colleagues identified ten tools, cognitive-affective or behavioral. The cognitive-affective tools, like consciousness-raising, dramatic relief, and self-reevaluation, are used in precontemplation and contemplation. Behavioral tools are used in action and maintenance.

RyanAnd the article's conclusion is simple to state: using the right tool for each stage is important.

SoheeThat same study gives a lovely example of consciousness-raising. Women in precontemplation often didn't recognize their partner's behavior as abusive. When a physician asked about violence, that question itself was raising awareness.

RyanHere's the exam trap. A client in precontemplation, and the answer choices include: build a detailed relapse-prevention plan, assign a quit date, or discharge them as unmotivated. All three mismatch the stage. The better answer raises awareness and explores their view, without pushing action they haven't chosen.

SoheeWhich leads us to the method most associated with that kind of conversation. Motivational interviewing.

RyanA systematic review by Rubak and colleagues in the British Journal of General Practice tells the origin story. Motivational interviewing evolved from treating alcoholism, and was first described by Miller in 1983.

SoheeMiller and Rollnick defined it as a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence.

RyanAmbivalence is the key word. The client wants two things at once. Wanting to drink and wanting the marriage. A review of reviews in PLoS One, by Frost and colleagues, puts it this way: motivational interviewing aims to explore and resolve that ambivalence in favour of change, and encourages people to say why and how they might change. The client voices the reasons.

SoheeAnd Rubak notes it draws inspiration from Carl Rogers and non-directive counselling. That same PLoS One review quotes the newer definition: a collaborative conversation style for strengthening a person's own motivation and commitment to change.

RyanNotice the tension in that first definition. Directive and client-centred. That pairing trips people up, so slow down on it. It's not purely non-directive like Rogers, because it has a direction, toward change. But it's still client-centred, and the newer definition calls it collaborative.

SoheeSo if an answer says motivational interviewing works by the clinician lecturing the client with reasons to change, that's the tempting wrong answer. The method encourages the client to say why and how they might change, and Rubak's review measures it against traditional advice giving.

RyanDoes it work? Rubak's meta-analysis pooled seventy-two randomized controlled trials. Motivational interviewing had a significant and clinically relevant effect in approximately three out of four studies, with about the same effect on physiological and psychological diseases.

SoheeWho delivered it mattered in their data. Psychologists and physicians obtained an effect in about eighty percent of studies, while other health care providers did so in forty-six percent.

RyanAnd brevity. In brief encounters of fifteen minutes, sixty-four percent of studies showed an effect. More than one encounter made an effect more likely.

SoheeTheir conclusion, with its own qualifier: in a scientific setting, motivational interviewing outperforms traditional advice giving for a broad range of problems. And they say large-scale studies are needed to show it can be implemented in daily clinical work.

RyanNow let's go back to Myra, because SAMHSA's program puts all this into a public health structure. SBIRT. Screening, Brief Intervention, and Referral to Treatment.

SoheeSAMHSA calls it a comprehensive, integrated, public health approach to early intervention and treatment, for people with substance use disorders and for people at risk of developing them.

RyanThat at-risk piece matters. Primary care centers, emergency rooms, trauma centers, and community settings give a chance to intervene before more severe consequences occur.

SoheeThree components. Screening quickly assesses the severity of use and identifies the appropriate level of treatment. Brief intervention focuses on increasing insight and awareness, and motivation toward behavioral change. And referral to treatment gives people who need more extensive treatment access to specialty care.

RyanPause and think. Look at Myra's first visit through the stage definitions. She said quitting mattered, but she wasn't ready to plan. Which stage fits better, precontemplation or contemplation, and what should the interventionist do?

SoheeShe recognized the importance of quitting, so she's not unaware. By those definitions it looks more like contemplation than precontemplation. And the fitting move is a brief, respectful conversation that builds awareness and motivation. Which is what happened, visit after visit, until she reached a plan of her own.

RyanAnd when she did, SAMHSA says the interventionist praised her for taking the next step. Reinforcing every step is part of the work.

SoheeRecap time. The transtheoretical model has five stages: precontemplation, contemplation, preparation, action, maintenance. People can move back to an earlier stage.

RyanPrecontemplation means no intent to change in the next six months. Contemplation means intending to change within six months while weighing costs. Preparation means a plan and steps soon. Action means overt change within the past six months. Maintenance means working to avoid relapse.

SoheeMatch the tool to the stage: awareness-building and emotional work early, behavioral tools in action and maintenance.

RyanMotivational interviewing is a directive, client-centred style that helps clients explore and resolve ambivalence. In Rubak's meta-analysis it beat traditional advice giving in research settings.

SoheeAnd SBIRT: screening, brief intervention, referral to treatment, a public health model that reaches people at risk, early.

RyanOne more thought for you, listening. If you're coming back to this exam after a hard result, you've probably cycled through a few of these stages yourself. Disappointment, deciding, planning, and now action. That's not failure. That's the model working.

SoheeEvery episode you finish is a step in that action. Thanks for listening to EPPP Prep.

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