The Transtheoretical Model

When counselling a client we need to realize that change does not happen over night. Therapy of any kind is a process.

Developed by Prochaska, Di Clemente and colleagues first proposed the Transtheoretical model in the late 1970’s and drew from various theories and schools of psychotherapy. It evolved as they studied and compared the experiences of smokers who quit on their own and those who required further treatment. It was an attempt to understand why certain individuals were capable of quitting on their own.

In the end it was established that people quit smoking when they are ready to do so.

The Transtheoretical Model focuses on the processes and stages involved in the decision making of the individual. It can be seen as a model of intentional change.

The assumption is that people do not just wake up one morning and change behaviors or thinking patterns – there is no quick fix and decisions often take some time. Change occurs, especially in terms of habitual behaviour, over time through a continuous, cyclical process.

The Transtheoretical Model, or TTM, has proven effective in helping with smoking cessation, treatment of alcohol abuse and the reduction of domestic violence. It has also been used to encourage compliance in hypertension mediation, and in regards to condom use under at risk populations, organ donation and needlesharing.

This model is highly adaptable and therefore has been used in a variety of settings. It can be adapted to the needs of the individual.

It is used by health promotion organizations, hospitals, addiction programs and corporate settings. TTM is considered the dominant model in the field of behaviour change, although it has received some criticism. These criticisms do seem to be more in regards to the more practical applications of the model, but for our purposes – that is to understand the decision making process of the addict or alcoholic, it proves sufficient.

The model relies on four key core constructs, self-efficacy, decisional balance, the stages of change and the processes of change.

For an individual to progress through the changes of stage the following needs to happen:

Self-Efficacy – The individual must have confidence that they can in fact make and maintain the change in situations where the temptation of relapse exists.

Decisional Balance – the individual must have a growing awareness that the advantages of the target behavior outweigh the disadvantages thereof.

Processes of Change – Strategies to help the individual make and maintain the change.

Stages of Change

In the Transtheoretical model change is considered a process involving progress through various stages. (Prochaska, 1997)

This means an individual will move from one stage to the next until action is eventually taken and maintained. Although researchers have tried to quantify this progression in terms of a time-frame it is often the most critiqued facet of the model. Because some individuals can take longer in making a decision, or act quicker, it is near impossible to accurately put a time-frame to the process.

The Stages of Change as proposed by Prochaska are:

· Precontemplation (“not ready”) – “People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic”

· Contemplation (“getting ready”) – “People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions”

· Preparation (“ready”) – “People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change”

· Action – “People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours”

· Maintenance – “People have been able to sustain action for at least six months and are working to prevent relapse”

· Termination – “Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping”

The Preparation and Termination stages were originally excluded but added later, and relapse was originally considered one of the stages as well, but later came to be a return from Action or Maintenance to an earlier stage.

Prochaska and his colleagues concluded that interventions to change behaviour are more effective when they are ‘stage-matched’ – that is to say, appropriately matched to the individual’s stage of change.

Self-Efficacy

Self-Efficacy can be described as “the situation-specific confidence people have that they can cope with high-risk situations without relapsing to their unhealthy or high risk-habit”. (Prochaska, 1997)

According to Bandura self-efficacy refers to an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments (Bandura, 1977, 1986, 1997).

It affects every area of human endeavour. It determines the beliefs we hold regarding our power to affect or change situations – and therefore influences the power a person has to face challenges competently as well as the choices we are likely to make.

Individuals with a strong sense of self-efficacy tend to see challenges in life as something to be mastered – eg. grabbing the bull by the horns – rather than a threat to avoi, or rather, running away from the “bull” altogether.

A strong sense of self-efficacy leads to a more positive outlook on life, fosters a sense of accomplishment and a better sense of personal well-being. People with a high level of self-efficacy are more resilient and recover from failure easier. They tend to handle setbacks like molehills rather than mountains. They are also more likely to attribute failure to a lack of effort, approaching even threatening situations with a belief that it is within their control. These characteristics have been linked to lower levels of stress and lower vulnerability to depression.

People with lower levels of self-efficacy tend to lose faith in their own abilities after failure or a setback. They tend to look at the skills they don’t have rather than the skills they do have, and difficult tasks are often taken as personal threats and avoided.

Self-efficacy plays a role in our decision making process – it determines whether or not we are ready to take action to facilitate the necessary change in our lives.

