The stages of change model

Adapted from Australian Institute of Professional Counsellors, Institute Inbrief, Edition 359.

Good day readers! How are you? … Shit? Depressed? Anxious? Angry? First of all, if you’re someone who says “I feel shit”, I would encourage you to use a more accurate descriptor instead of shit. Tell your brain what emotion or feeling you are experiencing. Shit can mean a lot of things. When we’re able to identify an emotion, it’s more likely we’ll be able to regulate or manage it. When I was learning Dialectical Behavioural Therapy, they had a saying: Name it to claim it to tame it. They also encouraged us to distance our identity from our feelings e.g., “I’m having the feeling that I’m angry” rather than “I’m angry”. I know it sounds like simple fluff but there is a profound difference between observing the experience of anger, loneliness, fear, guilt etc. and believing we (the self) are the embodiment or a manifestation of an emotion.

Alright, moving along to the subject of the article. The Australian Institute of Professional Counsellors sent me their monthly (I think it’s monthly) Institute Inbrief. If you’re someone who has lived with a mental health disorder or emotional difficulties for a long time, being in nature is not really a new antidote from the field. And it’s not always as simple as just going out into nature. When I was deep in the abyss of my own depression, there wasn’t a lot that would change my mood or perception of life. But, we do these practices anyway – and that’s kind of the point. It’s a practice. It may have to be initiated using a bit of self-force. Oftentimes, motivation comes after we begin the motion.

So, here are some examples from the article that support ‘nature has a therapeutic effect for the mind and body’:

• One study found that women who looked at pictures of nature for two minutes had lower levels of the stress hormone cortisol (Gillespie, et al., 2019).
• Another study showed that people who walked in a forest preserve showed lower levels of hostility, aggression and anxiety than they did before the walk.
• Gregory Bratman, PhD, an assistant professor at the University of Washington, and colleagues shared evidence that contact with nature is associated with increases in happiness, subjective well-being, positive affect, positive social interactions and a sense of meaning and purpose in life, as well as decreases in mental distress (Science Advances, Vol. 5, No. 7, 2019).

How can we most effectively reap the mental health benefits that nature offers?

Why nature?

I’m aware we’re in Covid-19 lockdown and restrictions at the moment (27/09/2021) so you will need to determine for yourself if what proceeds to be written is practical and realistic for you right now.

We need to understand that the psyche of the human-being is linked to the natural world in many important ways. The human brain constantly processes and assimilates incoming information, and it relies on external stimuli for guidance regarding how to think and behave. Not only does incorporating nature into our daily lives help us understand the world better, but it can also contextualise ourselves in accordance with this understanding; humans – as an animal – have evolved in tandem with the natural world, and thus it is able to promote the development of beneficial skills including improved visual–spatial acuity, attentional abilities, and memory (Oddie, 2019). Our world is full of beautiful and intricate natural structures, and even just a simple walk through a park can provide us with moments of joy, awe, and wonder (Fiebert et al., 1980; Lefebvre & Brucker, 2018).

Additionally, the seemingly chaotic stimulus that nature provides us with promotes creativity and abstract thought (Berman, et al., 2012); these qualities have been the cornerstone of our species’ evolutionary development over the past few thousand years, thus illustrating the primacy of our relationship with nature.

Our neurobiology is extremely complex, and as such cannot be reduced to simple terms. However, we can say with some certainty that our brains’ sophisticated processing systems are enhanced by our interactions with nature. Our brain naturally integrates external stimuli into existing mental frameworks—this is referred to as “cognitive recursion” (Oddie, 2019). This means that if we spend our time in environments that were designed and created by the human mind, then we are putting ourselves in an echo chamber of stimulus and will not receive new information to broaden our mental capabilities. If we spend time in nature surrounded by structures and patterns that are born of unfathomably complex and foreign processes, then our minds can assimilate this new content into its existing understanding of reality.

