Sunday, March 18, 2012

Context and the Stages of Change


Sitting here at the DFW airport waiting for my connection home seems like a good opportunity to put up a second post inspired by my experience at PaleoFx12, Theory to Practice Conference.  The previous post covers the first couple of days.  The final conference day proper began with my putting on my watch upside-down in the dark, so I arrived half an hour early, just in time to be asked to go on a morning panel unexpectedly.   The panel was for general Q&A and it devolved into a “safe starches” debate where Kruse, Gegaudas, and Rosedale warned of the dangers of glucose (glucose = DEATH) whereas Paul Jaminet and  Lane Seibring noted that insulin is not a dirty word, and Dallas Hartwig found that in his experience as a nutritional and training consultant (I would say to generally healthy folks, as opposed to Rosedale), the quality of the food seemed to matter more than the macronutrient class.  My major contribution was the admission that I had, indeed, consumed a banana that very morning, and that I was quite comfortable with that decision.

I’m sick of the whole debate, personally, as I take a sky-high view that excess energy from sat fat and glucose  is stored long term as palmitate (carb or fat) and excess energy in the form of glucose or too many free fatty acids floating around seems to cause damage and inflammation. And while there are a number of important details I am glossing over (but have looked at in excruciating detail, yeah, I know de novo lipogenesis and glycation and etc.), I don’t think either fat or carb as a macronutrient class per se causes one to overconsume.  Low carb and ketogenic diets can be fantastic tools.  Others do better and sleep better at even a high carb, low fat level, and I don’t think they are dooming themselves to an early grave.  (And the ketogenic folks still have to get over the hump of the low fasting insulin and the low glucose levels of the Kitavans or pretty much anyone who eats a low fat diet but has no problems with insulin resistance and obesity - Rosedale doesn’t know if the Kitava measurements were accurate but I encouraged him to email Dr. Lindeberg to ask about the methods.)  

On the other hand, I’m not convinced that we have an absolutely essential need for dietary glucose (for mucous formation or to protect the thyroid from damage), and I don’t think natural saturated fats are bad for you.  On balance I would hedge my bets in favor of including a bit of starch as that seems to be the most common ancestral precedent, and tubers and starchy fruits have some electrolytes and whatnot that are not always as robust in a meat+veggie+fat diet.  In general I think a macronutrient focus is confusing and spends too much energy looking in the wrong direction.  Think of all those billions of wasted money on poorly designed nutrition studies.  On a more specific level there are many conditions and personal needs that would weigh in favor of more fat for some and more carbs for others.  You know, context.  

Phew.  I hope that is the last time I have to write or say anything about that issue.  Hah.

After that panel I had little patience for the medical talks and spent much of the day networking or attending the training/fitness panels.  One of my general interests is training and athleticism and it was nice to see that side of the health industry.  While food and training methods were obviously highlighted, there was a lot of focus on the psychological aspects, reminding me that a trainer’s job is not so very different than a psychiatrist’s (though a trainer has a better chance of making his or her clients better-looking).

I was pleased to make more ancestral health doctor connections and further the dialogue with some old and new friends over the course of the day, and I did get an opportunity to speak with Chris Kresser (a careful and brilliant guy.)  Oh, and I met Andy Deas!  He was off to the hinterlands after I spoke with him so hope his trip turns out okay.

Finally, my panel came up, a discussion mediated by Dean Dwyer about the psychology of change.  I was excited about being on this panel, as it became clear over the course of the conference that some of my fellow doctors and the trainers and nutritionists (and layfolk on their own journeys through change) were in need of some guideposts.  Facilitating healthy change is the bread and butter of a psychiatry practice (in the guise of little pills sometimes), and there is a large body of literature on the subject.

I think all of us thrilled with the success we have had with an ancestral health influenced diet and lifestyle are happy to extol the benefits to the rooftops, buying copies of The Paleo Solution or the Primal Blueprint for all of our friends and relatives (or patients or clients).  We may have been hurt or confused when those same folks ignored us and continued to complain about the same issues or problems we thought might be helped by a little diet and lifestyle tweak (hint, the grains or vast amounts of soda just might be contributing to your tummy pains).  An understanding of the stages of change model can help us to direct our interventions and energies in a more productive manner than just proposing a big change and then being hurt-feelinged when our fantastic ideas are rejected.

There are five basic stages in a big lifestyle change, such as giving up an addiction or changing one’s diet.  The first stage is called “Precontemplation” (and in addiction circles is sometimes referred to as denial).  In Precontemplation you aren’t really thinking about changing your diet, drinking habits, or lifestyle habits.  Many of the folks who see me for the first time are in this stage, as are many of your friends and family.  Since Precontemplation can often be characterized by denial, saying “hey, you should really stop eating wheat to see if your stomach pains and skin problems get better” will often be met by responses such as, “well, I love bread.” Or “but I always eat whole grains, they are healthy” or “My brother only eats bread and he doesn’t have any stomach or skin issues.”  When someone is in a Precontemplation phase, a recommendation for dramatic change will often be met by arguing the other side.  The best strategy is not to urge someone immediately towards Action (the fourth stage of change) but rather towards the next stage, which is Contemplation.

