A Trans theoretical Model
Adapted from the works of Edith Springer(2003), by Gayle T. Thomas, 2003
How can we work with people in the community who don’t seem to want to change? How can we work with people who come to agencies for help with some things, or who we encounter during street outreach, but don’t want to address other important issues that may be negatively impacting their lives? In the past most of the services provided to consumers were office bound and this model of service delivery does not work for individuals who don’t want to access this model of traditional social services. Perhaps our assumption that people who came to us were ready to change was wrong. The HIV pandemic and other health issues, such as Hepatitis C, have required us to go out and reach people who don’t present themselves to our agencies for help. This avenue of outreach has also afforded service providers the opportunity to expand out to different populations of individuals. What became very apparent was that individuals we serve through our programs have very different motivations to change.
Behavior Change is Not Superficial Work
Behavior change is a complicated and textured process that requires far more than superficial behavior modification, just as curing diseases requires more than just treating symptoms. Sometimes it is worse to take a cold medication than to allow the body to heal itself naturally. Removing symptoms with medicines may actually cause the cold to last longer, as the medications interfere with the body’s natural healing process. Likewise it can be detrimental to move to action and try to change behavior or remove an individual from a high risk situation before a natural process of “getting ready to change” is allowed to unfold. Behavior change is a macro issue rather than a micro issue—i.e. sexual harm reduction work is not simply a matter of showing someone how to use a condom and practicing skills of talking to potential sex partners about HIV prevention (micro). Sexual harm reduction work involves delving into the meaning and purpose of sex in people’s lives. A sex worker who uses condoms with clients when she is working may not use one with her lover in her private life. The sex worker’s case manager may be at a loss to understand this, especially if it is known that her partner is a drug injector. Why would someone take risks in one part of her life that she wouldn’t take in another part? If the sex worker could explain she might say that the need to distinguish between commercial sex and personal sex and to demonstrate the intimacy and trust she feels for her lover is expressed by her decision to have sex without barriers only with her lover. Thus, the meaning of the sexual act has far more relevance than the act itself.
The First Stage: Precontemplation
People in this stage have no desire to change at all. They may have come to your agency for varying reasons, usually to get some need of theirs met. This does not mean they are ready to do what you say, nor does it mean they have resolved their ambivalence. There is a lot of preparatory work that must be done to move them along, but the first stance the worker must take is to not try to get them to change.
The first step is to create a container, or environment which is welcoming, safe, validating and non-threatening to the consumers. Design your agency to be user-friendly. When consumers arrive, warmly greet them and validate them as they are rather than pathologizing them and suggesting that they change who they are or what they do. For consumers who don’t come to you, but are part of the target population you seek to help, go out to where they hang out, and reach out to them. Outreach is the best way to find them, get to know their culture, and engage them in a relationship with your agency. Delivering services in using an outreach, helps to market your programs and may help in trying to get them to come into the agency. Give them what you can immediately. Give them practical help with their lives as they are. Forget about the concept of “enabling”. Giving people what they want is the best way of starting them on the road to improved health and happiness. Distribute HIV prevention materials (condoms, dental dams, bleach kits, interesting sexual lubricants), food, clothing, and show warmth and concern.
When people come into the agency, have a low-threshold intervention to capture them and keep them coming, like a drop-in center. Low threshold means the customer does not have to make a commitment in order to enter—no ID’s, no intakes, minimal red tape, no waiting, no come back next week. Have literature around, and signs indicating the services you offer. Honor the problems the consumers bring you and help with what you can; don’t push services on people. Keep it light and comfortable. They have many serious issues in their lives, but they may not want to be continually reminded of how dire things are.
