How enough becomes enough: Processes of change prior to treatment for substance use disorder

ABSTRACT

Aim: Explore patient’s perceptions of change processes occurring prior to inpatient treatment for substance use disorder, forming the basis for treatment entry. Method: Four single focus-group interviews including a total of 14 patients (11 men and 3 women) were conducted in accordance with a brief interview guide. Interviews focused on patient’s perceptions of change processes prior to treatment entry, associated factors, decision-making and implications for their way forward. A content analysis was conducted to identify code and subcategorize meaning units. Results: Patients describe complex processes of change involving a new perception of life situation enabled by accumulation and escalation of negative consequences, especially related to loss and health, along with an external pressure or trigger. The transition to treatment entry is either based on a deliberate and active decision or a result of spontaneous action and less deliberate decision to initiate in treatment. Conclusions: Patient’s perceptions of treatment entry as a result of a more or less deliberate decision challenges patient’s readiness at treatment entry, constituting an important clinical challenge of relevance for clarifying treatment goals and interventions which in turn may affect the course of treatment applied to the patient.

KEYWORDS:

• Substance use disorder
• change processes
• focus group
• treatment-seeking
• systematic text condensation

Introduction

In order to understand the complex mechanisms underlying change among persons with a substance use disorder (SUD), the primary attention has during the last decades been directed toward the role of motivation and readiness to change (DeLeon, Melnick, & Tims, 2001). Readiness has usually been examined in inpatient treatment (Rapp et al., 2007), and it has been a common perception that changes primarily occur in a treatment setting or when receiving a specific treatment (Barnett et al., 2012; McHugh, Hearon, & Otto, 2010; Willenbring, 2007). However, the assumption have been challenged by studies showing that change frequently occur in the absence of professional help (Sobell, Sobell, & Toneatto, 1991), and many change processes among those who seek treatment are self-directed (Orford et al., 2006). Change processes occur in a life context played out over time and must be understood in a wider context, including factors and mechanisms occurring independent of treatment (Redko, Rapp, & Carlson, 2007; Willenbring, 2007). Motivation to change is neither not necessarily related to an actual change in behavior, but may also involve a range of other measures (e.g., social, psychological, physical, and environmental), as well as emotional and cognitive changes.

Reviews of early studies on patient’s treatment-seeking processes have found problem recognition (Jordan & Oei’s, 1989), problem awareness, cognitive appraisal and attitudes toward treatment (Tsogia, Copello, & Orford, 2001) as influencing factors for treatment entry. However, studies are claimed to be limited by them having quantitative designs and methodological weaknesses, failing to address the complexity of the help-seeking process by looking into isolated factors, ignoring the relationships among these and the subjective meaning of life events, including perspectives of patients (Redko et al., 2007; Tsogia et al., 2001). The criticism also applies to recent studies. Despite a growing interest in patients readiness to change, which have become a frequently used measure for motivation for treatment when considering patients decision to enter treatment (Rapp, Carr, Lane, Redko, & Carlson, 2008; Rapp et al., 2007), studies mainly focus on single factors, such as perceived pressure (Goodman, Peterson-Badali, & Henderson, 2011; Polcin & Beattie, 2007), patients characteristics (Field, Duncan, Washington, & Adinoff, 2007), and cognitive barriers (Le Berre et al., 2012).

However, a few studies have attempted to address this criticism. Jakobsson, Hensing, and Spak (2005) found development of willingness to change to be the basic psychosocial process leading to treatment entry, continuously assisted by external factors, such as support from friends, family, and professionals. Motivators of treatment-seeking have been found to vary based on the mode of treatment entry (Andrews, Kramer, Klumper, & Barrington, 2012). Another study suggests that change from alcohol problems usually occurs after the accumulation of complex problems, leading to a realization of the existence of problems, combined with triggers or pressure to change (Orford et al., 2006). Consistent with these findings, resolution of disturbances in the health, psychosocial, and situational domains has been found to be the primary purpose for treatment seeking, rather than a desire or decision to stop drinking per se (Naughton, Alexandrou, Dryden, Bath, & Giles, 2013). Authors therefore claimed that there is an oversimplification of the cognitive transition from problem recognition to a decision that change is needed. It is suggested that recognition can be reached long before accepting what they need to do about it, which even sometimes can occur after treatment is being received.

