Small things have a big impact by Dr. Susanne Fogger

We all know that changing a habit can be hard. With the New Year, many people set out to improve their lives and health, and by this time of year—February—many of these plans have gone by the wayside. When faced with stressors such as long hours or interpersonal conflict, we tend to revert to old behaviors, even if they don’t work for our long-range goals.

Individuals with a substance use disorder can face the same challenges when trying to leave behind an old habit. If we can recognize change as a give and take process, made up of consistently made, small steps toward our goal, we can begin to uncover the best ways to support people.

Recognizing “right now”

One challenge with a new habit is overcoming the “right now.” Our habits tend to work for “right now” and help us cope. There may be ambivalent feelings toward a habit, forming a barrier to long-term behavioral change. A part of us may be happy as we are, and thereby resistant to doing anything different. For individuals with substance use disorder, they may state “I am fine” or that they aren’t ready to “give up” their behaviors or substances. They may fail to recognize the harm of continuing their behavior, and therefore do not intend on changing in the near future.

In the past, this thinking was viewed as “being in denial” with a focused effort to help the person “see” the negative effects of their behavior. As health care providers, however, it is important that we understand the thought process and motivators behind these behaviors. Only then can we best care for individuals and find next steps.

The process of change

There are various theories to help understand the puzzle of change in human behavior. About four decades ago, James Prochaska and Carlo Di Clemente developed the Transtheoretical model to understand the process of change. The Transtheoretical model has six stages of behavior changes, and the first two stages often the most difficult for health care providers.

The first stage is precontemplation. This is where the individual does not want to change and is not thinking about change. In this stage, a health care provider respects the person’s decision not to change but helps to inform them about health risks related to behaviors. This recognition of the person’s right to choose to continue a behavior can be frustrating or create a disquiet for the provider, as they may feel helpless to “make a person change toward health” (what the provider is supposed to do) and yet respect the person’s decision not to change today.

The second stage is contemplation. Contemplation is the stage in which people begin to think about change. Perhaps the seeds the provider planted about health risks have begun to take root. Circumstances may also dictate the “readiness” of the individual. For example, cigarette price increases may make the idea of smoking cessation more attractive and move the person to begin to think about quitting. In this stage, the care provider can recognize how small steps helps move the person closer to being ready to change a long-term habit, such as ending their substance use.

The next stages of change in the Transtheoretical Model are preparation, action and maintenance. These are areas where health care providers can help develop strategies, next steps and solutions for long-term adherence to a habit change. However, because the first two stages of change do not include direct action, they can be the most important for health care providers to remember.

Support despite aversion to change

It can be beneficial for health care providers to work with individuals who do not want to stop their behavior because it highlights that behavior change does not have to be an all or nothing process. The reality of substance use is some people never get to the contemplation stage of change; they don’t make a commitment to themselves to stop the behavior or substance. Risk reduction strategies, however, accept the person and their behaviors as they are. The provider and person look at how small changes can decrease the health risk related to ongoing use. Risks that can be modified with intervention may include infection such as HIV or Hepatitis C, accidents, worsening of their chronic condition, increasing debilitation, or death.

The best-known example of risk reduction strategies for substance use is the implementation of a needle exchange. Providing a safe space for this action works to decrease the spread of infection. Another risk reduction strategy is helping young adults establish guidelines for cannabis use during college. These risk reduction strategies support individual autonomy and help create a framework to supports the individual’s life goals.

Having a supportive health care focused relationship with patients can help individuals make changes. And even if people are not ready to for a wholesale change, they may be willing to make small adjustments that can reduce the health risks of substance use. Supporting the person during the process of contemplation can pave the way for when they are ready to take the next step. And like with your New Year’s resolution, it may take several attempts to incorporate the changes. Small things can have a big impact.