What elements seem to aid people in getting off the seesaw?
The topic of ambivalence is broad and its resolution complex, enough so that Engle and Arkowitz (2006) devote an entire book to its examination. Yet, it is a critical element in the choice to change addictive behaviors. As DiClemente has noted (DiClemente, 1999, 2003; DiClemente & Prochaska, 1998), the vast majority of clients coming for substance abuse treatment will arrive with at least some awareness of the need to change. However, the ambivalence dilemma often keeps people caught in an equilibrium of opposing forces. The PRIME Solutions workbook describes this as the person equally balanced on the seesaw. People become stuck, sometimes for many years, without being able to get off the center point. Despite its relative importance and a plethora of theoretical explanations, there is relatively limited empirical data about what helps people move out of this state of uncomfortable balance, but there are important hints.
The Transtheoretical Model (TTM) describes a shifting of the relative balance towards change, by first raising awareness of the negatives of the status quo and then enhancing the benefits of change. Early writing described these as the weak and strong principles because of the relative magnitude of change that occurred before this tipping point was reached (Velicer et al., 1994). That is, the negatives of the status quo increased by a .5 standard deviation over its starting spot (weak principle), while the positives increased by a full standard deviation from the same baseline point (strong principle). While these were demonstrated to be potentially important markers of change, more research is needed before these can be shown to be mechanisms of action (i.e., caused the change to occur).
In addition, this sorting and prioritizing of negatives and positives is more complex than a simple listing of pros and cons (Miller & Carroll, 2006). For example, addictions and their effects on brain functioning and physiology clearly contribute to not only the acquisition of addictions, but also the maintenance of these and the struggle in stepping away from the balance point (Barger, 2005). Context, in the multiple levels described by TTM, also influences how a person remains either stuck or changes at the center of this seesaw. Data suggests eliciting certain types of language from clients and minimizing others predicts outcomes and that therapist behavior influences the appearance of these client statements. Finally, there is a growing body of literature on the importance of positive emotions in change. Here is a brief review of some of that research literature.
In his excellent review of the brain, Barger of PRI (Barger, 2005) notes the interactive influence that addictive behaviors play on brain functions and brain development. These interactions include the growth and development of synaptic connections as habits are formed and the forming of potent memories of use, which include the presence of emotional tags. These memories are easily, powerfully and widely activated in response to cues for substance use.
Emotional tags may influence how we view the balance of elements in decision making and in a manner that occurs below our awareness. That is, what information we attend to, how we process it and then how we respond to it may happen at levels that are not always in our awareness (Kahler, 2001). Emotion may play a particularly critical role in this process. Indeed, DiClemente (2003), careful to note that decisional balance is not simply a cognitive weighing of pros and cons, refers back to the original thinking of Janis and Mann (1977) that describes the impact of emotional factors in the sorting of a decision. Emotions may weight elements in the decisional balance in a manner that is disproportional and therefore, may need to be made explicit. These associations need to be more available to examination and reflection by the substance user if they are to counteract them. That is part of the reason for asking people to consciously explore the pro and con elements in the PRIME Solutions workbook.
However, addictions also affect the availability of certain attitudes (Kahler, 2001). This is especially true as a person tries to replace well established habits with new ones. Cognitive psychology describes implicit versus explicit memory. Implicit memory refers to previous experience facilitating performance on a task without requiring conscious or intentional recollection of memory. Once learned, we don't think about how to walk or ride a bike - we just do it. In contrast, explicit memory requires recollection of a previous memory to perform a task. We have to think about how to do this activity. Kahler notes that implicit memory is formed by repeated performance of behavior and while it serves an important adaptive function, it may - in this instance - facilitate drinking because of its easy availability. That is, when a cue for use occurs (e.g., a sporting event on TV, an argument with a partner, a celebration) the behavior most readily available will be to use. In contrast, decision making - such as refusing a drink or choosing to get off the seesaw - requires explicit memory; this process in turn requires effort. It will feel and be harder to do - at least initially.