To move someone from Precontemplation to Contemplation, the best approach is a personal one.  You might ask if the person thought his or her symptoms had anything to do with diet, or poor sleep, or smoking (or whatever the major lifestyle problem is).  It’s important to support the person in understanding their current dilemma.  If they say, “yeah, maybe I shouldn’t eat so many donuts” you might say, “oh, yes, I know how donuts smell so good.  It can definitely be hard to give them up.  But you know, they don’t taste as good sometimes when you haven’t had one in a while.  Too sweet, if you can believe it.”  Sometimes folks stay in the Precontemplation time for a while, until their own understanding and circumstances cause them to move forward.  By serving as a supportive example and continuing to highlight possible issues or problems that might be caused by the bad habits (“I noticed you always have bronchitis in the winter.  Do you think it is due to the smoking?”), you can continue to nudge the person towards Contemplation.  In short, the personalized nudging just seems to work better and more often (and, over time, with less frustration) than: “You’ve got to stop smoking.  It will kill you.  Here, check out this smoking cessation website.”

The next stage, Contemplation, is where the fun starts.  This is the person who will welcome support going forward to the next stage, Preparation.  The Contemplator is still ambivalent, but not in denial.  This person may welcome more stories of anecdotes about successful life transformations and links to various resources.

The next stage is Preparation.  These are the folks who are calling the gym to ask about prices and class times, or newbies stumbling onto Mark’s Daily Apple.  Support and encouragement and resources are key here.  And, as always, a personalized supportive intervention focused on particular stumbling blocks is key.  “You mentioned it must be hard to go out to a restaurant when you aren’t eating dairy or grains.  Go to the Whole30 website because they have a ton of ideas about what to do…” (etc.)

Stage four is Action.  Exciting times.  These folks are often active on the forums and experiencing major changes.  Again, support is important here.  

Finally there is the last stage, Maintenance.  Maintenance can be tricky.  The early bloom of “wow, this is so awesome” has come off, and the grind of continuing lifestyle change (oh man, I really really want a donut, or I just want to sleep in and not go to the gym today) can go from one or two “slip-ups” to just not continuing (one day off the gym becomes a week or a month).   Robb Wolf noted in his talk that he had figured out a number of people dropped out of the gym after day 38, so he recommending instituting some protocols, such as a reduced cost or free personal training session or a supportive check-in email that would come into play around that time.  In addition, obviously, life is very different after a massive lifestyle change.  You don’t have that percocet to comfort you during the day anymore (which can sometimes feel overwhelming even though you are no longer spending $200 a day on your habit and your friends and family have started to trust you again), or maybe you are uncomfortable with the attention you get after losing 100 pounds.  You might feel distant from friends or family who don’t embrace the same change and might even (explicitly or unconsciously) prod you to go back to the old habits you fought hard to drop.  Maintenance can easily go to Stage 6 which in addiction is called Relapse.   In many respects, Maintenance requires more support than the previous stages, and the problems aren’t as obvious.  “You’ve lost 100 pounds and you look amazing” may feel uncomfortable to someone who has spent years being self-conscious about his or her body and is dealing with excess skin issues.  And Maintenance may look a little different and less magical than the final product you imagined at the Preparation stage.  I will never be a Sports Illustrated swimsuit model, for example, no matter how many Whole30s and Met-cons I do.    

So the underlying theme here is support, and the type of support needed differs as one progresses through the stages of change.  Providing the wrong type of support at the wrong time can be alienating and off-putting, and push someone the wrong direction, no matter how well-meaning you are.  And spending one’s energy providing the wrong support is very frustrating and can lead to ruptures of relationships.

Hopefully this post is helpful to anyone who hasn’t heard of this model and is struggling.  There’s one more PaleoFx post to come, when I get another moment!

14 comments:

  1. I may be a psychologist, but it's in the experimental, not clinical, paradigm. Your summary of the stages of lifestyle transition and how to guide someone through them serves as an excellent primer. Thanks!

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  2. That's a great description of the trans-theoretical model of change. Often when you see the diagrams it doesn't make much sense due to the use of terms like 'pre-contemplation' etc, but you've done a great job of contextualising it here. I prefer 'lapse' to 'relapse', but either term helps people understand that falling off the wagon is normal and to be expected: change is hard.

    In fact, I wonder if you've thought of putting something quite formal together as a resource for trainers/nutritionists and the like. So many take an evangelical approach that it immediately puts off the pre-contemplators & contemplators - the very people they're trying to convince. You've got the credibility within the blogosphere that they might just listen...

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  3. Great post. It's nice to hear the nuts and bolts, or stumbling points to success. Thanks

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  4. Now sprinkle another post with motivational interviewing (an evidence based practice for anyone who cares), add the two together, and you begin to have a very effective way of working with anyone with virtually any behavior/addiction/issue they want to change, or that you hope to assist them in becoming *motivated* to change.