Basically, if you spend your days in a white cube (i.e. a house) then your mental framework will be limited to the creative potential that a white cube suggests. If, however, you spend your days in an ever-changing fractal world of colours and shapes (i.e. natural environments) then your mind will reflect this, and adopt an expanded creative potential in order to perceive and understand its surroundings. This is a powerful reality; understanding how our connection with nature nourishes our minds is where spirituality meets both science and intuition.

What benefits does nature offer?

Perhaps the most important and relevant aspect of an active lifestyle in nature is its ability to reduce stress. Studies have shown that taking a walk in a park could decrease stressful thoughts, and even reduce blood pressure (Bush, et al., 2016; Robins, 2020). This finding demonstrates that simply being exposed to nature can decrease stress levels, and implies that returning to nature may be an effective way of keeping our mental health at its best. And here’s the kicker: any amount of time spent in nature is net-gain for your mental wellbeing (Robins, 2020). There is no threshold or minimum a dosage of nature that will have an effect on you – even just spending a short time sitting in your backyard enjoying nature will likely have a positive impact on your mental health.

Other studies have also shown that exposure to nature has an effect on our emotional outlook; particularly in regards to relieving us from pessimistic and fearful thinking (Lefebvre & Brucker, 2018). Life in the modern world is full of consequential decisions and options, the outcomes of which can dictate the quality of your entire life. Decision making is one of the more neurologically complex and taxing processes that our brains undertake, and research has shown that we make 35,000 choices per day (Huston, 2018).

This process involves assessing each option for its individual merit, sorting each option into a hierarchy in relation to every other option, making predictions about every possible positive and negative outcome of each option, and then weighing each outcome against that of every other option; golly, how exhausting! The fear and pessimism arises because each option invariably comes with the potential for myriad negative outcomes, and we are constantly coerced into assessing these. Thankfully, nature offers respite from all this noise. Spending time in nature relieves us from overthinking by presenting us with very few options, each with relatively inconsequential outcomes; ‘where will I sit while I drink from my water bottle?’ or ‘should I take the path leading towards the lookout, or the waterfall?’ are not taxing decisions to make, and will not prompt fearful or pessimistic thought patterns. There is an easiness to natural environments in which things seem to flow along their own course, and we are able to simply jump into the stream and flow along with it.

Aside from experiential benefits, time in nature can help us orient ourselves in the world in more grounded and productive ways. In today’s society, our attentional abilities are sapped by large corporations who profit from our distractibility, and it seems as though a way to remedy this mental breach is routine contact with nature. Attentional abilities are bolstered by spending time in nature (Ebata & Izenstark, 2017), making you less susceptible to the temptations of modernity (i.e. problematic social media scrolling, binging streaming services, etc).

Thus, making time in nature a priority in our lives – especially when we do not even feel stressed or anxious – can help us orient ourselves to the world around us and find a sense of personal empowerment. Taking time to be immersed in nature can help us regain confidence, ground us in a personal sense of meaning, and re-establish our wellbeing. Being in nature is correlated with increased positive emotions and feelings of control over one’s life (Chowdhurry, 2021), so even if we do not believe we need some sort of mental intervention, the benefits are there for everybody to experience.

How can I fit more nature-time into my life?

For the most part, we only need to reflect on our daily behaviours to see how we can incorporate time in nature into our lives. James Clear, in his wildly popular book Atomic Habits (2018), suggests incorporating a “budding habit” into an existing habit.

So for instance, if you have a lunch break during the work day, you could spend it outside on a park bench instead of in the staff room. If you come home at the end of the day and like to sit on the couch with a book, go outside and sit on the grass instead. These are simply ways to adopt more nature-time into your life, without having to add another separate activity to your schedule. In a 2017 study (Austin, et al., 2017), some participants were asked to take a brief walk in nature once per day, and other participants weren’t. The results showed that those who walked daily had higher levels of positive emotions and well-being than those who walked less. It doesn’t take a lot of time to nourish our minds in the deep ways that only nature offers us, and it seems to be a worthwhile habit to form.

