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Substance Abuse Tx and The Stages of Change
Transcript of Substance Abuse Tx and The Stages of Change
and The Stages of Change By Cassaundra Fees The Stages Of Change Assessment Measuring The Stages of Change These Include: Assessments Relevant to Those in the Precontemplation, Contemplation and Preparation Stages The 10 Processes of Change The Stages of Change Model has... The Precontemplation Stage Alcohol Use Alcohol and Drug Use
66% used alcohol in the past year
27% used cigarettes in the past year
12% used marijuana and hashish in the past year
8.9% of the sample reported use over past month
6.9% of the sample used marijuana (most common)
2.7% for non-prescribed prescriptions
.2% methamphetamine's 52% reported being past month drinkers
This is equivalent to 131.3 million people!
Nearly a quarter of the population (23.1%) reported binge drinking in the past month So how do we match an individuals treatment to their commitment to change and journey through the process? Described the change process in terms of stages and how coping and processes of change interact with these stages.
Generated more research than other models
Which has provided evidence for the validity of the model as well as for its clinical utility Individuals in this stage are:
Ignoring or unaware of their alcohol/drug use problem
If aware not considering making any changes. Several instruments have been developed to measure the stages of change.
All involve reporting on their perceptions, attitudes and intentions toward change as well as behaviors relevant to changing the behavior. The Staging Algorithm
5 dichotomous yes/no questions
University of Rhode Island Change Assessment Scale (URICA)
32 items shown to reflect factors related to the stages of precontemplation, contemplation, action and maintenance.
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
40 items constructed and scored similar to URICA
Scaled scores for each of the five stages of change: precontemplation, contemplation, preparation/(determination) action, and maintenance.
Readiness to Change Questionnaire
12 items clustered into three stages of precontemplation, contemplation and action, which is focused on readiness to change in drinking behaviors.
Readiness “Ladders”/ Rating Scales
Set up visual: ladder usually consist on 1-7 scoring/ the ruler asks to make a slash mark on a continuum. Biological Methods:
Blood Tests Dependence and Abuse 8.7% of the population had a diagnosed substance abuse or dependence disorder
67.8% dependent or abused alcohol but not illicit drugs
13.1% dependent on or abused both alcohol and illicit drugs
19% dependent on or abused illicit drugs but not alcohol 9.3% (23.5 million people) needed treatment for an illicit drug or alcohol problem
Only 2.6% million actually received treatment
Of those classified as needing treatment only 5% felt they actually needed treatment for their problem Treatment According to the 2010 National Survey
on Drug Use and Health of those 12 and older... Marijuana/hashish, cocaine, heroin, hallucinogens, inhalants, non-prescribed prescriptions Illicit Drug Use The Price of Drug Use The cost of illicit drug use (not including alcohol) totaled over $193 billion
$61.4 billion in crime (criminal justice system)
$11.4 billion in health (hospital and emergency room visits)
$120.3 billion in productivity (labor participation incarceration, specialty treatment, etc.)
Additional costs associated with alcohol use totals $185 billion annually
Combined annual costs associated with alcohol and illicit drug use in the U.S. ~ $375 billion (similar globally)
These numbers barely tap into the cost in human suffering related to the substance abuse. U.S. Department of Justice (2011) economic study using 2007 data One way is using The Stages of Change Model!! Experiential Behavioral 1. Consciousness-Raising—increasing awareness via information, education, and personal feedback about the healthy behavior.