The most recent studies addressing this topic found that decisions to seek treatment were made suddenly; prompted by mirroring events which further initiated a window of opportunity where the patients were responsive to suggestions to make changes (Roper, McGuire, Salmon, & Booth, 2013). Authors argued that findings are inconsistent with influential models of treatment-seeking indicating that change is a gradual process, such as the stages of change (SOC) (Prochaska & Velicer, 1997). In SOC, decision-making is primarily defined as a contemplation task involving a risk–reward analysis leading to decision-making. The decision itself is related to committing to and planning how to implement the change, which is an understanding supported by studies claiming that a specific change plan is predictive of change actually occurring (Gollwitzer, 1999; Gollwitzer & Schaal, 1998; Miller & Rollnick, 2013). Consistent with previous criticism of SOC (West, 2005), Roper et al. (2013) suggested that there are strong external situational determinants of behavior. These findings are clinically relevant since terms, such as commitment, decision, and planning of change are commonly applied in theories of change (DiClemente, Schlundt, & Gemmell, 2004; Miller & Rollnick, 2013). Research on smoking cessation has shown that up to 50% of change attempts involve no planning and are as likely to succeed as when changes are planned (West, 2005, 2006). Roper et al. (2013) suggest that psychological models emphasizing internal factors are not consistent with the evidence in the literature pointing to external factors. Bridging this gap can help clinicians understand the meaning and influence of external life events for the individual and thus provide correct information about interventions to improve patient’s engagement in treatment.

The aim of this study was to explore how patients understand change processes occurring prior to inpatient treatment for SUD, by examining (i) changes in patient’s perception of their substance use, (ii) associated factors, (iii) evaluations and decisions to change, and (iv) implications of perceived changes. Knowledge about processes of change underlying why patients enter SUD treatment can improve therapists understanding of individual change processes and thus help match treatment interventions and strategies to patient’s individual needs (Finney & Moos, 1995; Flores, 2001).

Methods

Recruitment and sample

We approached treatment units for SUDs in south west Norway, offering inpatient, long-term substance use treatment based on voluntarily participation. Inpatient treatment was the context of the study, however not the focus during the interviews. Thus, recruitment did not take into account variations in the content and structure of the provided treatment. To be enrolled in the study the patients had to (i) have initiated inpatient treatment for SUD for 1–6 months, (ii) have a minimum age of 18 years and (iii) sign a written informed consent form. Patients who had been (i) admitted to treatment for more than 6 months or (ii) legally mandated to receive treatment was not requested.

Sixteen patients agreed to participate; however, two patients did not attend scheduled interviews due to undisclosed personal reasons. The final sample comprised 14 patients (Table 1) with a SUD, representing a strategic sample designed to ensure that the participants could provide constructive associations about the study topic while also ensuring maximum variations in gender, age, and substance use history and treatment experience.

Table 1. Sample distribution (n = 14).

Category	Variables	n
Gender	Female Male	3 11
Age range	18–25 26–35 36–45	8 5 1
Previous treatment experience^a	In-patient Out-patient Both	0 3 10
Primary substance^a	Depressants Stimulants Depressants/stimulants Hallucinogens	4 2 6 1
Years of substance use^a	5–10 11–15 16–20	4 7 2
Previous periods of abstinence	Yes No	12 2
Most recent period of abstinence	<12 months >2 years	10 3

^a One missing.

Data collection and focus groups

Data was collected through four single focus group interviews divided between four treatment units, and consisted of two to six participants. Focus groups were chosen based on its potential to bring forth patient’s experiences and perceptions about common experiences, and facilitate for an illumination and discussion of these in social interaction with others (Miller & Crabtree, 1999). The number of focus groups was determined based on researcher’s assessment of having sufficient empirical data to elucidate the study topic.