Making the time to experience nature is easy to ignore in lieu of more ‘important’ tasks. That walk in the park you planned on taking this afternoon suddenly seems overshadowed by a looming deadline or a sink full of dirty dishes. For this reason, it can be beneficial to keep yourself accountable by planning nature-time with other people. Planning to go for a walk with friends means there is a lower likelihood of cancelling. Better yet, if you can join a weekly community group or class of some sort then you won’t even have to continually plan your time in nature.

There are volunteer groups who aid revegetation in nature reserves, there are community gardens who need people to tend to plants and crops, and there are clean up groups who dispose of discarded rubbish in bush-lands. If volunteering isn’t appealing to you, then you could change your routine by canceling your gym membership in lieu of outdoor exercise classes or yoga, or even new activities like cycling or rowing. Making scheduled appointments to spend time in nature can assist those who have trouble achieving this with sheer willpower, and your mental health will thank you for it.

Our acknowledgment of the value of time spent in nature is growing each day, which is why more urban living environments are incorporating ‘green spaces’ into their design. Using the latest neuroscience research, we are able to determine which types of natural environments compliments our mental states the most effectively. For example, it has been found that areas with high levels of biodiversity can alleviate symptoms of anxiety and depressions more-so than those with low levels of biodiversity (Wyles, et al., 2019). Similarly, people who watched videos featuring a diverse array of flora and fauna reported lower anxiety and higher vitality than those who watched videos of less biodiverse landscapes (Wolf, et al., 2017).

Findings like these offer valuable insight into how we can engineer our surroundings to best facilitate the highest levels of wellbeing possible. It is clear that spending time in nature is invaluable for our mental health, but a half-hour lunch break doesn’t give us time to go hiking through a biodiverse mountain landscape; what we can do, however, is have access to green spaces which replicate the stimulus that we would receive if we were in nature. This has proven to be an eloquent solution to the pressing issue of depression rates in urban CBD areas (Ebata & Izenstark, 2017).

Summary

In conclusion, the role of nature in our lives is of paramount importance to our health and should be a priority for us all. Although it may feel like adding a daily walk outside to our schedules would be in futility, the positive mental health benefits outweigh the costs significantly. Making time in nature a priority, no matter how little, can greatly increase our overall sense of wellbeing, and remind us that we are interconnected to the living world around us.

There is no minimum threshold required to reap the benefits of nature, so we can all find a way to capitalise on just a little bit of time in natural environments. As a species, it is our natural disposition to enjoy the outdoors, and the benefits are more abundant than you might expect. So pop on a pair of joggers, Google search ‘hikes near me’, phone a friend, and get out there amongst the fresh air; you can thank us later!

References:

1. Berman, M. G., Kross, E., Krpan, K. M., Askren, M. K., Burson, A., Deldin, P. J., . . . Jonides, J. (2012, November). Interacting with nature improves cognition and affect for individuals with depression. Retrieved from: Website.
2. Bush, R., Dean, J., Lin, B., & Fuller, R. (2016). Health Benefits from Nature Experiences Depend on Dose. Scientific Reports.
3. Chowdhury, M. (2021, February 19). The Positive Effects Of Nature On Your Mental Well-Being. Retrieved from: Website.
4. Clear, J. (2018). Atomic habits: An easy and proven way to build good habits and break bad ones. London: RH Business Books.
5. Hunter, M. R., Gillespie, B. W., & Chen, S. Y. (2019, March 15). Urban Nature Experiences Reduce Stress in the Context of Daily Life Based on Salivary Biomarkers. Retrieved from: Website.
6. Huston, M. (2018). How Many Decisions Do We Make Each Day? Retrieved from: Website.
7. Izenstark, D., & Ebata, A. (2017). The Effects of the Natural Environment on Attention and Family Cohesion: An Experimental Study. Children, Youth, and Environments.
8. Wyles, K. J., White, M. P., Hattam, C., Pahl, S., King, H., & Austen, M. (2017). Are Some Natural Environments More Psychologically Beneficial Than Others? The Importance of Type and Quality on Connectedness to Nature and Psychological Restoration. Environment and Behavior, 51(2), 111-143. doi:10.1177/0013916517738312

There have been various theories and models proposed over time to help us understand why individuals use alcohol and other drugs, and why some people become dependent or ‘addicted’ but not others. The following are several models or theories of addiction. They reflect the political, medical, spiritual, and social forces of those times in history.