2. Dramatic Relief/ Emotional Arousal—feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviors
3. Self-Reevaluation—realizing that the healthy behavior is an important part of who they are and want to be
4. Environmental Reevaluation—realizing how their unhealthy behavior affects others and how they could have more positive effects by changing
5. Social Liberation—realizing that society is more supportive of the healthy behavior 6. Self-Liberation—believing in one’s ability to change and making commitments and recommitments to act on that belief
7. Helping Relationships—finding people who are supportive of their change
8. Counter-Conditioning—substituting healthy ways of acting and thinking for unhealthy ways
9. Reinforcement Management—increasing the rewards that come from positive behavior and reducing those that come from negative behavior
10. Stimulus Control—using reminders and cues that encourage healthy behavior as substitutes for those that encourage the unhealthy behavior. 1. Reveling: “I am enjoying this too much”
2. Reluctance: “ I really do not want to change”
3. Rebellion: “No one can make me change”
4. Resignation: “I can’t change”
5. Rationalization: “I do not need to change” Not interested or concerned about problem or need to change
Resistant to suggestion of problems associated with their drug use
Lack awareness of problem
Uncommitted or passive in treatment
Engaging in little if any activity that could shift their view
Consciously or unconsciously avoiding steps to change behavior
Pressured by others to seek treatment
Feeling coerced by significant others
Not convinced that negative aspects of their use outweigh the positive. Common Characteristics of Individuals in the Precontemplation Stage: The 5 R’s That Help Keep a Person in This Stage: Processes of change associated with
movement into the next stage of Contemplation: Consciousness Raising
Emotional arousal/ Dramatic Relief
Environmental Reevaluation Treatment Planning Individual Treatment Group Treatment Couples Treatment
and Family Involvement Populations with Special Needs Relapse Applications in
Opportunistic Settings Final Thoughts and Future Directions The Contemplation Stage Individuals in this stage have:
Begun to think about changing their behavior but have not yet made a firm decision to change.
Are not engaged in behavior changing strategies. The most central aspect of this stage is evaluative balancing of the risks and benefits, and the advantages and disadvantages of substance use and behavior change. Common characteristics of individuals
in the contemplation stage... Seeking to evaluate choices and understand their behavior
Desirous of exerting control and mastery
Thinking about making change
Have not begun taking action and are not yet prepared to do so
Frequently have made attempts to change in the past
Evaluating pros and cons of their behavior
Evaluating risks and benefits of making changes in their behavior
Social Liberation Processes of change associated with
movement into the next stage of Preparation: The Preparation Stage Individuals in this stage are:
Planning to initiate change in the near future
In many cases have learned valuable lessons from their past attempts at change. The client at this stage has resolved the decision making challenges faced during contemplation and has committed to change. Common characteristics of individuals
in the preparation stage... Intending to change their behavior
Ready to change in terms of both attitude and behavior
On the verge of taking action
Engaged in the change process (maybe small changes)
Prepared to make firm commitments to follow through on the action
operation they choose
Making or having made the decision to change
Open to planning and creating a personal change plan Processes of change associated with movement
into the next stage of Action: Self-Liberation
Helping Relationships The Action Stage In this stage individuals:
Modify their behavior, experiences or environment in order to overcome their problems.
Have made a firm and clear decision to change and committed to that change
Show the appearance of behavioral manifestations of the commitment to change and the initiation of the change plans. Has decided to make change and reached the date to implement the change.
Has verbalized or otherwise demonstrated firm commitment to making change.
Efforts to modify behavior/ or environment .
Presents motivation and effort to achieve behavioral change.
Has committed to making change and is involved in behavioral change processes.
Willing to follow suggested strategies and activities to change. Common characteristics of individuals in the action stage: Processes of change associated with
movement into the next stage of Maintenance: Self-Liberation
Helping Relationships The Maintenance Stage Individuals in this stage are:
Working on sustaining and further incorporating changes achieved in the action stage into a lifestyle
Actively avoiding relapseHave accomplished at least some sort of minimal change as a function of successful efforts during the action stage.
Are on their way to developing a new stable pattern of non-using behavior. Common characteristics of individuals in the maintenance stage: Working to sustain changes achieved.
Considerable attention is focused on avoiding slips or relapses.
May describe fear or anxiety regarding relapse when facing a high-risk situation.
Less frequent but often intense temptations to use substances or return to substance use may be faced.
Beginning to build an alternative lifestyle that does not include the old behavior. Processes of change associated with staying in the stage of Maintenance: Self-Liberation
Social - Liberation Clinical Issues Relevant to the Precontemplation, Contemplation, and Preparation Stages Denial: A defense mechanism viewed as an unconscious process used by an individual to alleviate emotional conflict and anxiety.
Resistance: Occurs on both conscious and unconscious levels. Change produces anxiety and uncertainty and there is a tendency to resist this. Essential Motivational Methods for Promoting Change Among Those with Additive Behaviors Open Questions: Asking open-ended questions.
Affirming: Affirming, supporting, and reinforcing the client.
Reflecting: Reflecting back to the client.
Summarizing: Providing statements that link together and reinforce material that has been discussed. Clinical Strategies Applicable to Those in the Action Stage Maintain engagement in treatment.
Support a realistic view of change through small, successive, and successful steps.
