People change because they want to or because they have to. When neither of those things are true, change isn’t going to happen. When clients come to us, we have to focus on what they bring to the table. If they come to change a particular behavior, then we work on that. But what if they aren’t really committed to changing? Using the stages of change as a lens may help shift what you do in therapy. For substance use, the “readiness to change” may be one of the biggest factors in someone making long-lasting change in their relationship with their substance of choice.
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance Podcast. This is episode 109. Well, it is officially December, and for those of us in the northern hemisphere, that means that winter is here and for all of us around the world, it means holidays.
There are a number of holidays being celebrated from the end of November through January. In the United States. We just celebrated Thanksgiving. Thanksgiving is supposed to be a holiday where we eat Turkey and a big meal and are supposed to talk about the things that we’re thankful for.
The roots of Thanksgiving though are a bit darker, and so I know for me, I have a little conflict in my heart about Thanksgiving. As a vegetarian, the turkey holiday isn’t necessarily a big one for me. I did enjoy taking some time off though, and always appreciate a chance to relax. We’re back at it this week and today we’re gonna be talking about stages of change.
Talking about stages of change isn’t super exciting. I don’t know that it makes people want to learn more. There are a lot of theories about why people change. However, I find that the stages of change are actually really important.
I am often fond of saying that people change because they want to or because they have to. When neither of those things are true, change doesn’t happen. I talk to people all the time who are frustrated by things that aren’t changing. A lot of times it’s people in their environment and they wonder why the person isn’t changing.
I’m sure that you hear this in your practice as well. Typically, what we end up doing is helping the person focus on themselves, on what they can change, on what’s under their control, whether it’s changing their behavior or simply changing how they think about something.
When it comes to substance use, and for those people who are further down the path and into addiction, their loved ones often struggle with this. They see the person struggling and they’ve experienced consequences themselves of that person’s use, but the person doesn’t change. A lot of times that person has made a lot of promises about the fact that they’re going to change and those things don’t end up sticking.
Our role then is to help our person deal with the fact that the person may not change and may never change, and to help them figure out how to extricate themselves from being as impacted by the person’s use. It can be super frustrating for our clients and for us, as we watch our client being hurt and disappointed by someone else’s choices. We may find ourselves wondering, given the information, why that person doesn’t change.
I wanna tell you about a time where I was pushing for change and ignoring the stages of change. I met an 18 year old guy. He had had a really difficult childhood. Lots of trauma, parental substance use, sexual abuse, moving multiple times and being left at home for weeks at a time in late elementary school through middle. He got himself up and got himself to school because he knew that if he didn’t go to school that somebody would come looking for him, and it might mean that he was taken away.
By the time he was 18, his drug use had skyrocketed. It started out being marijuana and I think in sixth grade on a regular basis. Although I know that he had tried marijuana a few times before that. By the time he was in eighth grade, he was smoking marijuana numerous times a day and experimenting with other drugs.
By the time he got to me, he was a senior in high school struggling with trying to get off of pills and physically dependent on opiates. This was many years ago, and so we didn’t have quite the risk of fentanyl that we do now, and there weren’t as many pressed pills on the market. What he was taking were actually pharmaceuticals because the crackdown on prescribing hadn’t quite happened yet.
He was referred to me through the school counselor. His best friend had been talking to him about getting off of the pills because they were worried. He had been using them all day every day, crushing and snorting them. I saw him as he was trying to detox, and this was the first time I had met him.
If you know anything about opiate withdrawal then you know that that is incredibly difficult. It is by far the worst withdrawal that exists. It is the most painful. It is the longest, and it is the most debilitating. It’s not necessarily the deadliest. Because while people may want to die while they’re detoxing, typically they don’t. The deadly withdrawals, as I’ve said before, our alcohol and benzodiazepines. Still this withdrawal is a lot to handle, especially for someone who didn’t have a lot of distress tolerance and not a lot of coping skills.
This person had been struggling to manage their use since middle school. With detox came an incredible amount of feelings and pain. However they seemed motivated. We worked with a local doctor and helped them come down. I began seeing this person and communicating with them often. We got them set up with their school counselor and with local, and with other local supports.
I’m happy to say that they attended their graduation sober. They remembered all of it and felt really proud that they had been able to get a diploma even though high school was a very difficult time and honestly kind of hazy with all of the drugs. It was after this point that I started to make some mistakes.