The Moral Model

Alcohol and tobacco was introduced in the Western countries during the 1500’s. The widespread use and misuse of chemical substances resulted in a range of social problems and it was thought by some that substance use was “problematic” and “morally wrong” (Lassiter & Spivey, 2018). The moral model viewed AOD dependency as a moral and personal weakness that involved a lack of self-control, and was often viewed as a potential danger to society (Stevens & Smith, 2014).

The moral model considered addiction a “sin” and a result of free, yet irresponsible, choice. Therefore, many politically conservative groups, religious groups, and legal systems tended to punish the individual who uses AOD. The moral model or attitude towards addiction can still be seen today in certain cultures. Those who still believe addiction is morally “wrong” tend to perceive the most appropriate way to treat the individuals who use AOD are through legal sanctions, such as imprisonment and fines. For example, in many countries, drivers who are caught under the influence of alcohol or other drugs are not considered for treatment programs but instead receive court sentences as punishments (Fisher & Harrison, 2017).

This model has been rejected by alcohol and other drugs professionals as unscientific and contributes to the stigma surrounding addiction and substance use (White, 1991, cited in Fisher & Harrison, 2017).

The Disease Model

This model takes up the medical viewpoint and proposes addiction as a disease or illness that an individual has. It proposed that addiction is a disease that is progressive and chronic whereby the individual holds no control as long as the substance use continues. In other words, their addiction will continue to deteriorate with the continuous AOD (Thombs & Osborn, 2019). It also proposes that individuals who uses AOD can never be cured from addiction, though it can be readily treated through sustained abstinence such as self-help fellowships and treatment community. 

In the 1940s, Jellinek proposed a disease model in relation to alcoholism, arguing that it is a disease caused by a physiological deficit in an individual, making the person permanently unable to tolerate the effects of alcohol (Stevens & Smith, 2014). Jellinek identified signs and symptoms and clustered them into stages of alcoholism, as well as progression of the disease, which form the basis of 12-step or Anon-type programs (e.g., Alcoholics Anonymous and Narcotics Anonymous; Stevens & Smith, 2014). 

Under the disease model, treatment requires complete abstinence. Once an individual has accepted the reality of their addiction and ceased substance use, they are labelled as being in recovery, but are never ‘cured’ (e.g., “Once an alcoholic, always an alcoholic”; Thombs & Osborn, 2019). Whilst originally applied to alcohol dependency, it has now been generalised to other substances and many traditional substance use treatment models are based on this model (Capuzzi & Stauffer, 2020; Stevens & Smith, 2014).

The disease model offered an alternative to the moral theory, helping to remove the moral stigma attached to addiction and replacing it with an emphasis on treatment of an illness (Capuzzi & Stauffer, 2020). Disease theory helped to explain how some people experience the physiological effects of addiction such as dependence, tolerance, and withdrawal more than others, and how these mechanisms are caused by a biochemical abnormality in an individual which increases their likelihood of developing a dependency (DiClemente, 2018). 

While the disease model was well received by a range of professionals, many criticised it because research did not find that the progressive, irreversible progression of addiction through stages always occurs as predicted (Capuzzi & Stauffer, 2020). Additionally, many in the AOD field argued that the model did not address the complex interrelated factors that accompany dependency (Stevens & Smith, 2014). Finally, some professionals argued that the concept of addiction being a disease may also convey the impression to some individuals that they are powerless over their dependency and/or not responsible for the consequences of destructive addictive behaviours, which can be counteractive to treatment (Capuzzi & Stauffer, 2020).