The interviews took place between May and November 2014 and were carried out by the first author and an assistant, who in two of the four interviews had a history of SUD. To facilitate participation, interviews were located at the facilities of each treatment unit and lasted from 45 to 85 minutes. A semi-structured interview guide containing five open-ended questions was applied, including additional follow-up questions. The questions derived from relevant literature and primarily referred to changes occurring prior to commencing the current treatment program, including associated factors, but also included questions regarding previous change attempts. Following the completion of the first interview, adjustments were made to questions presupposing a conscious evaluation of changes and choices made prior to commencing treatment, and new topics emerging during the first interview were added.

Analysis

All interviews were audiotaped and transcribed verbatim and written notes were taken during and after the interview sessions. Based on a collaborative negotiation between two researchers a content analysis was conducted in four stages applying an explorative, descriptive and interpretive method for thematic cross-case analysis (Malterud, 2012), using NVivo10.¹ First, the transcriptions were read and impressions summarized through preliminary themes noted in the margin, using the patient’s own words. The researchers discussed themes, content and meaning, and subsequently revised the themes accordingly. Secondly, the material was scrutinized on a line-by-line basis in order to identify meaning units, which were systematized into codes and developed and adjusted continuously. Thirdly, nuances represented in the code groups were categorized into subgroups, before the content of each subgroup were summarized using patient’s words and illustrated by citations. At last, the relationship between the content of the subgroups were explored and refined, including a visualizing of patterns. Based on the condensates of the subgroups the analyzed material was finally re-contextualized and rewritten as a descriptive and interpretative analytic text.

Topics which emerged from the analysis included “reaching a point”, “loss and shame”, “significant events”, “desire for change and ability to change”, “stagnation and desire for a normal life”, “physical and psychological exhaustion”, and “escalation of negative consequences”. As patient’s descriptions appeared process oriented and topics closely related the findings are presented under the following headings; accumulation and escalation of negative consequences, external pressure or trigger, a new perception of life situation, and transition to treatment entry.

Results

Accumulation and escalation of negative consequences

Patient’s described a situation characterized by increasing negative consequences of their substance use. Two topics emerged as prominent. The first was related to loss, and mainly included loosing close relationships with family members, partners and friends, but also job and home which consequently influenced their sense of belonging. For some, loss was also related to custody of children or fear of losing still remaining but vulnerable relationships. Affected by substances, patients also experienced to lose themselves as their behavior contradicted the person they either used to be or wanted to be. Eventually, the substance use became the only thing they had left, as described by a male participant:

Before, I had everything, a house, wife and kids. I had everything. My substance use caused the loss of this (…). I managed to destroy everything. Lost the house and spent all the money from selling it. You are left with nothing, which makes you feel strong shame. For having destroyed everything. And what are you left with? You are left with nothing.

Secondly, patients overall functioning were strongly affected by the physical and psychological effects of their substance use. Physical effects were mainly described as bodily exhaustion, weakness, and lack of tolerance for substances and perceived benefit, demonstrated in remarks as “I was so sick” and “my body could not, and would not take it anymore”. Psychological consequences involved anxiety, paranoia, psychosis and being mentally weak and out of control. A female participant described the psychological effects as follows:

My mental health was destroyed. My emotions were destroyed; I was apathetic (…) I could just have taken an overdose and just die. And I was constantly paranoid and had a lot of anxiety. Even when I was sober and not intoxicated (…).

Patient’s total loss eventually resulted in a feeling of loneliness, which some disguised through increased substance use or isolation. Consequently, patients experienced to miss out on things associated with having a normal life, which led to a feeling of stagnation referred to as “being stuck in negative patterns” and “life being on hold”. Patient’s descriptions of the state they found themselves in demonstrated recognition of their perceived negative consequences relation to their substance use, but was however not sufficient to result in changes. For many, the perceived negative consequences had to lead to some form of saturation, followed by a trigger or external influence.