Higher levels of self-efficacy do not necessarily imply success – for example, the student who believes he is ‘good at languages’ and can be described as over-efficacious will be likely to study less and even fail in an academic setting. Where self-efficacy is important is not in its ability to lead to success, but to change.

Greater levels of self-efficacy lead to greater changes in behaviour.

It measures the confidence a person has to act and change a harmful or problem behaviour.

Decisional Balance

Decisions are not always simple and easy. There might be a lot of things to consider – one desicion could have both positive and negative impacts on your life.

Irving Janis and Leon Mann introduced the phrase ‘decisional balance sheet’ in 1959 and used the concept to look at decision making. It was later used by Prochaska in the development of TTM and suggested that, in general, for people to succeed at changing their behavior, the advantages of the change should outweigh the disadvantages before they move from Precontemplation to the action stage.

In TTM the Decisional Balance sheet is not only an informal measure of readiness for change but also an aid for decision making.

When dealing with an alcoholic, for example, the concept of decisional balance can lead to personal insight. Asking the alcoholic what they might see as the pros of drinking versus the cons is often more effective than bluntly asking them to think about the negative aspects of the problem behaviour as this might foster psychological resistance later in treatment.

In weighing the pros and cons of a behaviour, or future change, we are forced to really examine what would be best for us and the ideal self we are striving towards.

The more the advantages outweigh the disadvantages the more likely the individual is to make the necessary change.

It is therefore then counselors job to help the client understand the pros and the cons of a decision and lead them to action to quit, replace or abstain from harmful behaviour and engage in more positive behaviour.

As the individual moves through the different stages of change we see a gradual change in attitude before the person acts. Most of the processes of change are aimed at evaluating and reevaluating as well as reinforcing specific elements of current and target behaviors.

Processes of Change

Defined as the covert and overt activities and experiences that those attempting to modify problem behaviors engage in, the processes of change are broad categories encompassing multiple techniques, methods and interventions.

For example Stimulus Control which is the control of situational and other triggers which might cause relapse includes multiple interventions such as adding stimuli that encourage alternative behaviors, restructuring the environment, avoiding high risk cues, or fading techniques.

As with the rest of the model, the processes are drawn from various disciplines and theories and adapted to the individual.

Although there were only 10 processes originally, as proposed by Prochaska et al, helath researchers have extended the original with 21 additional processes.

The original 10 are outlined below:

• Consciousness-raising (Get the facts)

• Dramatic relief (Pay attention to feelings)

• Self-reevaluation (Create a new self-image)

• Environmental reevaluation (Notice your effect on others)

• Social liberation (Notice public support)

• Self-liberation (Make a commitment)

• Helping relationships (Get support)

• Counterconditioning (Use substitutes)

• Reinforcement management (Use rewards)

• Stimulus control (Manage your environment)

These processes are used by those wanting to effect change in their lives in various ways and in various combinations, adapted to the individual.

As a whole, drawing from a multitude of theories, schools of thought and approaches to therapy, the Transtheoretical Model provides us with a framework to not only understand the driving factors behind decision making and change, but also a place from which to offer hope and encouragement towards a new way forward.

The Processes of Change

The processes of change, conceptualized and developed by Prochaska et al, describes the overt and covert activities that the individual engages in when trying to change a negative behaviour, unlearn a bad habit or facilitate change in their lives.

These processes can be seen as broad categories of action and can consist of various interventions, techniques and methods to get where you are going.

Although adapted by Bartholomew et al, the original 9 are still the standard and a short description and examples of application will be given of each.

The ten processes of change are:

• consciousness raising,
• counterconditioning,
• dramatic relief,
• environmental reevaluation,
• helping relationships,
• reinforcement management,
• self-liberation,
• self-reevaluation,
• social-liberation,
• and stimulus control.

These were adapted and added to over the last few decades, but the original 10 do give us a good base to work from.

Consciousness Raising

Consciousness raising implies an increasing awareness and insight about oneself and the problem. Gaining insight and understanding in regards to the self defeating defenses that get in our way. This process implies an effort by the individual to seek new information and to get understanding and feedback about the behaviour, problem or situation that needs to change. Interventions could include observations and confrontations and the watching of documentaries or reading of educational books/pamphlets.

For example, someone who would like to stop smoking could start reading pamphlets about the dangers of smoking, watch videos about the benefits of smoking cessation or engage in dialogues about the problem.