Genetic and Neurobiological Theories

These theories suggest that some people may be genetically predisposed to develop drug dependency. For example, individuals usually begin substance use on an experimental basis. They then continue using because there is some reinforcement for doing so (e.g., a reduction of pain, experience of euphoria, social recognition, and/or acceptance, etc.). Some people may continue to use substances in a controlled or recreational manner with limited consequences while others progress to non-medical use and eventually develop a dependency. Why? Genetic and neurobiological theories propose that this is the result of a genetic predisposition to drug dependency (Fisher & Harrison, 2017). 

Factors being considered by researchers in the genetic transmission of dependency on alcohol include neurobiological features such as an imbalance in the brain’s production of ‘feel good’ neurotransmitters or in the metabolism of ethanol, which is the key component of alcohol (Stevens & Smith, 2014). Other researchers explored genetic differences in temperament and personality traits which they argued may lead to certain individuals becoming more vulnerable in the face of challenging environmental circumstances, leading to AOD use (Stevens & Smith, 2014). Genetic predispositions such as these may explain why some individuals develop dependency on AOD while others in similar situations do not.

The Psycho-dynamic Model

This model proposes that substance use may be due to an unintentional response to some difficulties that an individual experienced in their childhood. This explanation is based on the theory that was put forward by Sigmund Freud, whereby the problems of whether we are able to cope with difficulties as adults are linked to our childhood experience. Many counselling approaches today are based on this theory which aim to seek understanding of people’s unconscious motivations and to enhance how they view themselves (Capuzzi & Stauffer, 2020).

The Psycho-dynamtic model also believes that AOD use is often secondary to a primary psychological issue. In other words, alcohol and other drugs is a symptom rather than a disorder, and AOD use is a means to temporarily relieve or numb emotional pain. For example, an individual suffering from depression might self-medicate with stimulants to relieve the enervating effects of depression or manage their anxiety by using benzodiazepines (Fisher & Harrison, 2017). 

There is evidence to support this model, whereby childhood traumatic events are associated with mental health problems and substance use disorders. Wu et al. (2010) conducted a study among 402 adults who were receiving substance use disorder treatments. They revealed that almost all (95%) of the participants experienced one or more childhood traumatic events, and 65.9% of them experienced emotional abuse and neglect from their childhood. The authors also reported that the higher the number of childhood traumatic events experienced, the higher the risk of substance use disorders and mental health problems such as post-traumatic stress disorder. 

Personality Traits

Some theorists suggest that certain individuals have certain personality traits that are linked to AOD dependency. For example, dependency on alcohol has been associated with traits such as developmental immaturity, impulsivity, high reactivity and emotionality, impatience, intolerance, and inability to express emotions (Capuzzi & Stauffer, 2020).

Social Learning Model

This model suggests that social learning processes such as observing other peoples behaviours (i.e., modelling) and cultural norms are important in the process of learning behaviours. Albert Bandura proposed Social Learning Theory which would argue that substance use is initiated by environmental stressors or modelling people around you with “perceived status”. For example, a child observes their parents use alcohol in social situations and the child is therefore more likely to perceive that AOD use for social situations is appropriate (Harrison & Fisher, 2017); the association between socialisation and alcohol has been established.

The social learning model also recognises the influence of cognitive processes such as coping, self-efficacy, and outcome expectancies. Some researchers are currently focusing on how an individuals expectation of the effects of drugs influence the pattern of AOD use and resulting dependency. Russell (1976, cited in Wise & Koob, 2013) suggested that dependency on substance is not only chemical (biological) but also behavioural and social in nature. 

It has also been suggested that substance use occurs when an individual thinks substance use is a coping mechanism. This can be learned from television and film, social medial, peer influence, or messages from caregivers during childhood. The individual hopes the AOD use will relieve from them from stress (Stevens & Smith, 2014). 

