Understanding your readiness for behavior change: I have included a revised post to refer to when thinking about the YHF discussion community board.
I found out very early in parenting that even if you point out an unhealthy behavior in your child, the only way that they are going to change is when you partner with them or convince them that it is their own idea. This example applies to anyone that has developed a consistent behavior through time. Emotional reactions and behaviors are more reflexive in our brain’s neural circuitry than we may realize. Although the most egregious example is substance abuse, any other behavior can be an almost instinctual or subconscious automation. Fortunately, positive behaviors can also become that way. Anyone exercising daily can recall the feeling of absence or loss when they skip a day or two.
The Transtheoretical model (TTM), or the Stages of Change Model was developed by Prochaska and DiClemente in the 1970s. It is a useful tool in understanding the process by which one may overcome a behavior cycle. We are approaching a greater understanding of how these changes relate to the neurotransmitter and brain functional changes involved. As our understanding of neuroplasticity increases, we may be able to develop optimal strategies.
The steps to behavior change are described below. It is important when reviewing this that a behavior, by definition, represents a circuit that has fired many times before. Therefore, the wiring is well-established and entails action, thoughts, statements, senses (e.g. phantom odors, visual awareness, etc) and dreams. Although I use smoking to illustrate these behavior steps, any behavior could apply:
Precontemplation is the time before one begins to realize that their behavior is potentially harmful or associated with negative consequences. There is often a degree of rationalization to support the behavior, with an emphasis on the disadvantages of discontinuing the behavior. Some responses that I have heard from smokers that are precontemplative of quitting are “I smoke so I don’t get thrown in prison,” or “I smoke so my wife doesn’t kill me” or “it is one of the last pleasures in my life,” or “I don’t want to talk about it.” These responses are often seem completely reasonable to those who smoke, as they grapple with how stressors affect their lives and the behavior is well integrated in words and thoughts – denial, rationalization are reflexive. If I determine that a person is in this stage, I usually don’t bring up the point of quitting as much as I encourage them to look for healthier methods of coping and managing stress. I will usually bring up some of the benefits of not smoking and discuss resilience-building techniques without the price tag, literally and figuratively, that smoking has.
Contemplation is the stage when a person realizes that a behavior is more harmful than helpful and is considering the risks and benefits of changing that behavior. They may even have a goal in the next several months toward this direction. Sometimes, it follows an adverse outcome directly related to the behavior. When a person who smokes comes in with consequences related to smoking, e.g. a myocardial infarction, pneumonia or an asthma exacerbation, they will be at a heightened awareness of the behavior’s risks. This is a good opportunity to bring up the benefits of completely changing the behavior.
Preparation is the time when someone is ready to make a behavior change within the next few weeks to month. They may plan a quit date for abrupt withdrawal, work toward building other coping strategies or taper off. More recently, smokers have shifted to other nicotine delivery systems (e-cigarettes or juul) as a transitional phase – though have found themselves at risk of gaining a new nicotine delivery habit. It is at this stage that encouragement and providing resources is most useful. The national smoking quit-line offers a resource where a person can call for information and tips at 1-800-QUIT-NOW. They can register and be appointed a tobacco cessation coach. There are other resources online for smoking, substance abuse and behaviors.
Action is the stage when a person enacts the behavior change. S/he is motivated to make decisions that support the change and protect them from relapse. This is where the rubber hits the road. A smoker may decide to buy their “last pack” and divide the cigarettes out in plastic bags to smoke daily, maybe 4 cigarettes a day for 5 days or a taper of cigarettes. They may have contemplated this stage and mentally visualized it for many months before acting on it. It is at this step, where a person attempts to transcend the cycle of behavior. Tied to behavior are strong cyclical phases of dopamine, serotonin and norepinephrine that reinforce the behavior in emotional and memory centers in the brain.
A person may experience withdrawal symptoms, both physical and psychological during this phase. Mental images of smoking cigarettes in the morning, after a meal or sex, or during a work break spill into conscious thought from memory centers. Sometimes one may even hallucinate the sensory memory of the behavior, including odor of cigarette smoke, dream relapses, etc. There are also external cues that triggers memories include smelling smoke, performing co-behaviors (like drinking alcohol) or seeing someone smoking. These memories are likely related to dopamine receptor activity (D2/D3) in corticostriatal-limbic pathways in the brains, which cue into behaviors, motivation and action. After a period of time, the strength of the cravings diminish. Studies suggest that stress and trauma may strengthen the craving pathway and lead to relapse. Hence, the importance of having a context of stress management, resilience training and mindfulness before the action phase.
Maintenance is the stage where one develops a protective mesh around the new behavior to sustain the behavior and prevent a relapse of an old behavior. This usually takes several weeks of adjustment. Some may have small relapses, for instances smoking a cigarette, and at that point, either go back to repeat the behavior at the prior level of activity or reset their action plan. This is one of the reasons that relapses of opiates are at a high risk of overdose and death (More than 30,000 people die from opiate overdose yearly – many from relapse). In many cases, after a successful withdrawal, forced or planned, the effective and lethal dose are reduced. When the person relapses and uses the prior usual dose, they are supra-therapeutic in dose and may develop respiratory failure and anoxic brain injury and a chance of dying.
