Lifestage, Inc.

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ALL IN THE TIMING: CREATIVE STRATEGIES FOR ENGAGING AND WORKING WITH THE PRECONTEMPLATIVE PERSON

Association for Medical Education and Research in Substance Abuse Annual Conference

The “action” paradigm of behavior change is a model that enrolled clients in relatively brief programs designed to conquer smoking, weight, alcohol, spending or other problematic behavior and expected them to take action within weeks. Failure to maintain the action is attributed to the clients’ lack of will power or motivation.

90% of behavior change programs are designed for people who are ready to take action and change their behavior.20% of people who present for help are ready to take action or change their behavior.

Prochaska, Norcross & Clemente, Changing For Good , HarperCol l ins Books, 2006.

“TIMING HAS A LOT TO DO WITH THE OUTCOME OF A RAIN DANCE

” O L D W E S T W I S D O M

“The popular concept among behavioral therapists is that no time is better than the present to take action against an addictive habit. In theory, it sounds right. But the cold light of reality presents a diff erent picture. I am convinced that there is a tremendous advantage in a well-prepared, pre-emptive attack against the smoking habit.” Dr. Balasa Prasad Stop Smoking For Good

“REALITY IS THAT WHICH, WHEN YOU STOP BELIEVING IN IT,

DOESN’T GO AWAY.” PHILL IP K . D ICK

“THERE IS A TIDE IN THE AFFAIRS OF MENWHICH, TAKEN AT THE FLOOD,

LEADS ON TO FORTUNE;OMITTED, ALL THE VOYAGE OF THEIR LIFE

IS BOUND IN SHALLOWS AND IN MISERIES.ON SUCH A FULL SEA ARE WE NOW

AFLOAT,AND WE MUST TAKE THE CURRENT WHEN

IT SERVES,OR LOSE OUR VENTURES.”

WM SHAKESPEARE, JULIUS CESEAR , ACT 4, SCENE 3, 218-

224.

But change is not a lateral process.

CHANGE IS A PROCESS THAT PROCEEDS IN STAGES OR STEPS

ADDICT ION AND CHANGE:Understand ing and In terven ing in the Process

Car lo C .D iC lemente , Ph .D. ABPP UMBC Psycho logy www.umbc.edu/psych /hab i ts

“At certain moments in history, there are individuals whose minds are prepared to recognize the importance of things that unprepared minds ignore or throw away.” Prochaska, Norc ross & C lemente , Changing For Good , HarperCo l l ins Books , 2006 : 17

With pre-contemplative people, information about addictive behavior – or any other health-threatening behavior pattern – has to transcend the psychological barriers that allow the behavior to continue despite its negative consequences.

THE PREPARED MIND

INTERVENTIONS THAT DO NOT MATCH THE PERSON'S READINESS ARE LIKELY TO:

DAMAGE RAPPORT

BLOCK RECEPTIVITY TO THE MESSAGE

IMPEDE CHANGE

“MOTIVATIONAL INTERVIEWING AND THE STAGES OF CHANGE” SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION,WWW.SAMHSA.GOV/CO-OCCURRING/TOPICS/TRAINING/CHANGE.ASPX

The precontemplative mind set is operating from a protective network of defenses. These defenses inhibit cognitive awareness of consequences to behavior and block the capacity to absorb information about it.

THE PRECONTEMPLATIVE PERSON

tread lightly or they will run the other way

SELF-PROTECTION IS HEIGHTENED FOR

THE PRE-CONTEMPLATIVE

PERSON.

All effective strategies must really start where people are, with their unique, complex, subjective experience.

“There must be pragmatic acceptance that people are where they are, as well as compassion for any struggles and suffering linked to the problem behavior.”The Sm oke -F ree Sm oke B reak : S top Sm ok ing N ow W i th M ind fu lness & Accep tance , Pave l Som ov , PhD & Mar l a Som ova , PhD

TO AN ACTIVE SMOKER, E.G., SMOKING IS A FORM OF SELF-CARE

CHANGE CAN BE PERCEIVED AS A THREAT AND TRIGGER THE

“STRESS RESPONSE” --

FEAR-BASED INTERVENTIONS REINFORCE THE SUBCONSCIOUS PERCEPTION OF

THREAT

All information about the addictive behavior and its consequences is communicated over some kind of barrier, like speaking to someone through a closed door.

These defenses include: Denial: “I don’t see anything wrong here.” Rationalization: “I know that what I’m doing might be bad

for me but I couldn’t handle my stress without it.” Projection: “You’re not so perfect. You are judgmental. You

have no right to criticize me.” Blame: “Every time I try to quit my spouse sabotages me.” Internalization: I feel guilty and shameful about doing

this, so that’s something….”