External pressure or trigger

Reaching a point where patient’s reflections about their life situation changed derived from an accumulation and escalation of negative consequences followed by a trigger or external pressure, mainly from family members or other close relations, and health-care professionals. External pressure could be situations where the patient experienced to be given an ultimatum: “He put his foot down; I’ve done everything for you the last 10 years”. It could also be situations characterized by less direct pressure, but which still made a strong impression, as illustrated by a female participant:

My mother told me once that; this time, if you can make it now and become abstinent, it is the greatest gift you can give me.

External pressure were also uttered by health-care professionals who either confronted patient’s about engaging in or seeking treatment, repeatedly consulted them in their private home or in other ways did not give up on them. Some of the patients also emphasized the significance of being “given the opportunity to change”, for example through imprisonment.

For others, new reflections about their life situation were triggered by specific incidents or mirroring events, characterized by detailed descriptions of time and place and associated emotions. Incidents included episodes of severe violence, acute hospital admissions due to overdose or mental illness, compulsion or accidents. Mirroring events were situations that caused them to view themselves from an external perspective, as here described by a male participant:

I logged on to Facebook. (…) Then I see their names [old, sober friends] on Facebook, I see some pictures. Then I turn around and I look at him [referring to a guy sitting in the same room]; a tired addict. Then I looked at Facebook again, and I remember I started to cry. I just sat there, in despair.

However, triggers were not described as a direct reason for patient’s perceived need and desire for change. Following patients descriptions of triggers, this important aspect was demonstrated in remarks as “I was so exhausted I had no choice” and “I could not take it anymore”.

Only a minority of the patients found it difficult to express exactly how they got to this point and why it happened at that exact time, using descriptions as “it just appeared to me” and “suddenly I just realized”. However, a commonality among all of the patients was that at a certain point they experienced changes in how they perceived their own situation regarding their substance use, which reflected an acceptance of a need for change.

A new perception of life situation

Patients variously referred to this point as “enough is enough”, “hitting rock-bottom” or “reaching a personal limit”, and was perceived as being not only desirable but also necessary in order to change. Thus, changes in how patients perceived their life situation was for most of the patients characterized by an acceptance that change was required, rather than recognition of the negative consequences associated with their substance use, which already was present. Findings indicate a difference between recognition and acceptance, which involves a change in mindset that enables an evaluation of the life situation and way forward, as described by a female participant:

I made a choice that I wanted to get into [name of treatment]. I need to do something with my life. (…) It has appeared to me that enough is enough, I need to do something. Either I die, or I… (…) It goes only one way. (…) I do not want to be a drug user, right, I need to do something.

However, the point at which patients experienced to think differently about their life situation varied. Some described that they would most likely have continued their substance use if they had not experienced being so exhausted, while others found that they had reached a personal limit for how far they were willing to go.

Patients experiences with previous change processes and change attempts were characterized by ambivalence and unresolved willingness to change. This was demonstrated in remarks as “Before, I did not want to quit” and “I said; I will always drink alcohol”, and through descriptions of previous intentions to commence treatment which were based on poorly conceived actions, pressure from others, and an urgent need for rest, nutrition and gaining strength. This highlights not only the significance of clarifying willingness to change, but also the procedural aspect of change processes where each experience was perceived as essential in order to reach a point that enabled them to move forward. This was illustrated in remarks as “I had to go a few rounds” and in metaphoric descriptions of treatment episodes as “a seed growing bigger and bigger for each time”. However, the impact of achieving a new perception of their life situation and its implications for treatment entry varied.