This guy, and I formed a good bond almost right away. This was my kind of kid. The kind of kid who’s got trauma, they’re angry. They were using drugs and they kind of didn’t have a lot of time for most adults. I was that kid and I loved working with those kinds of kids.
He started attending a treatment group that I ran for teenagers and I was doing individual sessions as well. I would ask him often about his use and whether he had used it all and we got to the place where they had a month clean. That was a huge feat.
We continued working together and in the late summer it came out that they had been smoking marijuana. In fact, they had been smoking marijuana since right after graduation. They never had that 30 days clean, and they had just become too ashamed to tell me that they were smoking again. That is never a great feeling as a therapist.
It’s not great to find out that your client has been lying because they were too ashamed to tell you the truth. They didn’t wanna disappoint you. They didn’t wanna have you look at them in a certain kind of way.
I assured my client that I was so sorry that he felt that way and that I really wanted him to tell me the honest truth and that I would not be disappointed in him no matter what he chose to do. I backed up and tried to correct my mistake, making sure that I wasn’t creating an environment where he would need to lie.
I worked with this person for years. They continued to smoke marijuana and it was pretty much a non-issue for them. I was worried because I knew that this person had crossed over into addiction long before, and I firmly believe that if somebody has tripped those switches in their mind, that the brain changes that occur with addiction were well and thoroughly established. I have not met someone who was firmly in addiction that has been able to continue smoking weed and not end up back using other things.
I don’t have an issue with weed, and I don’t think it’s the worst thing on the planet. In fact, I’m gonna be talking about that in about a week and a half. On December 13th, I’m hosting a webinar called Considering Cannabis. It is a two hour event where I’ll be giving fact-based information about the good and the bad and the ugly regarding weed.
We’ll talk about the accuracy of claims, we’ll talk about the impact on therapy. And my goal is to help therapists form their own professional opinions about marijuana and I have no expectations that people will simply parrot what I might say.
I wanna provide the information because I think it’s hard to find information out there in the world that is even remotely neutral. If you’re interested in that webinar, head over to betsy byler.com/cannabis. You can register up until the day of the event.
With this guy, I did talk with him about what it meant to be using weed, and my concerns about the risks he acknowledged. Those said he felt like this was okay, and we moved on. About a year later is the first time he tried meth. He was surprised that he had tried meth because his parents had both used meth and he had strong opinions about it.
He had even gone the opiate route instead of going the meth route. However, meth is what it is. He began to experiment with meth and would talk to me about it: explaining that he was never gonna touch it again; that he wishes he had never done it, that he wished he didn’t know what it was like. Despite his best efforts, he wound up getting addicted to meth, and we began a four year span of time of him fighting with meth.
Here’s where my mistake happened. During that four years, I assumed that he was ready to quit. I assumed that because he was acknowledging the problems and saying that he needed to quit, that he was ready to make those steps. So we would talk about ways he could stop. We would talk about detox, we would talk about plans, things that he could do next, and then I wouldn’t see him for a week or two.
He’d come back in full detox and be in tears about how he failed. And this went on and on and on. I was so frustrated and worried. The use was escalating. He was dropping weight. He looked terrible and smelled terrible because that’s what happens when people are detoxing from meth.
I, of course, never scolded him, never sounded disappointed and was always encouraging. And so some might wonder what was the problem. Well, it wasn’t until later when I realized it. The stages of change were not present in my mind. I wasn’t evaluating where he was. If I had, I might not have been beating my head against a particular wall, and I would’ve focused treatment differently. Let me explain.
There are six stages of change put forth in the Prochaska model. This model was created in the late seventies by Prochaska and Diclemente. The theory was put forth based on the research they had done on people smoking cigarettes. They wanted to understand why some people could quit on their own and others could not. Thus was born the trans theoretical model or the stages of change.
We’re gonna talk about this in a bit of an overview. The stages are in order, pre-contemplation, contemplation, preparation, action, maintenance, and termination.
Pre-contemplation is what it sounds like they’re not even thinking about it. This is the stage where the person does not intend to take action at any point in the near future, which the model determines as being in the next six months. They’re often unaware that their behavior is a problem at all. If they do see it as a problem, they often are focused on the negatives of having to stop or change a behavior, and they don’t really look at what the positives would be. They might give a moment or a sentence to it but the negatives far outweigh in this stage.