PSYCHOLOGICAL BARRIERS TO COMMUNICATION IN PRE-

CONTEMPLATION

THE NEUROSCIENCE OF BONDING

REWIRING ONE’S BRAIN IS

UNCOMFORTABLE, ANXIETY-INDUCING

AND REQUIRES TIME AND

PERSISTENCE,

The will to change and the skills/tools to navigate change must occur at the same time.

Desire: “I want” – necessary for change to occur; but without the tools and skills needed to achieve some degree of success leads to repeated, frustrating attempts that do not succeed and produce more shame, anxiety and demoralization.

Competence: “I can”- tools, skills and knowledge are key to making a behavior change; but desire ignites the energy to use them.

SUCCESSFUL SUSTAINED BEHAVIOR CHANGE: ALL IN THE TIMING

When a person has the desire to change and at the same time the tools, skills and knowledge to get through the tensions of change action is possible.

DESIRE AND COMPETENCE

PROCESSES OF CHANGE

Experiential Processes Concern the person’s thought processes Generally seen in the early Stages of

Change

Behavioral Processes Action oriented Usually seen in the later Stages of

Change

ADDICTION AND CHANGE: Understanding and Intervening in the ProcessCarlo C.DiClemente, Ph.D. ABPP UMBC Psychology www.umbc.edu/psych/habi ts

Consciousness-raising – reframe problems to integrate new information with the person’s stated perspective, e.g. “when I take a smoke break I am breathing deeply and taking care of myself – what happens if I take the break and breathe without the smoke?”

Counter-conditioning - provide alternatives for the behavior that provide something that approaches it’s perceived benefi ts, e.g. medication, relaxation, emotional intelligence skills, mindfulness,

C a n c e r P re v e n t i o n Re s e a r c h C e n t e r Tr a n s t h e o r e t i c a l M o d e l , h t t p : / / w w w. u r i . e d u / re s e a r c h / c p r c / T T M / P ro c e s s e s Of C h a n g e . h t m

PRECONTEMPLATION AND THE PROCESSES OF CHANGE

Environmental re-evaluation – “My kids are upset that I smoke and are always on me to quit”

“It is very inconvenient to take a smoke break now that we have to go so far from the building”

Helping relationships –

Encourage social and interpersonal relationships with people who do not smoke – educate about the role of social networks in health behavior change;

MORE PROCESSES OF CHANGE

Every facet of health examined so far appears to “spread” from person to person.

The strength of a network effectdepends on the strength of a friendship.

“Friendship as a health factor” Science, Volume 323 23 January 2009, www.sciencemag.org

SOCIAL NETWORKS INFLUENCE BEHAVIOR CHANGE

Self-Awareness and Self-Control – an accurate understanding of how one’s behavior and words aff ect others

Emotional and inner awareness – an accurate understanding of how one’s emotions and thoughts aff ect behaviors

Accurate self-assessment of skills and abilities – an honest assessment of strengths and weaknesses

Conscious planning of communication – the ability to plan the tone of a conversation to achieve the best results

Respectful listening – listen deeply and seek to understand what others are saying

Creativity and sense of play – the ability to take one self lightly and engage with serious situations in a creative way

Dan Goleman, Emotional Inte l l igence , Bantam Del l , 2006

EMOTIONAL INTELLIGENCE IS THE FOUNDATION FOR EFFECTIVE

COMMUNICATION

“Emotional Intelligence (EI): Our ability to engage our emotionality in effective ways in order to facilitate positive outcomes in our relationships.”Dr. Michael E. Rock. one of a few special ists in the world currently l icensed to cert i fy professionals in the understanding of , the stat ist ical research background in, and the interpretation and use of the BarOn EQ- i

EMOTIONAL INTELLIGENCE: AN EXPRESSION OF THE RICH INTERPLAY OF CONSCIOUS FEELINGS, THOUGHT-ACTION

REPERTOIRES, AND ATTITUDES

EMBRACE THE “WOBBLE”

The fi rst rule of intervention in a behavior change process is the same as the fi rst rule in improvisation: Accept what is; Accept people as they are; Listen; Take in what is being expressed and build on it; Notice the facts – both spoken and unspoken;

“Improvising has much in common with riding a bicycle, surfi ng or skiing. Things are not stable, l inear, or predictable. The situation is always in fl ux. Our footing keeps changing. This approach may be uncomfortable or unsettling at fi rst, and it is natural to seek out security. ..We can stop trying to fl ee from the wobble.” Pat r i c ia Ryan Madson , Improv Wisdom , C rown Pub l i sh ing Books , 2005: 82 .

What is:A workplace wellness program in which employees earn points that reduce their medical deductible by increasing amounts based on their completion of requirements.

Employees who smoke must take all the classes other employees take plus a series of 6 90-minute smoking cessation classes.

All classes and exercises hours must take place on employees’ own time.

EMBRACING THE “WOBBLE” IN A WORKPLACE SMOKING CESSATION

PROGRAM

The employer’s objectives:

Reduce the number of employees who smoke;

Reduce health care costs related to smoking;

Provide tools and knowledge to help employees who smoke achieve cessation.