Counterconditioning

Countering or counter conditioning implies the process of replacing a problem behaviour with an alternative, a healthier substitute. Here we seek to replace the unhealthy behaviour with something healthy. This could range from exercise, to basic breathing and relaxation techniques.

One example could be, to replace negative thinking, to introduce a morning routine of self-affirmation.

When intrusive thoughts come we can confront those feelings with positive ones – but this does take practice, and therefore it is not just a band-aid for your thinking – but a process.

In the case of replacing a negative, compulsive behaviour, desensitization could be a good intervention. Looking at and understanding why a situation is a trigger and stripping it of its power can prove a helpful strategy against relapse later during the change process.

Dramatic Relief

Also called Emotional Arousal, Dramatic Relief is meant to evoke positive feelings about the change you are contemplating.

It also implies experiencing and expressing feelings surrounding both the problem and the solution.

This is achieved through roleplaying, open discussion, psychodrama and the grieving of losses as well as the celebration of success.

Environmental Re-evaluation

During this process we consider our physical and social environments and look at how the problem behaviour either affects our surroundings or are encouraged/reinforced by it. For example, if a drug addict does not make certain changes to his social and physical environment the likelihood of relapse increases.

This process goes hand in hand with consciousness raising as it is about mindfulness and awareness of what is around us.

Thus interventions once again include discussion, documentaries and pamphlets, among others.

The key here is to identify situations that reinforce the problem behaviour or prevent growth in a healthy way. Choosing an environment that suits your ideal behaviour is important.

Once again, to use the example of a recovering drug addict, finding activities that can be enjoyed sober rather than previous ways of doing things will be imperative to maintaining change.

Helping Relationships

As the saying goes, no man is an island. We can’t do everything alone – even with an uncannily strong sense of independence and perseverance, or high self-efficacy – social support definitely does help. Especially when trying to change problem behaviors, it is helpful to have a social support network to fall back on.

Whether your social network consists of family, friends or even counselors and clergy – having someone around to help you when you stumble, an ear you can talk to, a hand you can hold – definitely makes things easier.

Self Re-evaluation

This process involves an open and honest assessment of oneself – understanding your own thought patterns, values, beliefs and emotions can be invaluable in moving forward.

Taking stock of your current situation, doing a fearless moral inventory and recognizing how the change you are contemplating will affect your life is what this process is all about.

Social Liberation

Much of our lives are often built around what others expect of us. This can be an unhealthy way of looking at life. Social liberation then is the awareness and acceptance by the individual of alternative and problem free lifestyles in society. For example, although you might have grown up in a setting where alcohol abuse was common, or grew up in a community where substances were commonplace, finding that there are individuals living an alternative lifestyle (eg. Staying sober) can lead to social liberation – freedom from a perceived social norm.

Self Liberation

Also referred to as commitment, this is the decision the individual makes to change the problem behaviour. This can be a whole process in itself involving therapy and education, or as simple as a New Years resolution.

It is the finer details of this decision to make this commitment – whether overt or covert (subconscious) that makes this a process and not just an impulsive decision.

The action of choosing to change requires a stronger sense of self-efficacy, or the belief in your own ability to change.

Stimulus Control

In recovery circles we often make reference to the dangers of familiar people, places and things. Where the environmental re-evaluation looked at our physical and social environment – the people and places – here we look at the things – the situations, cues and circumstances whether tangible or intangible that could lead to relapse.

During this process we identify situations and circumstances which might trigger the problem behaviour and then take certain actions to protect ourselves against relapse. This could involve restructuring your environment, changing careers, or avoiding high risk cues altogether.

It could also involve replacing or adding stimuli that encourage alternative, healthier behaviour.

Reinforcement Management

As we go through the processes of change and our behaviour is modified we need to reinforce the change that we have been making.

Since many addictions or problem behaviors have been reinforced over time through the brains reward system, we need to do the same with the new healthier behavior.

This could be anything from an encouraging word from a family member, a contingency contract with your counselor, or a self-reward.

For example, if I had a drinking problem and drank every night the financial reward might be significant if I were to stop drinking altogether. Therefore I could use my savings to reward myself with something I wouldn’t have been able to do otherwise. I could go have breakfast with a loved one, or take the kids to do something fun.