There are several goals for the Precontemplation. The first goal is to create contact with consumers, which happens if they come in on their own or if you bring them in with outreach. The second goal is engagement, the creation of a relationship or therapeutic alliance with the consumer. With marginalized people, engagement can take a long time. Issues of trust and abandonment, class and racial issues, gender issues, sexual orientation issues may all impact upon the ability to open up to and trust a worker. Take your time; rushing can backfire. A third goal is to help with survival needs. There are many things drug users, homeless people need—practical things. Food, shelter, clothing, a way to do laundry, affection, a community to feel part of, etc. A fourth goal is safety. What are the immediate risks and harms that should be focused on. HIV prevention falls into this category: safer sex and safer drug injection. For consumers in violent situations, whether domestic and/or sexual violence, how can we help them become safer or avoid violence? How can we help sex workers stay safer when on the streets? In working with individuals at risk, safety must be assessed continually, and always be of utmost priority. A fifth goal during this stage is assessment, which starts the first time a worker sees a consumer, and continues throughout the relationship. It does not have to be formal or involve a questionnaire, pen and paper. In fact, it is better to avoid those bureaucratic instruments during this stage. As you talk to consumers, carefully asking questions and listening to the responses, make mental notes which can be written down later. Demanding too much too early in the relationship can cause the consumer to feel pressured and stop coming. People don’t like to feel coerced. If a consumer is coming into your agency, having a variety of activities, some formal and some informal, some educational and serious and some recreational and frivolous, allows the consumer to pick and choose what is comfortable. Group activities, table games, crafts, outings can all be utilized.
The first step is to create a container, or environment which is welcoming, safe, validating and non-threatening to the consumers. Design your agency to be user-friendly. When consumers arrive, warmly greet them and validate them as they are rather than pathologizing them and suggesting that they change who they are or what they do. For consumers who don’t come to you, but are part of the target population you seek to help, go out to where they hang out, and reach out to them. Outreach is the best way to find them, get to know their culture, and engage them in a relationship with your agency. Delivering services in using an outreach, helps to market your programs and may help in trying to get them to come into the agency. Give them what you can immediately. Give them practical help with their lives as they are. Forget about the concept of “enabling”. Giving people what they want is the best way of starting them on the road to improved health and happiness. Distribute HIV prevention materials (condoms, dental dams, bleach kits, interesting sexual lubricants), food, clothing, and show warmth and concern.
When people come into the agency, have a low-threshold intervention to capture them and keep them coming, like a drop-in center. Low threshold means the customer does not have to make a commitment in order to enter—no ID’s, no intakes, minimal red tape, no waiting, no come back next week. Have literature around, and signs indicating the services you offer. Honor the problems the consumers bring you and help with what you can; don’t push services on people. Keep it light and comfortable. They have many serious issues in their lives, but they may not want to be continually reminded of how dire things are.
There are several goals for the Precontemplation. The first goal is to create contact with consumers, which happens if they come in on their own or if you bring them in with outreach. The second goal is engagement, the creation of a relationship or therapeutic alliance with the consumer. With marginalized people, engagement can take a long time. Issues of trust and abandonment, class and racial issues, gender issues, sexual orientation issues may all impact upon the ability to open up to and trust a worker. Take your time; rushing can backfire. A third goal is to help with survival needs. There are many things drug users, homeless people need—practical things. Food, shelter, clothing, a way to do laundry, affection, a community to feel part of, etc. A fourth goal is safety. What are the immediate risks and harms that should be focused on. HIV prevention falls into this category: safer sex and safer drug injection. For consumers in violent situations, whether domestic and/or sexual violence, how can we help them become safer or avoid violence? How can we help sex workers stay safer when on the streets? In working with individuals at risk, safety must be assessed continually, and always be of utmost priority. A fifth goal during this stage is assessment, which starts the first time a worker sees a consumer, and continues throughout the relationship. It does not have to be formal or involve a questionnaire, pen and paper. In fact, it is better to avoid those bureaucratic instruments during this stage. As you talk to consumers, carefully asking questions and listening to the responses, make mental notes which can be written down later. Demanding too much too early in the relationship can cause the consumer to feel pressured and stop coming. People don’t like to feel coerced. If a consumer is coming into your agency, having a variety of activities, some formal and some informal, some educational and serious and some recreational and frivolous, allows the consumer to pick and choose what is comfortable. Group activities, table games, crafts, outings can all be utilized.
Treating consumers with respect and dignity, as “normal” people is essential, as is an egalitarian relationship. Providers and consumers are equal. Provides work for consumers, who pay our salaries. Our relationship to consumers should be that of a consultant or facilitator; it should never be paternal. Because of the difficulty in establishing trust with a worker, (especially for women in violent situations) it is imperative that we “honor” their experience and remain non-judgmental and non-biased with decisions they may make. The client is always the expert in their own lives. Attempting to set goals or move a person in a certain direction, (i.e. into a battered woman’s shelter, or away from her pimp), may in all actuality be causing her more harm.
