What a challenging time to be a provider in behavioral health care as the need for accurate assessments has been at the forefront of patient care with the revisions of the DSM-5 and ASAM 3rd edition. Practitioners need to be even more effective in assessing patients and matching comprehensive services to patient’s needs to achieve desirable outcomes.
Like most of you, I have participated in numerous trainings and webinars for both the DSM-5 and ASAM revisions; the common theme I have taken away from these updates is knowing the patients readiness to change is crucial. Both the DSM-5 and ASAM have reinforced that comprehensive assessments in which treatment is matched to the appropriate stage of recovery is essential. According to James O. Prochaska, “treatment frequently is unsuccessful because providers fail to recognize the distinct stages of recovery. Treatment failure is caused by misidentification of patient readiness.”
The revisions in ASAM Dimension 4 allow practitioners to focus on the degree of motivational enhancement interventions to attract a person into recovery. Dimension 4 reflects strongly on the research of Prochaska and DiClemente’s Stages of Change Model. What I love about the revision to Dimension 4 is that it reminds practitioners that a patient can be in different stages of change for different issues.
For example, I have a 22-year-old female patient who is seeking help for alcoholism. She assesses as highly motivated to address her alcohol use and has already started to explore changes necessary to begin recovery. We might say she is in the Preparation Stage for her alcohol use. However, the boyfriend whom she lives with whom physically beats her on a regular basis, she does not view as a problem. Regarding her relationship with her boyfriend who is “not a problem” we might say she is in the Pre-Contemplation Stage of change for this issue. How I choose to match appropriate strategies for these issues will differ. I can use behavioral focused strategies to address her alcohol because she is more motivated. I will have to adjust my approach to reflect motivational enhancement and cognitive approaches to address the relationship concerns.
Some may believe this makes treating a patient more complicated due to assessing each presenting issue and determining the patient’s readiness to work on those issues. Well…. it actually makes our work much easier- if there is such thing as “easy” in our field. When we accurately assess the stage of change then we can focus on matching the right interventions per stage. When we match readiness with the appropriate intervention, the patient’s motivation begins to shift, they start using change talk and as a practitioner we see changes occurring which reduces burnout.
Colleagues and myself confirm three things that we as clinicians know in treating patients: motivation matters, matching treatment styles to motivational stages matters and dependence complicates things. The experienced clinician recognizes that people who are at different points in reaching a decision to change need different interventions. The intent of Dimension 4 reminds me of skidding in a car: turn in the direction of the skid. When we turn into the skid with our patients we reduce resistance, increase compliance and achieve better outcomes for both the client and our programs.