Acknowledge the difficulties encountered in the early stages of change (withdrawal, distress, discomfort)
Help individual to identify high risk situations through a functional analysis and develop appropriate coping strategies to overcome these.
Assist in finding new sources of reinforcement to support positive change.
Help assess whether individual has strong family and social support.
Promote seeking support from mutual help groups. Clinical Strategies Applicable to
Those in the Maintenance Stage Help identify and sample drug-free sources of satisfaction.
Support lifestyle changes that support freedom from dependence on substances.
Affirm self efficacy.
Help practice, apply, and sustain new coping strategies to avoid return to drug use.
Maintain supportive contact.
Help resolve any additional mental health, physical health, and life context problems. Self-Report Screening Methods:
Michigan Alcohol Screening Test (MAST)
25 items relating primarily to negative consequences (physical, psychological, family, legal)
Popular and has led to two briefer versions (SMAST, BMAST)
Drug Abuse Screening Test (DAST)
MAST counterpart for problems with drugs, not alcohol. 20 items.
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
For primary health care settings. 8-items. Can be administered 5-10 minutes by a health worker.
Briefest, consist of 4 items.
Alcohol Use Disorders Identification Test (AUDIT)
10 item screener. Cutoff score 8.
49 items from the MMPI to discriminate empirically between those with alcohol problems and those without. Assessments Relevant to Those in the Precontemplation, Contemplation and Preparation Stages Intake Interview and Structured Diagnostic Interviews
Alcohol Use Inventory (AUI)
228-items measures multiple features of alcohol use and consequences. Takes ~35 minutes to complete.
Addiction Severity Index (ASI)
Structured personal interview designed to measure severity of problems in medical, employment, legal, family relations, and psychiatric areas.
Measures of Alcohol and Other Drug Use:
Timeline Followback (TLFB) interview: Given a calendar to recall daily drinking patterns over different intervals of time – up to a year.
Form 90 Family of Instruments
Like TLFB used in project MATCH: retrospective self reports of daily use over past 90 days. The Treatment Plan Developed as a result of a comprehensive assessment and modified over time.
Reflects involvement from appropriate disciplines.
Reflects the clients presenting needs and specifies the persons strengths and limitations.
Consists of specific goals that pertain to the attainment, maintenance, and/or reestablishment of physical and emotional health.
Identifies specific objectives that relate directly to treatment goals.
Identifies the services and/or settings necessary for meeting client’s needs and goals.
Specifies frequency of treatment contacts.
Includes provisions for periodic reevaluations and revisions. Qualities of Well Formed Individual Treatment Goals Are: Salient and meaningful to the client.
Incremental (more manageable).
Concrete, specific, and behavior focused.
Focused on increasing desired behaviors.
Include progressive steps for achieving goals.
Realistic and achievable.
Perceived as requiring work and effort.
Appropriate for the projected treatment period. Appreciating Diversity of Client The factor most taken into account is ethnic and racial background.
Miller (1999) emphasizes however the importance of acknowledging that clients differ along dimensions of:
All of these factors need to be taken into consideration in the evaluation of assessment data, in the development of treatment goals, and in the application of interventions focused on behavior change. Critical Tasks in Each Stage of Change Precontemplation: Generating concern, interest, and hope.
Contemplation: Risk-reward analysis, resolving ambivalence, decision making.
Preparation: Creating commitment, planning, prioritizing.
Action: Implementing a plan, overcoming obstacles, revising plan.
Maintenance: Sustaining change, preventing relapse, integrating change into lifestyle, avoiding change fatigue. Explore reasons why individual has come to treatment.Many reasons do not include changing behavior.
Advice giving – only beneficial who are in stage due to lack of information
Confrontation and advice are usually met with resistance.
Resistance can be a function of the approach therapist takes to work with client reluctance to consider change.
Motivational Interviewing and enhancement strategies are integrated with the stages of change model and recognize lack of motivation as part of the process of change. Precontemplation Stage Precontemplation Stage Meeting the Client’s Needs at Each Stage of Change Contemplation Stage
Requires continued engagement in the processes of consciousness raising, self-reevaluation, and environmental reevaluation.
Weigh Pro’s and Con’s/ For and Against
Motivational interviewing strategies to address ambivalence. Focus turns to personal evaluation of the pros and cons of behavior and the potential need to resolve ambivalence associated with decisional process. Preparation Stage Assist client to prepare for action.