Socio-cultural Model

Different from the previous models, the socio-cultural model perceives substance use as an issue of society as a whole instead of focusing only on the individual. People tend to overestimate the influence of internal and psychological factors while underestimating the external and environmental factors, even among some alcohol and other drugs workers (Gladwell, 2000, cited in Lewis, Dana, & Blevins, 2015). Thus, this model highlights the importance of how society shapes substance use behaviours, such as cultural attitudes, peer pressures, family structures, economic factors, and more (Bobo & Husten, 2000). For example, Coffelt et al. (2006) found that parents’ alcohol use are associated with their children’s drinking behaviour, whereby when the adult’s alcohol problems increased, the likelihood of their adolescent child’s alcohol use increased. 

The Biopsychosocial Model

Substance use behaviour cannot be explained or understood scientifically or spiritually based on a single variable, antecedent, or “cause”. Biological, psychological, learning, social and cultural context all contributes to explaining why addiction develops and maintains. The interactions between these factors are presented in The Biopsychosocial Model – arguably the most commonly used model to explain addiction today. The model suggests that substance use and the progression of substance dependency can be explained by recognising that the body and mind are connected within a social and cultural context (Skewes & Gonzalez, 2013).

The model allows any combination of biological, psychological, social and cultural factors to contribute to AOD misuse and dependency, rather than a single dominating factor. This is much more holistic and integrative when attempting to understand the determinant of addiction (Stevens & Smith, 2014).

References:

1. Bobo, J. K., & Husten, C. (2000). Sociocultural influences on smoking and drinking. Alcohol Research and Health, 24(4), 225-232. 
2. Capuzzi, D., & Stauffer, M. D., Sharpe, C. W. (2020). History and etiological models of addiction. In D. Capuzzi, & M. D. Stauffer (Eds.), Foundations of addictions counseling (pp. 1-22). Pearson Education.
3. Coffelt, N. L., Forehand, R., Olson, A. L., Jones, D. J., Gaffney, C. A., Zens, M. S. (2006). A longitudinal examination of the link between parent alcohol problems and youth drinking: The moderating roles of parent and child gender. Addictive Behaviours, 31, 4, 593-605. https://doi.org/10.1016/j.addbeh.2005.05.034 
4. DiClemente, C. C. (2018). Addiction and change: How addictions develop and addicted people recover. The Guilford Press.
5. Fisher, G. L., & Harrison, T. C. (2017). Substance abuse: Information for school counsellors, social workers, therapists, and counsellors. Pearson Education. 
6. Lassiter, P. S., & Spivey, M. S. (2018). Historical perspectives and the moral model. In P. S. Lassiter, & J. R. Culbreth (Eds.), Theory and practice of addiction counselling. (pp. 27-46). Sage Publications. 
7. Lewis, J. A., Dana, R. Q., & Blevins, G. A. (2015). Substance abuse counselling. Cengage Learning.
8. Skewes, M. C., & Gonzalez, V. M. (2013). The biopsychosocial model of addiction. In P. M. Miller, A. W. Blume, D. J. Kavanagh, K. M. Kampman, M. E. Bates, M. E. Larimer, N. M. Petry, P. D. Witte, S. A. Ball (Eds.), Principles of addiction: Comprehensive addictive behaviours and disorders (pp. 61-70). Academic Press.
9. Stevens, P., & Smith, R. L. (2014). Substance abuse counselling: Theory and practice. Pearson Education. 
10. Teesson, M., Hall, W., Proudfoot, & Degenhardt, L. (2012). Addictions. Taylor & Francis Group.
11. Thombs, D. L., & Osborn, C. J. (2019). Introduction to addictive behaviours. The Guilford Press. 
12. Wise, R. A., & Koob, G. F. (2013). The development and maintainance of drug addiction. Neuropsychopharmacology, 39, 254-262.
13. Wu, N. S., Schairer. L. C., Dellor, E., & Grella, C. (2010). Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addictive Behaviors, 35(1). 68-71. https://doi.org/10.1016/j.addbeh.2009.09.003