By rewarding positive behavior, not only do we reinforce that behavior but very quickly we find alternatives towards a happier, fuller life.

As mentioned before, the 9 processes have been added to over the years, and there is a multitude of information available on the internet, but personally I find the original nine points to be sufficient.

If you or a loved one are struggling with addiction or with issues related to mental health please consider reaching out by sending an email to andre@adlabuschagne.co.za and we will assist you with finding a solution that works for you.

Categories of Drugs of Abuse

One of the ways we as humans understand what is going on around us is through systematization of knowledge – and often this means categorizing or grouping concepts together.

In regards to drugs we categorize the various substances of abuse into categories. We do this for a number of reasons. These substances are grouped together based on chemical compostion, how they work and the effect of the substance on the brain and the body. The classification of drugs by chemical similarity can help us understand the usage patterns of the user. The typical drug user who is addicted to a specific substance will often be more likely to abuse a chemically similar substance. Although many drug users do experiment with a range of substances across these categories it is more likely that they will have a preference towards one specific category. For example, the meth addict will be more likely to abuse other amphetamines or stimulants such as cocaine, methylphenidate or MDMA rather than a depressant such as alcohol or opiates.

This does not mean to imply that the drug user will not abuse drugs from another category. It simply means that they are less likely to do so.

Categorizing these substances also helps us understand the health risks and impact of these substances as drugs of a similar chemical composition will often, but not always, have similar side-effects, symptoms and risks. The approaches to treatment is often also impacted by these categories. The stimulant addict’s program will differ from the opiate addict or alcoholic.

Below we will have a look at the different categories used to classify drugs of abuse.

Central Nervous System (CNS) Depressants

As the name implies a depressant is a class of substance that slows down the operations of the brain and body.

This category includes Alcohol, Benzodiazepines (Valium, Xanax, Ativan, Klonopin etc.), Barbiturates, GHB (Gamma Hydroxybutyrate), Rohypnol, and certain anti-depressants (Bupropion and Setraline).

Central Nervous System (CNS) Stimulants

Where the depressants slow down the operations of the brain and body, substances in this class raise blood pressure, ‘speed up’ or overstimulate the body. Many of the drugs in this class are also used for the treatment of ADHD – for example methamphetamine, methylphenidate and dextroamphetamine. These drugs are characterized by cognitive and emotional effects like increased wakefulness and feelings of euphoria.

Their main effects tend to target the norepinephrine and dopamine neurotransmitter systems.

Many users find themselves in a constant state of flight or fight as the adrenaline triggers are often overstimulated.

Drugs in this category include amphetamines, prescription medications like ritalin and adderal, cocaine (and crack) and methcathinone (CAT). This category also includes caffeine and nicotine.

They are commonly referred to as uppers.

Hallucinogens

Hallucinogens or Psychedelics have been used for centuries as a way to alter ones perception of reality. Although their medical use has been explored and continues to be explored especially as a treatment for certain psychiatric disorders, they are often used recreationally and can have serious mental health risks. These drugs are often not as addictive as other classes of drugs, but can still be just as harmful.

Their immediate effects are generally more severe and dangerous.

Characterized by visual and auditory hallucinations, this category includes drugs like LSD, Peyote, Salvia and Psilocybin.

Marijuana is also often categorized under this group but can also be classified as a CNS Depressant.

Dissociatives

Although closely related to Hallucinogens, these drugs work by interfering with the brain’s receptors for the chemical glutamate, which plays a significant role in cognition, emotionality and pain perception. This class of drug severely distorts the user’s sense of reality and causes them to dissociate causing a feeling of disconnection or separation from the self.

Drugs in this category include Ketamine, PCP (Angel Dust), Dextromorphan (DXM). These drugs can often have chemical similarities to stimulant drugs.

Opiates

Although all of the drugs in this category could also be classified as CNS depressants we refer to opiates as a separate category. Most opiates are distributed and taken in the form of prescription pain killers. Treatment for opiate addiction is very specific and usually if not always includes full medical detox.

Opiates are a type of drug that includes both illicit narcotics and prescription medications. Heroin, morphine , fentanyl and codeine are all examples of opiates.

These substances are derived from the opium poppy or substances with similar effects on the brain or body. Artificial substances with the same effect are referred to as synthetic opioids. These drugs depress your central nervous system and are used for pain relief and as anaesthesia but is often misused or abused because of the feelings of euphoria it produces.