Planning and commitment to enable client to take appropriate actions and follow through on the change plan.
Remove last of ambivalence.
Help client construct action plan.
Identification of strategies to successfully move into action and skills needed to implement these strategies
Contain specifics of what client will do to quit or modify behavior.
Functional Analysis (cover all areas of life functioning)
Addiction Severity Index Commitment is needed to negotiate the action plan, particularly in the early phases of action where discomfort, sense of loss, disorientation, and physiological reactions are the strongest. Action Stage Need hope of future relief.
Action plan implemented, reviewed regularly, and revised as needed.
Therapist has less to do in action stage if client is working on agreed plan.
Work on building strategies for coping with urges.
Create alternative reinforcers and responses for cues: relaxation training, refusal skills training, assertiveness, and positive communication training. Few clients remain in treatment unless focus of has shifted to client problems beyond those of substance use.
Treatment can be designed to occur at less frequent intervals and can include goals other than sobriety.
Long standing beliefs that undermine confidence/self-esteem
Fears and anxiety
Past abuse or familial problems
Check up visits:
Reinforce decision and stage tasks on path to sobriety
Problem solving any remaining issues
Examine any threats to sobriety
Medication may be helpful to assist making permanent changes in behavior.
Self help groups and mutual support. Maintenance Stage Violation of abstinence may raise feelings of suspicion guilt, recriminations, and doubt.
Relapses can be discouraging events.
Create atmosphere where client feels safe to come in and discuss slips and relapses.
Normalizing the process of relapse without creating a relapse self-fulfilling prophesy (challenging).
Don’t dwell on relapse but on recycling. Learning from past mistakes.
Assess where individual has landed after relapse in the stages of change
Evaluate what went wrong with treatment plan and action plan. Relapse Individual vs. Group Treatment Help raise their consciousness and increase their concern for for and awareness of substance related problems.
Psychoeducational information groups (whether open or closed format)
Motivational as well as educational.
Empathetic reflecting, reframes, affirmations. Precontemplation Stage Tilt the ambivalent decisional balance toward change and increase decision to change.
May be more receptive to information.
Begin to shift away from psychoeducation to more of a discussion format (more like processing)
Therapist should guide the process and have members openly discuss use patterns and implications.
Support shifting attitudes and provide feedback.
Assume less active role, serve to shape discussion, correct misinformation, reinforce contribution and self-disclosures. Contemplation Stage Shift in attitude from group: negative consequences outweigh the positives.
Committed to change plan to implement in near future.
Strengthen commitment and create an effective, acceptable, and accessible plan for making change. Preperation Stage Reinforce commitment to change and help develop, implement, and test out skills necessary for change.
Encourage any small steps made toward change.
Acknowledge difficulties and losses involved in change.
Help members identify access to services and social support.
Helping to generate possible solutions to problems.
Explore possible barriers to change. Action Stage Support individuals ongoing efforts and help maintain commitment to changing both use and lifestyle.
Maintain gains made to date.
Remain aware of personally relevant relapse triggers.
More focus on lifestyle change Maintenance Stage Support and reinforce members ongoing use of their successful coping strategies.
Minimize likelihood of a lapse.
Manage lapses if they do occur so they do not become full blown relapses.
The group itself:
Provides support for those struggling.
Having seen others relapse and come back to the group effectively will be beneficial. Relapse Genetic disposition towards substance abuse that runs within families and across generations.
Environmental context within which an individual is raised.
Substance abuse has negative impact on psychological and physical health of abuser as well as non abusing family members. “Family Disease” Lack of cohesion within family of substance abuser related to severity or individual and family’s psychological problems and leads to poorer prognosis. "Family" Family plays an important role in initiating treatment. Readiness to Change in Families of Substance Abusers: A Parallel Process Families attempts to cope with problems due to substance abusing member:
Tolerate the issue in an inactive and accepting way.
Withdraw from interacting with the user.
Engage in ways to try to change users behavior.
Family is likely to go through stages of readiness to change that parallel those of the abuser. Most coercive to least coercive:
Johnson Institute Intervention
Includes interventionist and intervention team.
ARISE program (modified from above)
Includes substance abuser in the process, providing alternatives, intervention falls on continuum, bond of caring in family unit, utilizing strengths of family and social network, family system benefits.
