As mentioned earlier, recovery is a process of change. In this section, you’ll learn about the process people go through when they consider making a change, decide to make a change, formulate a plan, and take the action steps change requires. Once you have completed this section, you will be able to:
- Describe the stages of change and approaches that are helpful at each stage.
- Discuss the role shared decision-making plays in recovery.
- Identify strategies peer support specialists can use to help people maintain their recovery.
What is the process of change?
Recovery from most chronic conditions requires lifestyle changes. But change is hard! Ask anyone who wants to lose a few pounds how hard it is stop eating after dinner or sticking to a program of regular exercise. The process of recovery involves continually making decisions and changes based on your #1 priority: your mental health, your freedom from compulsive substance use, or both. For example, people with high cholesterol often make dietary changes that can involve giving up foods that have been a part their culture for generations. Even when they succeed, their cholesterol may slowly creep back up over time, and they may decide it’s time to try medication.
How do these principles apply to substance use and mental health disorders?
It is said that the road to recovery is always under construction. Although the pathway to a better, healthier life is little different for everyone, there are a set of stages people tend to go through when making a change. They represent a cycle people usually move through more than once, sometimes taking two steps forward, and one step backwards. Peer support specialists can play a key role in this process by helping to motivate and encourage people as they face the challenges involved in making and maintaining positive changes.
Watch The Stages of Change Model
How can peer support specialists respond to the different stages of change?
It is helpful for peer support specialists to match their approaches to whatever stage people are in when it comes to making positive changes. The examples below combine Motivational Interviewing (MI), a specific communication approach that can support behavior change, with disclosure. The combination of these two strategies is a very powerful tool that is somewhat unique to peer support specialists. It also illustrates the kind of supports peer specialists offer that clinicians do not generally provide.
Matching Your Response to the Stage of Change
Precontemplation: Not considering making a change
Approach
- Offer empathy
- Support autonomy
Example“When my family kept pressuring me, I started to avoid them. No one else has the right to make decisions for you. Can you tell me about a time when someone tried to get you to do what they thought you should be doing?”
Contemplation: Thinking about making a change but not sure
Approach
- Listen carefully
- Reflect
- Reframe
Example“When I didn’t have a car, I had to spent 4 hours a day taking buses to and from work. You said you’re saving money to buy a car, but it sounds like you’re worried about losing your job when your drug test comes back. What do you think you’ll say if your boss wants to talk to you about that?”
Preparation: Deciding to try to make changes
Approach
- Affirm
- Encourage
- Talk about how to make change
Example
“I felt like I could tolerate my anxiety a little longer once I decided to start seeing my therapist again. Sounds like you know how you want to handle this. Tell me more about what you plan to do?”
Action: Have successfully made some changes
Approach
- Recognize milestones
- Support self-efficacy
Example
“Wow! I’m impressed. I get how hard those first few days are. I remember when I couldn’t go an hour without a cigarette no matter how bad my asthma got. Tell me exactly how you were able to do it?”
Maintenance/Relapse Response: Learning to maintain positive changes
Approach
- Focus on achievements and learning from setbacks
Example
“It took me a while to figure out that working a lot of overtime led to isolation and exhaustion – and eventually to depression. I realized that getting to the gym and connecting with supportive people are more important than a few extra bucks in my paycheck. You’ve had a lot more good days than bad days for a while now. Why do you think things have improved?”
Different strategies to support change
Long-term recovery generally requires ongoing effort. Most people go through periods when it seems more difficult. Peer support specialists can remind people of the actions they took to make it through other tough periods. They can help people make a list of action steps to take when they need to get back on track. When people are struggling, they don’t usually have the energy or clarity to work out a plan of action. Having something ready to grab on to can help. Recovery is an experiential process. It is the ‘doing’ that is key.