Inhalants

Inhalants are any chemical substance that can be inhaled to produce an altered state of mind. Common especially among adolescents this category includes aerosols, gases and solvents – chemicals like glue and paint thinners or even petrol, paint and butane (CADAC) gas.

If you or a loved one are struggling with addiction or with issues related to mental health please consider reaching out by sending an email to andre@adlabuschagne.co.za and we will assist you with finding an option that works for you.

Characteristics of Addiction: The Three C’s

Regardless of how the addiction may present itself, it almost certainly looks the same – whether the addiction is a chemical dependence such as drugs or alcohol, or a behaviour such as masturbation, shopping, cybersex or gaming – it almost always has the following characteristics, also known as the three C’s.

• Compulsive usage.

• Loss of Control.

• and Continued use despite negative consequences.

Below we will take a look at these three characteristics of addiction.

Compulsive Usage

The word compulsive is an adjective often used to describe people who engage in risky and harmful behaviour beyond their control. As an example, a compulsive liar would be someone who has little or absolutely no control over the lies they tell. A compulsive gambler would be someone who cannot help but sit down when they walk past a poker table. Often the person with compulsive tendencies would have very little control over their actions, and so it is with addiction.

I remember when I was an addict. It was a strange feeling, wanting to quit, and perhaps setting out with the best of intentions to walk to the corner shop, only to find oneself redirected by an unknown force. Before you knew it you would be in the bottle store or at the dealer.

According to A.W. Blume (2005) this compulsive use often has 3 elements. Reinforcement, craving and habit.

When the substance user first picks up his drug and experiences relief from stress or physical pain – or the action is rewarded by the pleasure centers of the brain – reinforcement occurs. This reinforcement occurs every time the user engages in this behaviour. Over time tolerance may develop and larger or more concentrated doses will be required to produce the same effects.

Over time the chemical balance of the brain is altered and the user will experience craving, a strong and often intense signal sent by the brain to the body to signal that the substance or behaviour is needed. The brain is essentially telling the body that it needs the substance for survival.

Psychological or physical withdrawal symptoms can occur if the craving is not fed. Withdrawals are often very unpleasant symptoms that are caused when the drug(s) or behaviour is withheld.This could be psychological, eg. anxiety or depression, or physical such as muscle fatigue, pain or insomnia.

The third element, habit, is often the result of deeply ingrained patterns of memory in the nervous system. Addiction often goes hand in hand with a myriad of automatic behavior over which the user has very little control.

Loss of Control

We, as addicts, often cannot determine how much of a substance we will use. In the rooms of Alcoholics Anonymous there is a saying that comes down to the fact that one drink is never enough – once we start engaging in the behavior we often find we cannot stop.

There is almost no doubt that this could be the result of impaired brain function and memory.

Substance use can often impair judgement and affect decision making.

Continued use despite negative consequences

Often an addict will find that the pleasure or relief derived from their usage of the drug outweighs the negative consequences of their use.

We are often blissfully unaware of the negative consequences of our behavior even though it negatively affects our careers, relationships and health.

It is usually keenly felt by those around us. Addictive behavior is almost always self-destructive and leads to the deterioration of ones quality of life.

Once again, the twelve step fellowships have a cliche that applies – continued drug or alcohol abuse will eventually lead to jail, institutions or death.

This last C – continued use despite negative consequences – is possibly one of the most distinct characteristics of addiction along with craving, tolerance and withdrawal.

Tolerance and Withdrawal

Tolerance and withdrawal are two sides of the same coin – both urging the user to use more. Tolerance builds over time and forces the addict to use more of the substance or engage in more of the same behaviour to experience the same relief or reward.

Withdrawal on the other side is what keeps the user from getting clean. As soon as the effects of the drug subside, and because the body has adapted to the drug, negative symptoms present themselves to signal the absolute need for the substance. The withdrawal symptoms are often severely unpleasant and can be life threatening if left untreated.

It is important to detox under medical supervision, and withdrawal from certain substances might require medication under certain circumstances.

Luckily there is hope, and we never have to go through these things alone.

If you or a loved one are struggling with addiction – if you have been experimenting and notice any of the above traits in your life or in the behavior of a loved one, or if you relate with what you just read, please consider reaching out by sending an email to andre@adlabuschagne.co.za and we will assist you with finding an option that works for you.