The employees’ objectives:

Reduce insurance co-pays;

In most cases, continue to smoke while fulfi lling the employer’s mandate to attend smoking cessation classes;

WHO WANTS WHAT

EMPLOYEES ACHIEVE THEIR OBJECTIVE BY ATTENDING SMOKING CESSATION CLASSES.

CHANGES IN SMOKING BEHAVIOR CANNOT BE MANDATED.

What is

PRE-CONTEMPLATIVE PEOPLE IN A

WORKPLACE SETTING SPENDING THEIR OWN

TIME TO TALK ABOUT SOMETHING THEY DO

NOT WANT TO TALK ABOUT

What works:Acceptance that

the defenses associated with pre-contemplation will disrupt and distort messages that directly challenge smoking behavior.

Talk around the closed doors by connecting through open pathways:

Emotional connection

EmpathyRespect for a

person’s humanity, individuality and freedom to think for him/herself

IF WHAT IS: LITTLE OR NO DESIRE TO CHANGE SMOKING BEHAVIOR

“This is not for the faint-hearted but nor is it for the indelicate and insensitive. We are seeking to unbalance someone, to pull the defensive carpet from under their feet. This is a role that in any ideal scenario would sit with a skilled therapist in a perfectly crafted environment. But as we’ll say a thousand times, assertive engagement is about working in an imperfect environment and still seeking change. It is okay to challenge defenses but be mindful that the client rarely is in a safe space and even more rarely will return to a safe space after having met with you. So we proceed with care but we proceed nonetheless.”“Precontemplat ion and Asser t ive Soc ia l In te rvent ion” Asser t ive Engagement Resource

ASSERTIVE ENGAGEMENT: IT’S ALL IN THE TIMING

Focus on developing competence in other areas that can impact health: Identify stressors at work and home;Teach about the stress response and its eff ects on

health and ability to cope with change; Identify and build on individual strengths, e.g.

perseverance, resourcefulness, humor, social skills;Cultivate competence in getting through stressful

situations and states of mind through the processes of change;

HOW TO “EMBRACE THE WOBBLE” BETWEEN EMPLOYER AND EMPLOYEES’

OBJECTIVES:

CHANGE CAN MAKE A PERSON FEEL LIKE A FISH OUT OF WATER – IT HELPS TO UNDERSTAND THE

TENSIONS OF CHANGE AND OUR OWN APPROACH TO CHANGE

Reduce the reactive, fear-based “threat” response to change.Give only small bits of information that are easily digested and applied

INCREASE EMOTIONAL RECEPTIVITY

THROUGH EMOTIONAL

CONNECTIONS;FOCUS ON: WORKING THE SOIL & PLANTING

SEEDS

3 Brain Regions are involved with nicotine dependence and cravings

BLUE: the thalamus, the brain region critical to one's abil ity to calm down when stressed.

RED : the striatum, a region implicated in the pleasure system of the brain.

GREEN : the anterior cingulate cortex, a region vital to self-control and concentration.

C r e d i t : I m a g e c o u r t e s y o f D u k e U n i v e r s i t y M e d i c a l C e n t e r

EXPLAIN THAT NICOTINE CHANGES THE BRAIN AND IMPACTS THE FREEDOM TO THINK FOR OURSELVES

EXPERIENCES CHANGE THE BRAIN

Teach Breath Work and Why It Matters

YOGA BREATHING MINDFULNESS CHAIR YOGA BREATH WORK

Emotional intelligence grows through increasing connections between emotions and higher cognitive functions.

SELF-KNOWLEDGE PROMOTES EMOTIONAL INTELLIGENCE

“Through increased self-awareness, individuals are more able to detach themselves from events and regulate their emotions in order to prevent them from becoming ‘immersed in’ and ‘carried away’ by emotional reactiveness.”Mark Slask i and Susan Cartwr ight , “Emotional inte l l igence tra in ing and i ts impl icat ions for stress , heal th and performance” Stress and Heal th Volume 19 2003

• Everyone has blind spots – if we are open to seeing

our own ambivalence toward change we will be more

open to acceptance of others’ ambivalence;

• Compassion and understanding toward self is the

doorway to empathy toward others;

• Recognize and respond to the eff ect that role

hierarchies have on perception and communication;

Goleman, Daniel (1998) Working with Emotional Intel l igence , Bantam Books

PROVIDER RELATIONSHIP SKILLS:

EMPATHY COMMUNICATION BOUNDARIES

Jude Treder-Wolff , LCSW, RMT, CGP

Nicholas Wolff , LCSW, BCD, TEP

496 SMITHTOWN BYPASS SUITE 202 SMITHTOWN, NY11787

631-366-4265WWW.LIFESTAGE.ORG

Training in effective approaches to working with precontemplative clients is available for your staff, organization or conference.