| Substitution | Sometimes, it helps if a person swaps in a new “preferred” activity for the old activity. For example:
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| Connection with others | Find a partner to support the change. For example, ask a friend to be a walking partner. |
| Volunteering | Get involved in little ways. For example:
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| Rewards | Sometimes recognition or appreciation is its own reward. However, some people are motivated when they reward themselves for achieving a goal. For example:
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| Making a verbal commitment | Saying intentions aloud makes people more likely to follow through with the action. If a person tells a friend they will meet them and go to a support group, or informs family members of the decisions they have made about their recovery, it can help them complete the action. |
| Changing the environment | Certain stimuli can trigger certain responses. For example, a person might avoid neighborhoods where they used to buy drugs to reduce urges to use again. |
Motivational Interviewing
Motivational interviewing (MI) is an evidence-based communication approach that can support behavior change. Some basic MI techniques were introduced in the last section. Bill Miller, a primary creator of MI, puts it this way:
MI is a complex skill, like playing a musical instrument. You can read about it, watch people do it, and study it in school. But you cannot master it without practice, practice, practice.
The purpose of MI is to resolve ambivalence. This means reinforcing a person’s existing commitment to change and introduce other approaches to current behaviors. To do this requires careful listening, effective questioning, asking permission, and offering reflections.
Listening
A key skill related to motivational interviewing is listening. Listening carefully can help you identify where a person is at in their change process, as shown in the following table. It also helps guide you responses.
| Unaware | Contemplative | Preparing/ making decisions | Trying | Maintaining behavior |
| I don’t know anything about it. I don’t intend to change. | I know about it and I’m thinking about trying it. | I’ve decided that I’m prepared to give it a try. | I’ve tried it a few times – sometimes successfully, sometimes not. | I try to do it all of the time. The more I do it, the easier it is and the more it bcomes a regular habit and a normal part of my life. |
Source: Adapted from J.O. Prochaska and C. C. DiClemente, 1986
Questioning
MI is a directive process – you may be meeting people “where they are” but that doesn’t mean you want to leave them there. You are modifying your response based upon their current feelings and either information or asking questions that can help them consider different behaviors. Different types of questions can be effective at different times.
Motivational Interviewing
Motivational interviewing (MI) is an evidence-based communication approach that can support behavior change. Some basic MI techniques were introduced in the last section. Bill Miller, a primary creator of MI, puts it this way:
MI is a complex skill, like playing a musical instrument. You can read about it, watch people do it, and study it in school. But you cannot master it without practice, practice, practice.
The purpose of MI is to resolve ambivalence. This means reinforcing a person’s existing commitment to change and introduce other approaches to current behaviors. To do this requires careful listening, effective questioning, asking permission, and offering reflections.
Listening
A key skill related to motivational interviewing is listening. Listening carefully can help you identify where a person is at in their change process, as shown in the following table. It also helps guide you responses.
| Unaware | Contemplative | Preparing/ making decisions | Trying | Maintaining behavior |
| I don’t know anything about it. I don’t intend to change. | I know about it and I’m thinking about trying it. | I’ve decided that I’m prepared to give it a try. | I’ve tried it a few times – sometimes successfully, sometimes not. | I try to do it all of the time. The more I do it, the easier it is and the more it bcomes a regular habit and a normal part of my life. |
Source: Adapted from J.O. Prochaska and C. C. DiClemente, 1986
Questioning
MI is a directive process – you may be meeting people “where they are” but that doesn’t mean you want to leave them there. You are modifying your response based upon their current feelings and either information or asking questions that can help them consider different behaviors. Different types of questions can be effective at different times.
Open-ended questions are those that are not answered with a “yes” or “no.” It is important to listen carefully to the person’s responses. Examples may include:
- How would you like things to be different?
- How can I help you with that?
- What happened yesterday that made it hard to stick to your plan?
Closed questions generally require yes or no response. Examples include:
- Are you completely against medication?
- Did I get that right?
Follow-up questions are open-ended questions that provide an opportunity for a person to think more deeply about a situation and give you more information. Examples include:
- Can you say more about that?
- How did you do it?
- What makes you say that?
