You Asked, Dr. DiClemente Answered! Stages of Change and Integrated Care

Relias hosted a webinar on Integrated Care and Stages of Change with Dr. Carlo DiClemente presenting on the application of the Transtheoretical Model of behavior change (TTM) across the healthcare continuum. Dr. DiClemente (co-creator of TTM) was a fabulous presenter and delivered a high quality and insightful discussion. Hundreds of professionals from different segments of healthcare and all across the country (a few international too), joined the webinar and a few thousand more asked for the recording. We were unable to get to all the Stages of Change questions that were asked during the live webinar, so we created this blog post to address everything our audience brought up.

Unanswered Stages of Change questions from our webinar

Below are some of the Stages of Change questions submitted during the webinar but we were unable to answer due to time constraints:

Question: What can we do, with the people in precontemplation and they don`t go with a professional? The people we don`t know?

Answer: People in precontemplation for seeing a professional probably have a lot of reasons that may not be based in solid knowledge. So we must really “sell” the benefits before even giving the referral. Your task is to promote interest and concern, and tip the decisional balance. Not knowing someone might give some advantage so you can explore their attitudes with them using motivational communication strategies.

Question: We purchased Epic for our hospital. We tried to implement our substance use treatment services within this program; but, upon several years of investigation, our lawyers determined that we could not integrate due to 42 CFR. Any changes coming in law?

Answer: 42CFR has been updated to be less of a block to share info.  I would go on the SAMSHSA website and look up the latest changes.

Question: People often confuse low confidence for lack of motivation. How do you distinguish between the two?

Answer: Low confidence can lead to a lack of motivation and getting stuck in Precontemplation. I often assess temptation to use and self-efficacy to abstain across situations using our alcohol or drug abstinence self-efficacy scale. The discrepancy between temptation and confidence is a good predictor of future success. If someone is overwhelmed with the addiction and they feel helpless and hopeless they are most often in Precontemplation, so the two are connected. However, motivation or readiness is often about having intentions and the commitment to make a quit attempt. They are not highly correlated, so they seem to be different concepts.

Question: Where does harm reduction/substance use factor in the stages of change process?

Answer: Harm reduction is getting the change you can while waiting for the change you want. So, individuals in Precontemplation, or stuck in the ambivalence of contemplation, are often willing to reduce harm (clean needles, cut down on marijuana or alcohol use, engage in safer sex practices) but not to change completely. From a change perspective, any concern and consideration about the danger of the current lifestyle can move people forward; so, harm reduction can help with contemplation and preparation activities down the road.

Question: I´m from {an organization} in Chile. When working on the prevention of problem drug use in organizations, we try to give a process vision, which often implies starting from the pre-contemplation. Suggest some way to start this intervention that allows a better understanding of the process of change at the organizational level?

Answer: Not certain I understand this completely. The stages work at the individual and organizational levels. In prevention initiation of substances, we are trying to keep individuals in Precontemplation for initiation so they do not start using. So, if I am working in an organization that is trying to address prevention, I would first assess if the organization is really convinced of the need to act. Moving organizations through the stages is more complicated since there are multiple players and roles. So, my ideas are to identify the problem clearly, highlight the effective actions that could support prevention and then explore attitudes and views of individuals at different levels of the organization. If you are looking for a way to simplify, I often use getting people or organizations Ready, Willing and Able.

Question: Are there any significant differences to keep in mind when working with organizations and systems (rather than individuals)?

Answer: See above. Also, it is important to make sure that there is support and readiness at all levels especially at the point of implementation of the innovation or change. The administration often tries to implement a change that the workers are not convinced by or ready to implement, so they end up either not making the change or doing it half-heartedly or in an undermining manner.

Question: We have developed an IT intervention to address multiple health risks; can you suggest any analytic techniques that would allow us to assess multiple behaviors using SOC {stages of change}?

Answer: We have assessed multiple behaviors in terms of the stages either by using a readiness ruler that goes from 1 (not at all ready) to 10 (very ready). We have also offered definitions of the stages and asked folks to place themselves in one of these boxes:

1. Not seriously thinking about doing this
2. Seriously thinking about doing this (like eating five or more vegetables and fruits daily)
3. Starting or getting ready to do this
4. Already doing this but for less than 6 months
5. Doing this for more than 6 months

Individuals seem to be able to identify where they are on these stages.

Question: Is there a preferred method/measure for measuring Readiness to Change?

Answer: See above. It differs for research and for clinical work. Clients can stage themselves once stages are explained simply to them.

Additional questions we covered

Below are some more Stages of Change questions that Dr. DiClemente answered in webinar:

1. When someone misunderstands the stage of precontemplation and says, “Well, they’ll come back when they are ready,” what would you say to that?
2. What is the role of group intervention in implementing the TTM model?
3. I’m curious about what the TTM perspective is on repeated relapse, longitudinally? I’m thinking about this in terms of substance use.
4. Have you seen the Transtheoretical model applied when trying to help change racist/sexist behaviors? Or when trying to change stigmas associated with mental health?
5. DiClemente briefly touched on technology needs. There are a lot of homegrown software programs that don’t talk to each other. Do you know of any apps or other programs that aim to make communication across care-providers happen?

Thank you all for joining us and asking such thoughtful and insightful questions. It was a personal and professional honor for us to work with Dr. DiClemente, and we appreciate his generosity, time and knowledge.

Dr. DiClemente has authored a course with Relias on the Transtheoretical model of change that we recently released. If you’re interested in that course and other training for your staff on issues related to substance use, addiction, treatment, opioid misuse, recovery and more, schedule a call with a Relias representative to learn what we offer.