Contemplation then is when they are considering it. They recognize that their behavior is causing problems and they intend to do something about it in the next six months. There is a lot of ambivalence about changing at this point, and people often go back and forth on whether they want to change.
In the third stage preparation, people are ready to take action within the next 30 days. They start to take small steps towards the goal, and they have a belief that changing will lead to a healthier life.
Action, of course, is what it sounds like. The person begins making the change in behavior. They are actively involved in doing something different. This period of time also lasts for six months and can last of course, much longer.
When someone has sustained a behavior change for six months, then they’re considered to be in the maintenance phase. This, of course, is helping them continue this change. Mainly this is about further relapse prevention.
Termination happens when the person has no desire to return to the previous behavior. The documentation about the stages of change states “since this is rarely reached, and people tend to stay in this phase, this phase is often not considered in health promotion programs.”
Typically people don’t talk about the termination phase because people are always in the maintenance phase when making behavior changes, almost always anyway. And so we usually think there’s five stages of change. But to be thorough, I wanted to make sure we knew there were actually six.
So let’s go back to my story about my person. When I met him, he was in an action phase. He was actively stopping using opiates and other drugs. He was in withdrawal and he was working on the behavior change. He hadn’t planned on doing it within the next 30 days he did it. I saw him a few days after he started the change.
My first mistake was assuming that he would stay in the action phase. I hadn’t considered that this guy who had had very little positive adult interaction might want me to think that he was doing amazingly. That he might not wanna tell me about the struggles that he was having, being sober.
There was a lot of trauma and of course I knew that that would be popping up. I had talked with him about it. I know that people relapse. I’ve worked doing treatment for years. Not to mention being in recovery myself. I don’t see a relapse as something to be ashamed of, and I missed it.
I missed that there would be this struggle, even though yes, I asked about it, of course I did and I was concerned, but I just was really impressed thinking, well, he must have just decided that he was done using and therefore he’s done. I should have been listening with that kind of third sense. I don’t know if I would’ve caught it. I don’t know that it would’ve turned out different, but I know I wasn’t even considering that he might not be telling the truth.
I think I did okay. In view of the stages of change when dealing with his smoking weed, I knew that he didn’t see it as a problem. I knew that his intention was to keep smoking weed. I didn’t argue with him about it. I didn’t try to convince him. I did occasionally discuss it and when I started seeing the use go up, I did talk about my concerns, but I dropped it.
I was able to stay with him in that precontemplation space. It was during the years he was using meth that I just didn’t get where he was. I have seen meth do things so devastatingly awful to people’s lives, to their lives and everyone around them. I have seen people broken by meth and deeply bewildered and in pain over why they even bothered touching it and why they couldn’t stop.
Everybody knows what meth does to them. Nobody is gonna tell me that meth isn’t a big deal and it’s not a problem. What they underestimate is that they’ll be able to stop before it gets to that. In the episodes I did about meth, I talked about this part, and it is that in the beginning, you can function while using meth.
You can eat, you can sleep. You don’t look bad. You don’t go through massive withdrawal, you’re not missing work. In fact, you seem happy and highly functional. People during this phase feel like they have found an answer. They’re able to do so many more things. They know that this danger is out there, that at some point meth turns bad. But each one of them over the years that I have met, believed that they would know when to pull the plug on it.
The problem is almost none of them are able to pull the plug. There are a lot of reasons for that and I won’t get into that here. If you wanna listen to the meth episodes, you can head over to betsy byler.com/podcast and listen to them there.
With my client, I was acting as though he was in the preparation stage. Each time he would come in and tell me that he had to quit, I jumped into problem solving mode. I jumped into making plans about how to get him through the next couple weeks without using, I didn’t listen to see whether he was in the preparation stage.
I’m certain that in those years he was using meth. There were times where he was in the preparation stage. It was during those times when he had more success with getting some clean time together. And by clean time, I mean not using meth, not total sobriety. Because weed was always there, but that was definitely not the focus at that time.
As I looked back, I realized that he spent a lot of time in contemplation and a lot of time in pre-contemplation. He was moving in and out of stages, which is super normal. And at the time, if I was doing this message, I would have told you that, but for a few reasons, I didn’t see it. And so what I feel like happened was a push pull.