The research suggests we must practice and make new associations, which then become increasingly more implicit and weaken the associations of the prior implicit memories. There are complications and influences in the decision making process. For example, the number of reasons available to the person to choose not to drink or use substances is critical. This "availability" in turn is influenced by what information drinkers attend to, encode, and retrieve about alcohol-related information. For example, the thoughts, "The game is on, we are having fun, everybody is drinking" may lead the person to have greater reasons why "having a few drinks" is not an issue. There are selective biases in this process. The person may not attend to several people drinking nonalcoholic beverages. Nor may the person note that several people are getting into more heated exchanges about their rival teams or the intoxicated couple fighting in the corner. Also, the generation of information is related to expectancies ("I'll be more social and have more fun if I drink") and past experience ("I've enjoyed having a buzz on and watching my favorite team"). While this process is weighted in favor of the implicit memory, Kahler (2001) notes that people can influence it.
Kahler (2001) describes data that shows having clear intentions to stop drinking and having regularly thought about these reasons in the past month, is important in the decision making process. The data indicates that drinkers find it easier to generate information consistent with current intentions. Also, the amount of time spent thinking about reasons in the past month increases the ease with which reasons are generated. While Kahler's focus is on decision making at the moment when drinking might occur, it also seems linked to decision making that occurs in the process of deciding to step off the seesaw.
Physiology also plays a role in the individual staying on the seesaw. The physiological process of dependence, the related element of craving, and the emotional component of these phenomena, all play important roles in preventing individuals from committing to a change or staying with a decision once it has been made initially. Yet, as has been noted by many writers (DiClemente, 2003; Miller & Carroll, 2006) these issues alone do not explain the continuation of problematic use or addictive behaviors. These issues, their influence on making changes and methods for addressing these are discussed in the Listening to the Wolf module and will not be repeated here. Three primary methods that are often noted for managing these elements include medication for craving, body quieting activities (e.g., meditation) and urge surfing. However, these elements are typically addressed once the person has decided to step off the seesaw.
Once again, there are multiple levels and considerable complexity in looking at psychosocial factors. Social context is an area of ongoing research interest (Moos, 2006). For example, behavioral economics refers to the alternative reinforcements provided by use and non-use activities, and the resulting risk and protective factors that might emerge from each. Social networks play clear and strong roles in decision making processes, as well as coping with challenges (Stein, Dixon & Nyamathi, 2008). TTM refers to these factors as the context of change and notes these occur at multiple levels. Within PRIME Solutions, the 3-2-1-0 module addresses these areas in terms of building support for changes; however, these external elements also contribute to the person's relative balance on the seesaw and are important to review in this context in making an initial decision.
Values, as noted in This Is Who I Am, also play an important role in making changes. If core values are in conflict with use, this represents a powerful motivator for change (Miller & Rollnick, 2002). However, if core values are consistent with use or are only marginally affected by struggles with addictive behaviors, then their enlistment may have little effect or undermine efforts to change (Rokeach, 1973, 1979; Downey, Rosengren & Donovan, 2001). Understanding the nature of a person's values, and how these are related to the behavior in question, can also provide a significant understanding to what may or may not influence the person getting off the seesaw. These, along with emotional elements, may add considerable weight to one side of the balance.
Miller and Rollnick (2004; 2008) have become increasingly focused on client language in the process of resolving client ambivalence. In particular, they note the importance of elicitation of client talk that signals change and the avoidance or reduction of talk that supports the status quo. Change talk includes two types: preparatory and mobilizing language (Miller et al., 2006). Preparatory language includes desire for change (Desire), a belief in their ability to change (Ability), the positive benefits of change (Reasons) and negatives in the current circumstance that require change (Need). These terms form the acronym DARN. Amrhein and associates (Amrhein et al., 2003; Amrhein et al., 2004; & Amrhein et al., 2005) have shown that DARN only weakly predicts change, but does strongly predict mobilizing language, which in turn predicts behavior change.
Mobilizing language falls into two categories currently (Commitment and Taking Steps); a third form is under investigation (Activation). Commitment refers to the person making active verb statements that indicate the intention to change. The person says things such as, "I will..., I promise..., I am done with it". However, there can be variations in the strength of this commitment language (e.g., "I hope to..."). Taking Steps refers to the person doing things in support of a change ("I ordered a diet coke instead of a drink", "I stayed in the two drinks limit of the low-risk guidelines"). Activation refers to the person's readiness and willingness to do an action, though it is not the same as a commitment statement or actively doing the action.