Unilateral Family Therapy
Provide support and increase well-being and functioning of individuals engaged in a relationship with substance abuser is the goal.
Community Reinforcement and Family Training (CRAFT)
Primary goal is to help family members encourage the substance abuser to stop drinking and enter treatment. Motivating Behavior Change and Engaging the Substance Abuser in Treatment Behavioral Marital Therapy
Targets both the client’s substance abuse and the marital relationship.
Community Reinforcement Approach
Principle is to provide the substance user access to valued reinforcers to help them remain substance-free.
Intent is to develop a lifestyle in which the other sources of reinforcement become more rewarding than using substances.
An active attempt is made to change environmental contingencies that may influence substance use behaviors.
To help with contingency management .
Contract specifies clearly, in client’s own words, the target behaviors to be changed, the contingencies surrounding change, and time frame for desired behavior change to occur. Action and Taking Steps Behavioral Continuing Care Contracts
Involves continuing care appointments, and is created when client is going to transition from more intensive care to less intensive continuing care.
Couple Relapse Prevention
Help substance abuser, significant other, and their relationship maintain positive gains made during couples therapy.
Deal with unresolved relationship problems.
Self Help Involvement
Nar-Anon Maintenance of Behavior Change Interventions meant to encourage treatment range along a continuum of coercion. Many studies have focused on men
Information may not be generalizable to women
Women are often underrepresented and underserved in substance abuse treatment
Women face multiple barriers compared to men in accessing specialty treatment.
Women are more likely to seek mental health or primary care treatment vs. addiction treatment programs.
Women are less likely to seek treatment Women Women misuse alcohol in response to stresses related to current circumstances or life events.
Middle aged (divorce, bereavement, children leaving)
Higher prevalence of comorbid psychiatric, eating and PTSD issues.
Often victims of abuse, which may lead to mood disorders.
Report more heavy drinking in response to negative emotional states and interpersonal conflicts. Women's Reasons for Substance Abuse Women are at greater risk to a wide variety of health problems and may develop medical side effects to their abuse more readily than men.
Typically women have a later onset of drinking, however they tend to progress faster than men between:
First getting drunk regularly and experiencing their first drinking problems
First loss of drinking control and onset of worst drinking problems. Women's Consequences of Use Internal Barriers for both men and women:
Belief that one does not have a problem.
Negative or lack of social support for seeking treatment.
Fear of treatment.
External Barriers for both men and women:
Difficulties and conflicts in scheduling time for treatment.
Treatment entry difficulty.
Financial problems. Reasons for and Barriers to Treatment Seeking: From Contemplation to Action Women more often:
Express greater levels of negative social support
More financial concerns.
Child care responsibilities.
Opposition from significant other.
Seek treatment to alleviate problems other than substance abuse.
Problems with children.
Barriers that lead women to delay or not seek treatment:
Structural (many programs structured for men) Reasons for and Barriers to Treatment Seeking for Women Child care
Assessment of psychiatric disorders and treatment for depression when indicated
Methods of building self-esteem, perhaps through skills training
Support offered to and education of family and friends
Assessments of accompanying medical disorders
Availability of staff to work with families
Teaching of coping skills for dealing with stress and other negative emotional states Gender Specific Features that Would Enhance Treatment Outcomes for Women Strong advocacy for women only programs
However, results from studies evaluating treatment outcomes from both have been equivocal.
Needs further evaluation. Female-Only vs. Mixed Gender Treatment
Interpersonal problems and conflicts
Low self-esteem and self-worth in intimate relationships
Severe untreated childhood trauma and concurrent trauma and PTSD
Strong negative affect
More symptoms of depression
Greater difficulty disengaging with people
Failure to establish new network of friends
Lack of relapse prevention skills
More likely to report depressed mood
More likely to escalate use following a relapse associated with unresolved trauma.
Shorter relapse episodes
More likely to seek help following relapse Women: Maintenance and Relapse
Mandated individuals usually have low levels of intrinsic motivation to change their use behaviors.
Especially when compared to those receiving pressures from family or friends.
Legal pressure and readiness to change are independent constructs
Readiness to change related to improvements in retention and therapeutic engagement vs. legal pressure.
Some evidence suggests those who are coerced:
Have outcomes comparable to those who “volunteer” into treatment.
Have less severe substance use and psychosocial issues
Are less likely to drop out of treatment Motivational Issues in Those Mandated for Treatment Individuals mandated into special programs for drinking drivers may be more motivated than is often thought.
