Utilizing the Stages of Change in Adolescent Substance Use: A Clinical Perspective 9/25/24

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Adolescent substance use is a multifaceted public health issue that poses significant opportunities for intervention to clinicians, including physicians and counselors. The complexity of this issue is heightened by the developmental stage of adolescence, a period characterized by experimentation, identity formation, and at times, risk-taking behaviors. The Transtheoretical Model (TTM), also known as the Stages of Change model, provides a structured framework for understanding and intervening in adolescent substance use. This model, developed by Prochaska and DiClemente, delineates the stages through which individuals progress as they contemplate, initiate, and maintain behavioral change. Utilizing this model in clinical practice allows for tailored interventions that align with the adolescent’s readiness to change, thereby enhancing the efficacy of treatment.

The Stages of Change Model

The Stages of Change model comprises five primary stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance. A sixth stage, Termination, is often included but is less applicable to adolescent substance use due to the fact that they may remain in treatment for substance use disorders until they reach adulthood. The fluidity of these stages, with possible progression and regression, underscores the importance of continuous assessment and individualized intervention strategies.

  1. Precontemplation: Adolescents in this stage are not considering change, either due to only seeing the benefits of substance use without the downsides, the fact that they haven’t had adverse life experiences yet from the substance use (i.e. “rock bottom” in older substance use lingo), denial of the problem, lack of awareness, or perceived invulnerability. This stage is particularly challenging as adolescents may not perceive their substance use as problematic, or they may resist change due to peer influence and a desire for autonomy. However, adolescents are often willing to think about changing their substance use and move into another stage when clinicians approach them in a non-judgmental manner and ask them openly about the benefits of substance use prior to asking about the potential downsides. Note that pure psychoeducation and “advising” the patient often only firmly cements them in the precontemplation phase.
  2. Contemplation: At this stage, adolescents acknowledge the potential risks associated with their substance use but are ambivalent about change. They may weigh the pros and cons of their behavior, often resulting in prolonged deliberation. This stage is critical for clinicians to build rapport and enhance motivation through motivational interviewing, a technique that helps resolve ambivalence by eliciting the adolescent’s own reasons for change.
  3. Preparation: Adolescents in the preparation stage have made the decision to change and are planning to take action in the near future. At this point, specific goals and strategies for change should be developed collaboratively between the clinician and the adolescent. Interventions might include the development of coping strategies, addressing environmental triggers, and fostering supportive relationships that encourage sobriety.
  4. Action: This stage involves the implementation of change, where the adolescent actively alters their behavior and environment to reduce or eliminate substance use. Clinicians play a crucial role in supporting adolescents during this stage by providing ongoing reinforcement, addressing challenges and setbacks, and ensuring that the strategies devised in the preparation stage are effectively employed.
  5. Maintenance: In the maintenance stage, the focus shifts to sustaining the changes made during the action stage and preventing relapse. Adolescents are at risk of relapse due to the persistent nature of cravings, social pressures, and emotional triggers. Long-term success in this stage often requires continued counseling, participation in support groups, and ongoing monitoring by healthcare providers.

Clinical Application

Effective utilization of the Stages of Change model in adolescent substance use requires a thorough assessment of the adolescent’s current stage, followed by the implementation of stage-appropriate interventions. Physicians and counselors must be adept at identifying the subtle indicators of each stage and tailoring their approach to match the adolescent’s readiness to change.

  1. Assessment and Rapport Building: Initial assessment should focus on understanding the adolescent’s perception of their substance use, their readiness to change, and any co-occurring mental health issues. Building rapport is essential, as adolescents are more likely to engage in treatment when they feel understood and respected. Tools such as the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) can be used to gauge the adolescent’s stage of change.
  2. Motivational Interviewing: Motivational interviewing can be highly effective in all stages. This client-centered, directive method facilitates the exploration of ambivalence and strengthens the adolescent’s intrinsic motivation for change. Key techniques include expressing empathy, developing discrepancy between the adolescent’s goals and their current behavior, rolling with resistance, and supporting self-efficacy.
  3. Tailored Interventions: Interventions should be stage-specific. For example, adolescents in the precontemplation stage may benefit from open-ended and non-judgmental discussions about the benefits and consequences of substance use, while those in the preparation stage might require help with developing actionable plans and identifying triggers. In the action stage, clinicians should focus on skill-building and problem-solving to navigate real-world challenges.
  4. Relapse Prevention: Maintenance strategies should incorporate relapse prevention techniques, such as cognitive-behavioral therapy (CBT), which helps adolescents identify and challenge cognitive distortions that could lead to relapse. The use of contingency management, where positive behaviors are reinforced through rewards, has also shown efficacy in maintaining long-term sobriety.
  5. American Indian/Alaska Native (AI/AN) Populations: In AI/AN populations, traditional cultural practices can be a very strong, powerful, and highly effective adjunct to western medicine approaches. For example, when it comes to the contemplation phase, the cultural identity of the adolescent can largely shape how they see themselves in the world and their sense of purpose. In the preparation phase, the AI/AN youth, family, and provider can look into traditional and indigenous medicine and/or cultural offerings in the region. In the action phase, the youth can engage more with their AI/AN community to foster a sense of identity and enjoyment in sober activities, and this can continue on to the maintenance phase.

Conclusion

The Stages of Change model offers a comprehensive framework that enables clinicians to deliver personalized care in the treatment of adolescent substance use. By aligning interventions with the adolescent’s stage of change, physicians and counselors can more effectively support the adolescent’s journey toward recovery. Continued research and training in the application of this model are essential to improving outcomes in this vulnerable population.

References

  1. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
  2. DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 3-24). Springer US.
  3. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press.
  4. Moyer, V. A., & US Preventive Services Task Force. (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 159(3), 210-218.
  5. Wagner, E. F., & Ingersoll, K. S. (2013). Beyond cognitions: Broadening the treatment of adolescent alcohol and drug use. In E. F. Wagner & H. B. Waldron (Eds.), Innovations in adolescent substance abuse interventions (pp. 171-188). Elsevier.
  6. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325-334.
  7. Liddle, H. A., & Dakof, G. A. (1995). Efficacy of family therapy for drug abuse: Promising but not definitive. Journal of Marital and Family Therapy, 21(4), 511-543.
  8. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive-behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33(3), 511-525.
  9. Kaminer, Y., & Godley, S. H. (2010). Adolescent substance use disorders: Developmental considerations. In Y. Kaminer & K. C. Winters (Eds.), Clinical manual of adolescent substance abuse treatment (pp. 1-24). American Psychiatric Publishing.
  10. Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. Guilford Press.

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Vista Hill Native American SmartCare Program

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