Frequently, new information is crucial (but not sufficient) for behavior change. Create opportunities for consumers to learn about the issues that impact on their lives. Try to make the education interesting and painless. Be creative. Use humor where appropriate. It is also the responsibility of the worker to stay on top of the resources that are available in one’s community
Frequently, new information is crucial (but not sufficient) for behavior change. Create opportunities for consumers to learn about the issues that impact on their lives. Try to make the education interesting and painless. Be creative. Use humor where appropriate. It is also the responsibility of the worker to stay on top of the resources that are available in one’s community
People stay in the Precontemplation stage as long as they need to or maybe even forever.
Don’t be attached to your desire for the consumer to change. Attachment to goals you set for consumers will end in frustration and burnout. Have your goals in mind, but let go of them and help the consumer create his own goals and objectives. Don’t ask consumers to change for you. It is essential that they take on changes for their own reasons rather than to please or placate you. Don’t judge your competence or worthiness as a worker by the consumer’s changes or lack of them. Outcome is the consumer’s responsibility; process is the worker’s responsibility. Help consumers embark upon a process and let go of the your worker’s responsibility. Help consumers embark upon a process and let go of your attachment to specific outcomes. As Twelve Steppers say, “Let Go and Let God”
Don’t be attached to your desire for the consumer to change. Attachment to goals you set for consumers will end in frustration and burnout. Have your goals in mind, but let go of them and help the consumer create his own goals and objectives. Don’t ask consumers to change for you. It is essential that they take on changes for their own reasons rather than to please or placate you. Don’t judge your competence or worthiness as a worker by the consumer’s changes or lack of them. Outcome is the consumer’s responsibility; process is the worker’s responsibility. Help consumers embark upon a process and let go of the your worker’s responsibility. Help consumers embark upon a process and let go of your attachment to specific outcomes. As Twelve Steppers say, “Let Go and Let God”
The Second Stage: Contemplation
Once consumers feel comfortable in your agency and have developed relationships with one or more workers, it is time to begin a process of helping consumers become conscious about what they do. Here, people start to think about things they have done unconsciously or automatically, without really being present. Conversations about sex, drug use, relationships, homelessness, life in general begin to make an impact. Since people are ambivalent about most things in life, it is important to create situations where people can explore all sides of their ambivalence. Thus, in talking about drug use we explore the positive aspects of drug use, and the role it has played in the consumers’ life. We help them look at the meaning of the drug use, and the ways in which they have used it. We help them see the impact their emotional states have on their use, as well as the effect of their peers, families and communities. We also help people look at the negative side of their drug use: how is it keeping them from doing other desired things, how costly is it, how has it impacted on relationships, work, education, physical health, emotional health, etc. The goal of these explorations is to help people resolve their ambivalence (to the extent possible). Some people will decide that they like things just the way they are. They may continue contemplating (for months, years, etc.) or they may recycle back into the Precontemplation stage and continue as they were. Those who go back receive the services and attention discussed previously, without judgment. Those who decide they want to change something (no matter how small; baby steps are the key to lasting behavior change)move into the next stage.
The Third Stage: Preparation
In this stage the person has decided to make some change or another and now is getting ready. She may already be making small changes toward her goal. She may also jump too quickly into change, driven by anxiety and anticipation. Precipitous leaps into change should be avoided, as they rarely succeed. This is a huge stage and is often the preparation for this stage is skipped over. Here you want to narrow down the commitment to change: what is going to be changed, how will things look after the change? What is the short-term goal? The long term goal? When you make the change, how are you preparing for the consequences in your life? Each plan that is developed at this stage will be individualized. Workers may want to latch onto the commitment and move quickly, but exploration into these issues is very helpful. Once the goals and desired outcomes are laid out, the worker helps the consumer choose a plan, an intervention, a program. How will this goal be reached? Workers should lay out all the choices for intervention: traditional agencies including drug treatment, counseling models, alternative treatments, and whatever else is available in that locale and can be accessed y the consumer. Once a treatment plan is created, the worker helps facilitate the consumer’s entry into the plan. Harm reduction asserts that slow, incremental change is more solid and lasting, and more “do-able” than trying to change everything all at once. Small changes that build incrementally allow coping mechanisms to be created and solidified. Some people may become anxious and disappear in this stage. When they return, it is a good strategy not to mention the aborted plan, but to warmly greet the consumer and see what the consumer wants to talk about today.