    This is also an excellent example of how LONG it takes for change to happen. My training in Stages of Change and MI was in 1994 in the High Arctic AK, and we immediately began using it in all of public health and in behavioral health/substance treatment services. But in my experience in the years since I left that work in 2001, it has not "caught on." It fact, it has not caught on in the extreme. I did work a contract position in the state hospital system in Hawaii in 01-02 in which it was moving like wildfire throughout services in that system, but since going back to the mainland, what I've experienced is that finally, in the last few years, it just barely inching forward.

    I hope that by the time I am 80, all healthcare providers of all kinds will be using Stages of Change and MI.(One can hope.) It would be a powerful addition, as you stated, to those working with movement, exercise, etc.

    For those who may be interested, just google "stages of change" and "motivational interviewing." MI has now been validated in a number of areas, including use in hospitalized patients with medical/surgical issues and there are specific books dedicated to training in different areas.

    IMO, for really motivated people who want to learn, there are now excellent books in both areas for self teaching.

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  5. I snuck the motivational interviewing in there. Didn't want to make things too confusing...

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  6. Emily, it was great spending time talking with you at Paleo fx this week. We have a lot of work ahead of us as practitioners in the implementation of the Paleo lifestyle. Your post highlights something that I feel was underrepresented this week. The nuts and bolts of actually taking the theory to practice. We have the medicine...but what you've discussed here is the syringe. This is as important as the dietary and movement based prescription itself. We need to talk more...

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  7. The DOJ just completed a five year stint at our hospital fully entrenching the "Recovery Model".

    Initially, we incorporated the five stages to all psychiatric conditions (even though we defined 11 foci domains). Eventually, we narrowed its application to one foci, substance abuse, based on clinical argument. This was troubling because I believe the model carries a wider spectrum of use.

    Our hospital system's persistent resistance to the DOJ most likely stunted its application. This was an unfortunate outcome. Now that they (DOJ) are gone, we are reverting to some practices that brought them here in the first place. Huh?

    As far as the whole dietary issue of fat, safe starches, and carbs, etc. To each his or her own. I say, "do your best and flush the rest".

    We all have limited knowledge and information regarding this issue. In the end, its the people that matter. That, we should not forget.

    I need to learn more about motivational interviewing for health, prevention, etc. Although I found mine in bed at 0230 with a weak, thready pulse one night too often, there are obviously less dramatic and equally important reasons to get healthy. Is identification or application the problem?

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  8. Thanks for the article. I stumbled though some of it on my own journey, but have not actually viewed it as a whole process and it helps. Your words describing the feelings of someone who is not yet comfortable in their new body size reminded me of the lost feeling I had after dropping a lot of weight. It was like I couldn't go home. It did dissipate as time went by.

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  9. I like the font change just sayin......nice to finally meet you formally in Austin.

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  10. Yes, yes, yes, this really in many ways is the heart of the issue. A similar model has been prevalent within athletic training circles for a number of years in the arena of injury and recovery. The denial (trying to train around the injury), then the reluctant acknowledgement (and attendant depression very often), then the long haul to recovery ... and the biggest issue - not slipping back into the behaviour that caused the problem in the first place. In obsessive/elite athlete types - over-training most usually!

    IF more attention was paid to the subtle psychology behind a resistance to necessary change and it were better understood there would be a great many more success stories and far fewer individuals feeling they had failed.

    My observations of friends and relations who really need to address lifestyle issues (most notably diet and exercise) has brought me to the conclusion that one must help them identify what they have to lose by getting well. This is often neglected - well meaning types list endless benefits of recovery but don't realise these are actually very threatening to an ego that has often developed the ill-serving behaviours for very logical reasons when they first began. I've noted that one of my relations has a great deal invested in being a very overweight and unfit person - she literally hides within and doesn't need to 'bother' - being stripped of her outer shell so to speak creates massive subconscious resistance. And then the friend who has been treated with drugs for GAD for 2 decades who believes her husband has only stood by her because he a decent man that wouldn't leave an ill wife ... need I say more.

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  11. I like the way Bruce Lee interpreted Buddhist Eight fold path on change better. He wrote in Jeet Kune Do:

    You must see clearly what is wrong
    Decide to be cured
    Speak so as to aim at being cured
    You must act
    Your livelihood must not must not conflict with your therapy
    The therapy must go forward at the "staying speed" -- the critical velocity that can be sustained
    You must feel it and think about it incessantly
    Learn how to contemplate with the deep mind

    He also wrote:
    Simplicity is the key to brilliance.

    Just my thought.

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  12. "I will never be a Sports Illustrated swimsuit model, for example, no matter how many Whole30s and Met-cons I do." I think that you, Emily, are amazing and I very much appreciate you.

    I never had a blogger recommend any music in the middle of a blog. I have been a big fan of classical music since I was 11 when my auntie turned me on to L'Arlesienne Suite; my first time that a blogger suggested any music to me was when I read your suggestion of L'Arlesienne Suite. I was floored!!! That was so cool. Keep doing what you are doing, Emily.

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  13. Interesting post. Interesting combination of trans-theoretical models in psychology and diet.

    Willpower is also an integral thing to build in all of this
    http://www.learningthesteel.com/books/

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