Individuals identified as being in the precontemplation stage may require less intensive treatment than those in contemplation or those who are ambivalent but whose problems are more severe
Those in contemplation stages, with more serious risk and higher rates for recidivism, may benefit form multicomponent approaches that combine more intensive court mandated sanctions and increased court monitoring. Treatment to Increase Motivation and Treatment Engagement Women appear more likely than men to engage in continuing care following completion of an intensive phase of treatment. Relapse refers to a return to substance use following a period of abstinence.
Lapses and relapses are common post-treatment phenomena.
A variety of theories and models have been developed to account for the relapse process
Most emphasize immediate relapse precipitants. Relapse Lapse: single episode of violation of an individuals attempt at restraint
Relapse: reoccurrence of some problem after a period of improvement Definitions Successful maintenance emanates from four interrelated activities:
1. Proactively countering threats to maintenance and temptations to return to substance abuse.
2. Regularly assessing and renewing ones commitment to the behavior changes achieved.
3. Ensuring that one’s decisional balance on substance use remains on the negative side for a return to substance use.
4. Setting up a protective environment from substance use and establishing lifestyle that provides satisfaction. Maintaining Abstinence Avoiding risky people and places
Recalling drinking related problems
Substance free environments
Using treatment skills
Recalling benefits of sobriety
Remembering sobriety as top priority Maintaining Treatment Gains
Identifying situations where client is at greatest risk for relapse
Focus on development and application for coping skills especially in the high risk situations.
Build confidence. Preventing Relapse What to do if Relapse Occurs A lapse does not not necessarily lead to a relapse! Use the relapse as a learning experience.
See the relapse as a specific, unique event.
Examine the relapse openly in order to reduce the amount of guilt and/or shame felt.
Analyze triggers for relapse.
Examine what the expectation about use were at the time.
Plan for dealing with consequences of the relapse.
Let client know control is only a moment away.
Renew commitment to abstinence.
Make immediate plan for recovery – don’t hesitate, do it now!
Encourage contact with counselor to discuss slips. The majority of individuals with a diagnosable drug or alcohol use disorder do not recognize that they have a problem and therefore do not seek treatment in traditional substance abuse settings.
Stage-based brief interventions delivered in opportunistic settings have several advantages over intensive and longer types of treatment:
They take advantage of teachable moments.
Identify problematic use earlier.
Motivational enhancement can be offered at an opportune moment. Applications in Opportunistic Settings Assessment of readiness to change can be easily accomplished in opportunistic settings using readiness rulers.
Interventions can be tailored accordingly.
Complex cases require staging multiple intervention targets and selection of the prime intervention target to avoid overwhelming the client. Applications in Opportunistic Settings Interventions that focus on building motivation appear to be effective and useful for clients in earlier stages of readiness.
Those in the later stages may benefit more from receiving advice or skill-building strategies. Applications in Opportunistic Settings The stages-of-change model focuses on the identification of important components in the process of intentional behavior change.
The stages highlight the critical issues of denial, decision making, anticipation, action, relapse, and maintenance for specific behavioral problems. Final Thoughts and Future Directions A significant contribution of the model is the identification of different tasks and challenges faced by the client and the therapist at different points in the process of changing addictive behaviors.
Clinicians should identify where a client is in the process of change and use that knowledge to guide the selection of intervention goals and strengths. Final Thoughts and Future Directions It is important to avoid overly simplistic views of motivation for treatment or for change.
Approaches to facilitating change processes need to differ, depending on the client.
It should be kept in mind that the use of the experiential and behavioral processes and other change variables happens both inside and outside of the treatment session. Final Thoughts and Future Directions It is necessary to track motivation and change process use frequently and adjust treatment strategies accordingly.
There is debate in the literature on some aspects of the stages-of-change model.
One issue is whether the process of change is most productively viewed as involving stages of change or as a continuous process.
It is argued that the process of change for substance abusers involves a series of stages or phases that require different strategies and address different issues. Final Thoughts and Future Directions While much has been written about the application of the stages-of-change model to substance abuse problems, there is more to be learned about the stages and how the model can be most productively used in clinical practice.
Additional knowledge and insights will undoubtedly emerge as researchers and practitioners continue to apply the model to different populations and problems. Final Thoughts and Future Directions THE END!