I was carrying his desire for a better life and pushing him in that direction, trying to be the anchor, trying to be the one that when he felt out of control, he would come back and I would help ground him and what he told me he wanted. And no, that’s not bad. And I know that he needed that and that my office was the safe place for him. And there were many times where he would express that there was literally nowhere else that he felt that he could go and just stop.
As you’re listening, for some of you, maybe it’s really easy to see where I messed this up. For others, as I have shared this story before, have said that they don’t see the problem. I still was able to help him. I still was able to be his person. The problem was largely inside of me.
I was very attached to him and am very attached to him. This was one of those cases where I knew that if this person could just have some stability, some adultier adults who weren’t using, who could put his needs before their own, that he would be remarkable.
I knew this kid so well, and I was terrified that something awful was gonna happen. Awful to the point that he would end up in prison or dead. I didn’t pay attention to my feelings getting in the way. I didn’t sit back and think, why does he keep failing at getting off of meth? I just assumed that it’s because meth is powerful.
What I needed to do was, listen. I needed to listen to what he was saying and not hear it through a lens that told me that he was ready, that he wanted to make a change right now. And I’m betting that if I had listened, there were many times where he was not in that place.
Remember, in the stages of change, that preparation is making a change within 30 days. Contemplation is they intend to make a change within six months. Pre-contemplation is they don’t have any intention of making a change in the near future. I think I would’ve saved myself an incredible amount of angst and worry.
I think I would have served him better, and I don’t know whether the outcome would’ve been different. I don’t have any control over what he chose or any of my other clients for that matter, but at the very least, I wouldn’t have had so much frustration myself and I would have been able to set better emotional boundaries to keep my own self safe.
I am typically very good at setting emotional boundaries and finding that balance of connecting with my clients while also remaining appropriately guarded, so to speak.
I know that there are some people who listen to the podcast who are not therapists, and so I want to say to you it is not that we guard ourselves against caring for our clients. It is that in order to keep showing up for people We have to be able to detach ourselves from whatever the outcome is going to be. Because we can’t let our lives rise and fall on other people’s successes and losses.
Last time I heard from my client who is now pushing 30. He was getting married and was off meth and had been off meth for a number of years. He was happy and living with his partner being a stay at home dad and had not touched meth. I didn’t ask about weed. For those of you who are wondering, it wasn’t a session so much as communicating with me via text as he had moved out of the area.
When someone is using it is very tempting to jump ahead because we are ahead, we can see their use, and it’s clear that it’s a problem. It’s clear that the person needs to change and we jump to what we can help them with? How can we help them get past this thing? If you find yourself thinking that, we need to step back and determine where they are.
Otherwise, you too can get caught in this circle of beating your head against a wall. This is what I talk about briefly in the Substance Use Decision Tree. The Tree is something I designed as a tool for all of you and therapists out there who don’t know who I am to be able to use with your clients. It has two parts.
The first part is to help you determine whether or not your client’s use is appropriate for you to handle in outpatient therapy. I often say that you do not need a specialization, and I stand on that. You do not need to specialize in substance use to help people with their problematic using. There is a limit to that though. There are types of use and with certain substances that fall above the outpatient level of care.
The Decision Tree that I made for you is to help you figure out whether or not you need to get a substance use specialist involved or if you can handle it in house. Part two of the Substance Use Decision Tree is about how ready they are to talk about their use.
If you don’t have this Substance use decision Tree yet, head over to betsy bler.com/tree and you can download it. It’s a hundred percent free and the download link will show up in your inbox right away. When you are talking with your client about use, you are listening for what we call change talk. These are statements that make it sound as though the person might not be satisfied with the status quo.
Things like, man, I am getting tired of being exhausted on Monday because I didn’t get good enough sleep. You know, from talking with them, that this is because they typically spend Friday and Saturday night drinking and end up with a hangover.
Someone could say something like, I am always struggling with money. I spend way too much going out with friends, or I hate not being able to remember what happened the night before. Or, I am so tired of getting that look from my partner, parent, roommate, whomever when I wake up in the morning after I’ve been drinking, or I feel like I can’t breathe going up a flight of stairs, man, I smoke a lot.