Moyers and colleagues have demonstrated active links between clinician attitude and behavior and client language (Moyers et al., 2005; Moyers et al., 2007; Moyers et al., 2008). In particular, Moyers and colleagues have demonstrated links between attitude and skills, skills and in session client behavior, and in session client behavior (i.e., change talk and status quo talk) and treatment outcome. Although Moyers became interested in change talk in the context of Motivational Interviewing (MI), she has also demonstrated that change talk is not limited to MI sessions and that its presence in a session predicts outcome across therapeutic modalities (Moyers et al., 2007). However, Moyers is careful to note that at present the research does not tell us what role the change talk plays. That is, it may be that articulation of change talk causes changes or it may simply reflect some other internal process happening (as smoke reflects the presence of fire).
There has been increased interest in the role of positive psychology (i.e., focus on strengths rather than on pathology) in well-being, as well as positive emotions in change. Wagner and Ingersoll (2008) describe a contrast to the prevailing view of motivation as the avoidance of negative emotions (i.e., negative reinforcement). They note that inspiration, rather than discontent, may also form the basis for motivation and that motivation based on positive emotions tends be more powerful. Over-simplified, this is the power of moving towards something rather than away from it.
Self-Determination Theory (Ryan & Deci, 2000) is one example of this tradition that demonstrates more powerful, persistent and ongoing change when individuals view change as autonomous and chosen rather than forced by extrinsic motivators. Wagner and Ingersoll (2008) suggest that decisional balance activities can be strengthened by,
"...helping clients conceptualize more clearly what could be, how things could be better now, and how life could be better in the future. Decisional balance can be performed in a way that emphasizes the positives about change instead of the negatives related to the status quo, defining and moving toward a future positive state rather than escaping an undesirable current state or avoiding a negative future state (p. 196). "
As noted throughout, helping people get off the seesaw cannot be a simple weighing of cognitive factors. It is more complicated than that approach. However, the decisional balance activity can provide a framework within which the clinician can explore and help the client sort these factors. Being aware of these other complicating issues can aid in making this process more effective.
Clinicians need to be aware of tendencies at the brain level to move towards certain actions and sort information in a manner that it is consistent with certain biases. Helping the individual become aware of these tendencies and practice thinking through alternatives and reasons for doing so will help strengthen these processes and assist with the decision making process.
Physical dependence and accompanying fears may prove powerful counterweights to deciding to change, but are not the final explanation for why the person stays on the seesaw. Providing the expectation of strategies for managing these issues may aid in reducing the weight this element provides in the decision making process.
Social networks are powerful factors in both staying stuck at a balance point and moving towards change. Similarly, values are important weights in this decisional process and may aid or hinder the process of moving forward. Understanding these factors in the context of this person's life may aid greatly in helping the person proceed, though it may also explain why change is not occurring and what may need to be altered for the change to occur.
Finally, the language and focus of decisional balance discussion matter in the resolution of ambivalence. Listening for, eliciting and reinforcing change talk, as well as minimizing a focus on the status quo may help in forward movement. In addition, the focus on positive emotions, rather than simply avoiding negative events, may provide longer and more sustained efforts at change.
Here are some suggestions based on these findings and the TTM model:
- Review the modules on Finding the Fire Within and This is Who I Am more than once to reinforce reasons for change, and find the positive emotions for the decisional balance exercise, and build the strength of associations at the brain level.
- Elicit information about how temptation and craving may impact them and indicate these issues will be addressed in an upcoming session. Note that these are important factors, while reinforcing that deciding to change is the initial and perhaps most critical step.
- Use the decisional balance as a point of discussion, not an activity to simply fill in the blanks. Inquire about emotions attached to these answers. However, avoid the standard question (How does that make you feel?) and go for greater depth or breadth in your queries (e.g., What sort of emotions, if any, do you attach to that situation?)
- Ask about social network factors that influence the seesaw for him or her (e.g., How does family feel about the possibility of making some changes? Others? How might they help or hinder you, if you decided to make a change?")
- Provide differential attention to language. Reinforce change talk and ask for examples or elaboration (e.g., What would it be like if you had more of this positive thing in your life? Tell me about an instance when that happened.). Also actively seek to elicit change talk (e.g., How would you like things to be different?) Ask for inspiration and positive emotions (e.g., How would things be better if you made these changes?).
- Commitment seems to be key, so ask for it. Bear in mind that how you ask is important. Instead of asking, "Are you committed?" you might ask, "Where does this leave you now?" or "What's your next step?"
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