Permissions
In order for Motivational Interviewing to be effective, the relationship must be based on trust and the person must be open to hearing your perspectives. Before offering your experiences or opinions, make sure that the door is open. You might ask or say:
- Do you want some feedback?
- Can I share something similar I went through?
- Would you like more information about that?
- It’s up to you.
- The choice is yours’.
Reflections
Reflections serve multiple purposes. They are statements that can summarize what you heard, and therefore confirm you were paying close attention to the person’s story. They may also add clarity to the situation by pointing out something the person may not have noticed about how they feel about a situation. Examples of different types of reflections include:
This type of reflection points out how a person feels about a situation, and may help them understand how their strong feelings contributed to their actions. You might say:
- It sounds like you were furious with your friend.
- That conversation with your daughter seems to have made you feel very sad.
Sometimes, a person might have negative self-talk or dwell on experiences that might prevent them from seeing the progress they have made or keep them moving forward. You might say:
- You’ve made some good progress. You haven’t been back in jail for more than two years.
- You’ve given a lot of effort to stopping your drug use. Every time you have managed to keep it going a little longer.
Often, knowing that a person is not alone in their feelings can be reassuring. You might say:
- A lot of people feel anxious before they see the doctor.
- Building new habits is such a struggle. I have a hard time with it myself.
- Our friendships are very important. It makes sense that you would worry about your friends’ opinions about this change.
There are always benefits and negatives to every change. Sometimes, it’s hard to see how they balance. It can be helpful to point out both:
- It sounds like you want to take the class, but you don’t know if it’s worth getting up so early.
- You seem like you are excited about the idea of a job, but don’t know if you are ready for a big commitment right now.
Summaries can be useful to pull together multiple parts of the story and to move forward into discussing potential changes – particularly if a person acknowledges that they see a need for change. For example, you might state:
- Alcohol has caused you a lot of legal problems. How important is it to you to avoid those problems in the future?
- On the one hand, it sounds like you don’t think you can handle quitting right now. On the other hand, you are worried about the risk of overdose. Did I get that right?
Supporting Decision Making
Part of change is making decisions.
Many people with mental health and substance use problems have experienced stigma and discrimination in health care settings, especially people who have been in jails or institutions. These experiences can intimidate people and discourage them from seeking help. Peer support specialists make it clear they are not qualified to help people make decisions about medications. However, in some settings they work with people before they meet with a prescriber. Peer support specialists can:
- Help people make a list of questions for their prescriber
- Explain any logistics involved and provide information on local resources
- Provide access to patient information on medications
- Help people make a list of concerns they want to discuss with their prescriber
Sometimes, peer support specialists who have experience with medication-assisted treatment for opioid use disorder check-in with people who are starting treatment to see if they need locked boxes to safely store their medications or help with transportation. Peer support specialists can help people build trusting relationships with prescribers who explain their options and respect their choices.
Shared Decision-making
The process of shared decision-making comes from treatment of medical conditions for which there are more than one effective options. Shared decision-making is based on collaborative helping relationships that support choice and autonomy. Key principles include:
- The choice of treatment options should be a shared decision between provider and patient.
- It involves discussing your preferences, past treatments, logistics, and costs.
- It means understanding the risks and benefits of each option.
- When it comes to medications several decisions are involved:
- Whether to take medication to support your recovery,
- Which medication can support your recovery,
- And how to get started.
HEAR FROM EXPERTS!In 2008, the Center for Evidence Based Practices at Case Western University compiled a series of audio files where experts on MI shared their insights and experience. – Listen here!
References
Case Western Reserve University. (n.d.). Motivational Interviewing. Center for Evidence-Based Practices. https://case.edu/socialwork/centerforebp/practices/motivational-interviewing
Jones-Smith, E. (2020). Theories of Counseling and Psychotherapy: An Integrative Approach (3rd ed.). SAGE Publications, Inc.
Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 3–27). Plenum Press. https://doi.org/10.1007/978-1-4613-2191-0_1