After many years of maintaining this new behavior, it becomes automatic enough to prevent someone from having a craving to return to the prior behavior, at least in theory. This is known as the Termination stage. Most people who have had experience with quitting smoking, alcohol or drugs are aware that significant stressors can sometimes bring them back to thinking about returning to their unhealthy life. I would consider the maintenance stage of the healthy behavior to be a life-long journey.
Shortcomings and Strategies
Although this model is useful, there are some shortcomings. It doesn’t take into account various factors, such as socioeconomic status and other influences on sustainable behavior change. People with higher socioeconomic status may have more resources to protect them from relapse or provide a greater support system. In my care of patients with opiate addiction and an infection, many are in a marginalized state, such as homelessness and have mental health diagnoses and post-traumatic stress disorder. To try to maintain a drug-free behavior is often approaching futility.
Another important thing not described in this model is that if someone fails to maintain a behavior by relapsing, they are not necessarily back to the beginning. They may have stopped a behavior with some tools, such as smoking but they relapsed. They are setting up a framework to make a future attempt more successful. I remind this to the patients I see who use drugs. They may have come in with an infection and were unprepared to learn other coping techniques required to maintain the behavior change after acute withdrawal. Or very commonly, they may have no resources to provide them socioeconomic stability. Relapse is all too common. I encourage them that they are starting a path to behavior change that may be circuitous but not a failure as they are still working toward that goal perhaps with new social support or rehabilitation contacts (e.g. social worker, quitting resources). The shame of failure is often a power inhibitor to future behavior change.
In the clinic setting, I often address wellness and substance issues toward encouraging behavior change even at a new patient visit. During this visit, we discuss health behaviors and habits, as well as review their medical diagnoses and medications. If during this visit, I come across some consistent behaviors that could be contributing to the patient’s health issues, I will start to lay the foundation toward future discussion. A discussion of this approach is often tailored to the patient’s readiness to change their behavior. A patient may be unmotivated to change, or exhibit amotivation, a state when he/she may lack intention to make a change (source, Vallerand). Yet, a visit with a clinician could be viewed as a health-seeking behavior.
Strategies to motivating the unmotivated with motivation interviewing have been posited. Unraveling this barrier to change often begin with determining the factors that are involved in the behaviors, the pros and the cons of maintaining the behavior and stopping the behavior, and learning of cues to the behavior. Other forces may be involved in derailing one’s willingness to change. These include low self-efficacy, value and effort beliefs and outcome expectancies. If an individual has challenges with self-esteem or confidence, he/she may not be able to envision a change of an unhealthy behavior because of this barrier. They may not have yet developed reliable approaches or coping strategies to persevere through a behavior change. Value and effort beliefs relate to a patient’s perception. The patient may not perceive the behavior change outcome as worthwhile enough to pursue. The patient may not feel that they are capable of applying sufficient effort toward this new behavior or stopping the harmful behavior.
Counseling toward behavior change
The following section will describe the harmful behavior of drug addiction. However, this can be applied to changing any behavior. The approach to coaching a person who is in the beginning of making a behavior change should be toward identifying positive skills and attributes a person has. A person who is in the grips of a behavioral cycle often has poor alternate coping skills – given that a destructive behavior can consume all of their conscious and subconscious faculties and wipe away any other support network. In this way, homelessness can be the face of a severe addiction, such as heroin.
There also can be a lot of shame associated with destructive behaviors, such as IV drug use, smoking or alcohol. A person may be distrustful or lukewarm when they are approaching counseling, often concealing or lying about facts. I like to approach it as objectively as possible. I counsel them about the difference between the “brain” and the “mind”, even if it may be a semantic distinction. I mention that the brain is stuck in a behavioral loop that has caused them harm and has prevented them from being free, almost as if they are caught in an orbit. This means that the brain will call up all its resources, including thoughts, perceptions, words and actions to complete the circuit and repeat the behavior. The brain has received supra-normal neurotransmitter cues and has reshaped the brain for the addiction, causing other parts to atrophy.
The brain is causing harm to the rest of the body. The mind is conscious that the behavior is harmful and enslaving it. I urge them not to listen to the brain cues to relapse. I ask them to Identify another activity – a hobby like art or writing, walking, or even listening to music — even if for just the next several minutes. They can also call a support friend to talk it through. Usually the wave craving will pass after that. Eventually, the cues and cravings will diminish – and a person will build a new life – free of the grasp of addiction – though the brain will always remember the experience- gone but not forgotten. I counsel them to remember the harm that the behavior has caused – and never let their brain convince them that the “grass is greener” on the side of the harmful behavior.