Transition to treatment entry

Two main modes of transition to treatment entry emerged. The strongest distinction between the two was related to whether patients perceived treatment initiation as a result of a deliberate decision or not. While some patients experienced that a changed perception of life situation resulted in a decision to enter treatment, others did not experience to deliberately make such a decision. The first mode of transition to treatment entry involved a planned action based on a deliberate decision. In most cases, the decision was followed by active engagement in the process towards treatment entry, involving establishing or re-establishing contact with treatment services, or focused engagement in already established outpatient programs, as described by a male participant:

I made a choice, that enough is enough. Then I went to my psychologist, and there was something that drove me and caused me to bother attending all the meetings with the psychologist on the road [towards inpatient treatment entry]. I bothered to attend because I wanted to get in [to treatment].

However, the time perspective between having made a decision and entering treatment varied from days to months; a period often characterized by continued substance use.

The second mode of transition to treatment entry lacked a deliberate decision and was to a greater extent characterized by irresolution regarding when and how to attempt to change, and thus associated with less-planned actions and less-active engagement. These patients described that they commenced their participation in current treatment program as a result of less-planned actions, often caused by acute hospital admissions or being given a sudden opportunity to engage in treatment, as here described by a male participant:

I have wanted to try to change on my own. (…) I have thought that I don’t need professional treatment. So I have tried a little [to change his substance use] myself, with ups and downs. (…) Then I hit the bottom, and I started using needles and everything. It ended with me being hospitalized. Then I was taken in acutely for detoxification and then I came in here [referring to his current treatment unit].

Consequently, there were also greater variations in the time period between changes in perception of life situation and treatment entry among these patients. For some, the transition took several years. Some patients did not even consider treatment to be the preferred alternative for achieving the desired change, before having spent some time in the current treatment program, as demonstrated by a male participant:

I felt like such a drug addict; this won’t work out. There is no hope. But as I got better and healthier, after having spent some time in [name of treatment unit], I started to see that there might be hope, I can make it.

The content, meaning, and close relationship between the topics emerging from the analysis emphasizes the procedural aspects of change processes, providing a basis for formulating an empirical model (Figure 1). The model highlights the complexity of change processes prior to inpatient SUD treatment, forming the basis for patient’s treatment entry. Patients change processes occurred over a time frame ranging from months to years, of which the patients partly had gone through several times before, and the model must thus not be interpreted as a simple, linear process.

Figure 1. Empirical model of change processes occurring prior to treatment entry.

Discussion

In line with previous research (Orford et al., 2006), we found that accumulating and escalating disruption to other life domains, especially those related to health and loss of family and other close relationships, affected how patients perceived their substance use and life situation. Patient’s perceptions of life situation varied with negative consequences of their substance use, showing that resolution in these areas was essential to how patients perceived personal change processes occurring prior to treatment entry. This is in line with previous research (Naughton et al., 2013) and is clinically relevant for therapists meeting patients at treatment entry, and for planning of treatment goals and interventions.

Previous research has emphasized the significance of recognizing negative consequences associated with substance use as an important factor in the help-seeking processes of patients (Jordan & Oei, 1989; Orford et al., 2006; Tsogia et al., 2001). However, the patients in the present study described an early awareness of the negative consequences associated with their substance use, but this did not seem to be decisive for their treatment-seeking process. Instead, it seems like patients had to reach an acceptance that change was needed, which resulted from accumulating and escalating negative consequences followed by a trigger or external influence. The acceptance that change was needed was often described as reaching a point where “enough was enough”, representing a change in the state of mind enabling patients to intentionally reflect on and evaluate their situation and future directions. Findings support previous studies emphasizing a distinction between recognition and acceptance (Naughton et al., 2013).

Reaching a point that enabled patients to evaluate their life situation and way forward, involved change processes occurring over a longer period. Parallel with an accumulation and escalation of negative consequences, patients had received treatment repeatedly. Previous treatment episodes and change attempts were described as less successful due to an unresolved willingness to change (Jakobsson et al., 2005), but was however perceived as important for their recovery process. In addition to resolution of willingness to change and the significance of multiple treatment episodes, another potential explanation for why patients perceived treatment episodes as essential for their recovery could be the period of abstinence while in treatment, which has been shown to be a strong predictor of future recovery (Scott, Dennis, & Foss, 2005). It has been suggested that even when patients commence treatment without being motivated enough to change or ready to complete a treatment program, the treatment may provide patients with important experiences related to their change process, which underlines the importance of encouraging inpatient treatment admission regardless of the patient’s stage of recovery.