The Fourth Stage: Action
Whereas in the disease model Action is the first step after assessing a drug problem, in this model there are three prior steps which prepare the person for this most difficult stage of change. It is this process of getting ready for change that makes all the difference. Now the individual who has made a plan undertakes to carry it out. Even if the action plan involves a referral to another agency, e.g. a drug treatment program, it is helpful if the original referring worker can stay in touch with the customer to allow continuity in the process. This is the stage that many people will not complete. They may leave treatment, stop attending groups, give up, or go back into contemplation. Often when clients leave treatment or stop attending interventions, they disappear for a while. They may be ashamed of feel like they’ve failed the referring worker. It is very important to remain nonjudgmental when the client does finally reappear at your agency. Your must convey that your affection and concern for the customer has not altered in any way. Often you must help the customer re-build self esteem, eliminate feeling of shame and find compassion for herself. giving the customer the sense that the worker is disappointed will impact negatively on the process; the worker’s disappointment is countertransference (feelings in the worker that are inappropriate to the client/worker relationship) and are related to the worker’s ego and not to the clinical situation. Sometimes when the customer leaves an intervention or treatment agency, they realize that the plan was faulty. In such case, the worker should help the customer come up with a new plan. Perhaps the modality chosen was not a good fit with the consumer’s personality, history and culture. Some customers may repeat interventions before they are successful.
Psychology indicates that for human behavior, primacy is stronger than decency. This means that the first thing we learn in stronger and more deeply etched in our brains than the last thing we learn. In times of stress or crisis, we may revert to old behavior patterns. We often call this “relapse”. Behavior changes in order to be lasting, must be reinforced. The Twelve Step fellowship provides a system of lifetime reinforcement to its members through group meetings that people can attend as needed, free of charge, with no waiting lists, intakes, or I.D. required. In fact it is anonymous. Structures like this, or interventions to support new behaviors should be developed in your agency. Bottom line is at this stage consistency in maintaining the behavioral change and reinforcement of the change will continue to ensure that the change is maintained throughout one’s lifetime.
Lapse/Relapse
When people lapse or relapse to old behaviors, they need a lot of support and compassion. The last thing they need is judgment. Shame based work is unethical and harms people. Behavior change is difficult; there is no reason to be ashamed if it cannot be maintained. Workers can help consumers who lapse by showing them their strengths and their achievements, rather than focusing on their weaknesses and failures. Pavolov proved that reward works better in behavior change than does punishment. So if someone says “I was off drugs for three weeks, and then I picked up. I feel so bad,” the worker’s response is “You stayed off drugs for three weeks! How did you do that?” I makes more sense to explore what worked and what was successful than to explore the lapse. The building blocks of a lasting solution are already there in a person who was able to stay off drugs for three weeks. Use them to mount another attempt.
In Harm Reduction consumers may go through the Stages of Change multiple times with small changes. In drug treatment they may use the stages to get to total abstinence from drugs. The model works with small or large behavior change. It works with any populations, any issue.
When people lapse or relapse to old behaviors, they need a lot of support and compassion. The last thing they need is judgment. Shame based work is unethical and harms people. Behavior change is difficult; there is no reason to be ashamed if it cannot be maintained. Workers can help consumers who lapse by showing them their strengths and their achievements, rather than focusing on their weaknesses and failures. Pavolov proved that reward works better in behavior change than does punishment. So if someone says “I was off drugs for three weeks, and then I picked up. I feel so bad,” the worker’s response is “You stayed off drugs for three weeks! How did you do that?” I makes more sense to explore what worked and what was successful than to explore the lapse. The building blocks of a lasting solution are already there in a person who was able to stay off drugs for three weeks. Use them to mount another attempt.
In Harm Reduction consumers may go through the Stages of Change multiple times with small changes. In drug treatment they may use the stages to get to total abstinence from drugs. The model works with small or large behavior change. It works with any populations, any issue.
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