[PDF] - INTEGRATING STAGES York: Guilford Press. OF CHANGE Miller, W. R., PDF Document

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 1

INTEGRATING STAGES OF CHANGE IN DAY TO DAY PRACTICE

BY Judith Magnon RN-BC, BS, CAC APNA Conference, Hartford, CT

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Conflict of interest note: This presenter has no conflict of interest, commercial support,

r
ff label use to disclose.

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Learning Learning Objectiv Objectives:

■ Gap: 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.

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References:

Mueser, K. T., Noordsy, D. L., Drake, R. E., Fox, L (2003). I ntegrated treatment for dual disorders: A guide for effective practice. New York: Guilford Press. Miller, W. R., & Rolnick, S. (2002) Motivational I nterviewing (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. TI PS: # 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)

IDDT/Stages of Change

BASED ON Recovery Thinking

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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.

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10% of Programs Address The 80% Who

are in:

Precontemplation, Contemplation, Preparation

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?

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 2

READINESS TO CHANGE

Individual

STAFF

Not interested Very interested in change in change

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1 2 3 4 5

(Precontemplation) (Action)

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Precontemplation Contemplation Preparation

Action

Maintenance

Stages of Change in which particular CHANGE PROCESSESS are most useful

Consciousness-Raising Social Liberation Emotional Arousal Self-Reevaluation Commitment Reward Countering Environment Control

Helping Relationships ACTION

Precontemplation

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Characteristics:

Unaware of Problem
Problem is external
Resistant,
Hopeless
Demoralized,
Defenses:
Denial, minimize,

Thi Thinking Stage Stage

I nternalize, Projection,

Rationalization

Displacement
Present as Depressed,
Anxious,
Afraid to risk,
Believe they are in

control

Precontemplation

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GOAL: Shift the focus to THI NKI NG and I NSI GHT Increasing information about self & problem

Change Process:

Consciousness Raising Social Liberation

Techniques: Observations, “confrontations”, interpretations,

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TASKS:

Become aware of self defeating

defenses— what they are and how they

perate
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

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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

vernight.

How to help Precontemplators

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 3

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

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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

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 Analysis- thoughtfully 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.

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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.

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

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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

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 4

Contemplation

■ 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, ■ Action 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.

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Characteristics:

Thi Thinking Stag Stage

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

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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

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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

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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
Action is avoided
Await some type of type of external

intervention

Preparation

Characteristics

■ 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.

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Pract Practice ce beha behavi vior

r

chang change Stag Stage

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 5

Preparation

■ GOAL:

Using the decisions made in Contemplation Stage to develop specific steps to solve the problem for implementation during Action 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.

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Preparation

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

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Preparation

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.

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Action

■ 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

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Characteristics:

Action

■ GOAL:

Purposefully modify lifestyle in order to alter behavior based on commitment.

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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

Action

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.

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 6

Change Process:

■ Environmental Control:

Restructuring the environment so that the likely

ccurrence 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.

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Action

Change P ge Process: ess: ■ REWARD: Rewarding self, or being rewarded by

thers, 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

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Action

Tasks

■ Be aware of time, effort and energy needed to change, ■ Relapse prevention skills ■ No simple solutions to complex problems

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COMMENTS:

Relapse may occur,
Need to have support system in place

already,

Change in lifestyle,
Treat core issues.

Maintenance/

Recovery Management

Goal Maintain new behavior FOCUS On Behavior and Lifestyle

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Relapse Prevention: Task Continue integration and utilization of new coping skills Goal

Abstinence

Maintenance/

Recovery Management

Change Process and Techniques:

■ Commitment, countering, Environment control, Reward as reviewed earlier ■ Relapse Prevention tools

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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

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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

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 7

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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

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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

Nursing practices that can effectively incorporate Stages of Change

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Documentation

Treatment Plans 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”.

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Documentation

Treatment Plans

Preparation Stage S. A. Sample:

“I will explore how my use negatively impacts my reaching my goals”.

Goals--

Action Stage S. A. Sample:

“I will be sober and clean”.

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Documentation

Treatment Plans

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”.

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Documentation

Treatment Plans

Preparation 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.

Objective---

Action Stage

“I will not use any alcohol or drugs”.

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APNA 30th Annual Conference Session 4016: October 22, 2016 Magnon 8

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Documentation

Treatment Plans

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.

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Documentation

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.

Presenter Information

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