You are listening for things that are negative about their drug or substance of choice. This is not saying that they are an addict. That is a totally different conversation. All you’re listening for is discomfort, dissatisfaction. That is the sign that they might be moving into the contemplation stage and you’re just testing that out.
Are they in that place? When you ask them if there’s something that they wanna change, you listen for how they talk about it. They may shut it down or they might be like, maybe, I don’t know, maybe it’s not a problem. And all we’re doing is walking beside them. It is not our job to micromanage where they are in their stages of change.
We are simply getting a temperature, it’s like a PHQ nine where we’re asking them about their depressive symptoms and we’re just checking what it’s been like over the last two weeks. As we take their temperature, we get a feel for where they are and that helps inform where we go. If they firmly are still back in pre-contemplation, you leave it alone.
If there is significant risk, then I would say something and document that. So for instance, if somebody’s drinking and they’re drinking a lot, where I might be concerned that if they stopped, they would go into withdrawal. I would say, okay, so I wanna talk about something regarding drinking and talk about a concern I have for a few minutes and then we can drop it. But I’d feel like I need to put this out there.
I would discuss with them about alcohol withdrawal, the fact that it is dangerous and can kill you, and that if they ever decide they’re gonna go without drinking, and it’s been several days if they think they’re getting the flu. It’s probably not the flu, and that I really want them to pay attention and not brush it off. I’ll tell ’em that I have no idea if this is gonna happen to them, but that I don’t want something bad to happen. I want them to remember my voice and be like, oh, maybe that’s what’s going on. Maybe I don’t have the flu, huh? I should probably get this looked at.
Once I’ve given them the warning right, about whatever the risk is, then I let it drop and I keep listening. These are incremental moves. This is typically not someone coming right out and being like, I have got to stop drinking. Will you help me?
Just because someone says, I have got to stop, does not mean that they’re in the preparation phase. They are contemplating, and you can ask them, tell me what that means. Why do you feel like you need to change that? Have you thought about how you would make that change? Do you feel like you want to start that? Is that something you want help with?
There are a number of things that people say and they’re just throwing it out there. This change talk is important for any change that people are making. In regards to the client I told you about earlier, my love for him and fear for his life was driving my actions. I saw tremendous potential in this person and cared deeply about them and was the only sober and stable adultier adult in their life, which sucks, and that was the reality.
He needed me to be the adultier adult in his life, and he knew I was concerned. However, I feel like I could have done it better, and at the very least for myself, might have saved some sleepless nights.
I encourage you to think about the stages of change. If you find yourself getting frustrated with a client over lack of change, take a step back and think about where they are. Listen to what they’re saying and listen for the kinds of change talk for each stage. I encourage you as well to go download the Substance Use Decision Tree. It’s at betsy bi.com/tree and it’s totally free.
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=Next week we’re gonna be talking about something a bit different and by a bit different. It’s actually a lot different. Some of you may recall that about a year ago I did a series called the Student Edition, and it was, I think, an 11 part series about becoming a therapist, picking schools, internships, and those sorts of things.
In our Facebook groups for therapists I see some of the same questions over and over, and I got to the point where I was like, you know what? I am not gonna answer every one of these every time I see it. And so I’m just gonna do an episode, and when somebody asks that question, I’ll point them there and then they can listen.
What I’ve noticed now is a different issue that pops up and that’s about the practice of being a therapist, productivity expectations, agencies and private practice. In the private practice conversation, there’s also the conversation about taking insurance and private pay. These things on the surface don’t seem related to substance use work. But I believe that there is a correlation with the work I am encouraging you to do regarding substance use.
It won’t be every episode, but there will be a private practice edition of the podcast. This isn’t going to be a weekly thing, but I will be talking about certain topics. If you aren’t interested in hearing that, you can of course skip those and there will be a private practice edition in the title or if you see the initials p p, that means private practice, and you can move right along if you’re not interested.
For those of you who are considering private practice or are in private practice or think they may someday be interested in private practice, I encourage you to listen. I never thought I would go into private practice, and if I did, it was gonna be like 20 years from where I am right now.
But here I am in private practice and I do not ever see myself going back to agency work. So that’s where we’re gonna start and we’re gonna start that next week. I hope you’ll join me for that podcast. And until then, have a great week.
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