However, recognition and acceptance does not necessarily lead to a determination or decision to enter treatment or implement other changes, supporting that the transition between recognizing the need for treatment and deciding that change is needed is more complex than previously reported (Naughton et al., 2013). We found that for those who had actively decided to enter treatment, the decision was often followed by active engagement and planning of seeking and commencing treatment, supporting change as a result of a specific change plan (Gollwitzer, 1999; Gollwitzer & Schaal, 1998; Miller & Rollnick, 2013). However, we also found that for some of the patients treatment entry was spontaneous and less planned (West, 2005, 2006), and stimulated by sudden events or incidents (Roper et al., 2013). There also seems to be a difference between acceptance or decision that change is needed and a decision to actually enter treatment, supported by Rapp et al. (2008) claiming that not all patients identify treatment entry as a part of their change plan during the pre-treatment period. In line with Naughton et al. (2013), there might be a long time delay between recognition of problem and accepting that change is needed, and treatment entry. We found that the time delay was shorter among those who reported having made a decision to enter treatment than among those who did not. The delay was in most cases characterized by cognitive processes of change, but also active substance use.

Our study illustrates the complexity of change processes and cognitive stages occurring prior to inpatient SUD treatment. Variations in decision-making processes, and thus modes of treatment entry, reflects the complexity and importance of interactions between internal and external factors which reportedly has not been covered well in the literature (Roper et al., 2013). Although two main modes of treatment entry emerged as prominent it is not the intention to claim that patients enter treatment based on one of the two, as it may be more accurate to assume that patients move on a continuum between a more-or-less deliberate decision. Patients varying readiness to change – or initiate in treatment emphasize the importance of identifying – and assessing individual change processes at treatment entry for allowing both therapists and patients to clarify and agree on treatment goals, which has been shown to affect the treatment alliance (Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013), and for choosing strategies and interventions.

Design and study limitations

Individual interviews could potentially have given more in-depth knowledge about themes the patients had a high degree of awareness of, however, the focus groups facilitated for reflections on past events and reactions that the patients were initially not so conscious of, which was of relevance for the study. The sample is designed to ensure homogeneity and variation, strengthening the external validity of the results. Retrospective interviews were chosen as it has the potential to help patients manage an uncertain future by bringing the past into the present time consciousness (Ochs, 1997). Although the pre-treatment period may have been different while in it, it is the patient’s recollection and reconstruction of past events that forms the basis of how they understand their own change processes at treatment entry.

Possible weaknesses are the limited number of patients, lack of scheduled attendance in two of four focus groups and that the organization of groups did not involve a mix of patients among the four treatment units. Conversely, despite a low number of participants the discussions within the groups were meaningful and rich. As the purpose was not to explain the processes of change based on different characteristics of the patients, we did not examine whether patients perceptions of change processes differed with gender, age, or socioeconomic status.

Conclusion and future directions

Patients enter inpatient SUD treatment based on individual decision-making – and recovery processes. Treatment entry ranges from being a result of a deliberate decision to change or to enter treatment to a less deliberate decision and spontaneous action challenging patient’s readiness at treatment entry. If so, this constitutes an important clinical challenge that is highly relevant for clarifying both short-term and long-term treatment goals, which is essential for choice of intervention and treatment intensity as it in turn may affect treatment retention. Consideration of the mode of treatment entry of a patient could act as a useful starting point for exploring a patient’s own understanding and interpretation of individual change process and stage of recovery.

Future research should focus on how therapists assess and adapt to individual change processes in patients entering inpatient SUD treatment, and how this may affect treatment retention.

Notes

¹ A platform for managing unstructured data (http://www.qsrinternational.com/products_nvivo.aspx).